‘Dual practice’ by doctors in south/south-east Asia

Private practice by doctors employed in government jobs, sometime at the cost of access and equity for the patients, is a common problem in low and middle income countries of the world, especially south and south-east Asia such as Bangladesh. In the literature, this is termed as ‘dual practice’ and is tolerated at varying degrees in different countries which have poor regulatory measures. This ‘dual practice’ is important from the perspective of public health because ‘it negatively affects health service access, quality, efficiency and equity’ as the involved doctors frequently sacrifice public work for private work to maximize their income and other benefits. 

The most important underlying factors behind ‘dual practice’ are the poor salary structure and lack of appropriate incentives for doctors working in the government health services, besides poor regulation of doctors’ activities. The doctors tend to compensate poor salary by earning from ‘dual practice’. Dual practice becomes specially prevalent when the financial attraction from the private sector is high.

Dual practice affects health system in different ways. It may result in absenteeism of the doctors or when available, cutting into the time the doctors attend the patients in government facilities. Doctors often compel patients to visit private facilities to increase income, sometime extending waiting time. Sometime resources from the government facilities are used for treating private patients. Doctors may work at a level below their competency in the government facilities, only to divert patients to the  private facilities promising quality care. But, dual practice may have some benefits as well. It increases doctors’ retention in the public sector, reduces informal payments, diverts well-off patients from accessing government facilities, provide better care in government facilities to build good-will for private practice etc.

Researchers and policy makers have explored various options to counteract this dual practice. Broadly speaking, three options are proposed: taking no action, and therefore, allowing unregulated dual practice and its associate negative outcomes on health system; banning to enforce it or limiting dual practice in terms of location or time spent and capping the income which are only possible when there is a functional regulatory agency to enforce these; and lastly, more practical, allowing dual practice with some degree of regulation which is context-sensitive e.g., varying demand and opportunities for private practice, capacity of local regulation through citizen’s watch dogs or other measures or differential demand and income opportunities for different types of practitioners.

In Bangladesh also we have the same problem and it is a very sensitive issue related to the configuration of the medical profession in the power structure of the ruling elites. Previous attempts to remedy this, e.g., by military dictator Ershad, cost him his presidency. Any attempt to control or limit dual practice should be well thought out, taking all factors in account. However, this is absolutely necessary to improve universal access to healthcare, especially the poor.

Source: Dual practice by health workers in south and east Asia: impacts and policy options. Policy Brief 2(1), 2013. Asia Pacific Observatory on Health Systems and Policies.