Navigating Dual Practice: Balancing Public and Private Health Care Sectors

The WHO report “Governance of Dual Practice in the Public and Private Health Sectors” sheds light on the challenges and opportunities of managing dual practice in healthcare. While it can improve access and efficiency, it also risks undermining equity and the quality of care. Effective governance, through regulatory controls, payment incentives, and monitoring, is key to balancing the benefits and drawbacks of dual practice. Countries must adopt context-specific policies to navigate this complex issue and achieve Universal Health Coverage.

Dual practice, where health professionals simultaneously work in both public and private healthcare sectors, is a widespread phenomenon across national health systems. While it can provide benefits, such as improving access to care, it also poses significant challenges for countries striving to achieve Universal Health Coverage (UHC). According to the World Health Organization's (WHO) report "Governance of Dual Practice in the Public and Private Health Sectors," managing dual practice effectively requires careful governance to mitigate its adverse effects and ensure equity and efficiency in healthcare delivery.

Understanding Dual Practice and Its Impact on Health Systems

At its core, dual practice involves health professionals, primarily physicians, working in both public and private settings. This practice can take different forms: private care offered outside public hours, private services within public facilities, or entirely separate private practices. While it's often seen as a way to supplement healthcare workers' income, especially in resource-constrained settings, it also introduces complexities into national healthcare systems.

The impact of dual practice is double-edged. On the one hand, it can enhance access to healthcare by allowing patients who can afford private services to access them, potentially reducing pressure on public facilities. In some cases, it may expose healthcare workers to innovation and advanced technology in the private sector, which can be beneficial when applied to public healthcare.

On the other hand, dual practice can exacerbate existing inequities. In low- and middle-income countries, where public healthcare is often underfunded, dual practice may lead to longer waiting times and lower quality of care in public facilities. There's also the risk of health professionals prioritizing their private practice at the expense of public service, contributing to absenteeism and the misuse of public resources. This diversion of patients into private care, sometimes for unnecessary services, undermines the goals of UHC.

The Governance Challenge: Managing Dual Practice

Governments face a complex dilemma when dealing with dual practice. Should they ignore it, regulate it, or ban it outright? Each approach has its pros and cons, but WHO emphasizes the importance of a governance response that keeps dual practice within the regulatory framework of the health system.

Regulatory control is one of the key tools to manage dual practice. Some countries have imposed restrictions on the types of services health professionals can provide in the private sector or placed caps on private earnings. Other governments require physicians to seek permission from public employers before engaging in private practice. However, such measures are only effective if they are strictly enforced and aligned with broader health system goals.

Another strategy is to introduce reward or payment systems to incentivize public service. For instance, countries like Norway have successfully reduced dual practice by offering exclusive contracts with higher salaries to public sector physicians, dissuading them from private practice. In contrast, in low-resource settings, raising public sector wages to match private earnings is often financially unsustainable, making this approach less viable.

Information and monitoring systems are also critical. Transparency about health workers' dual roles and the services they provide, both public and private, can help governments monitor the practice more effectively. Patient information systems and practitioner performance data can guide regulatory bodies in assessing whether dual practice is improving or undermining healthcare equity and quality.

Case Studies and Policy Responses

Countries have adopted different approaches to dual practice, reflecting their unique healthcare landscapes. In Canada, physician dual practice is officially discouraged in many provinces, but virtual healthcare models have increased the complexity of regulation. In contrast, Vietnam encourages dual practice as a solution to physician shortages, allowing doctors to work in private facilities outside of public hours.

In some countries, banning dual practice has led to unintended consequences. For instance, Greece and Mumbai, India, experienced an exodus of health professionals when bans were imposed, as many sought better pay or conditions abroad. This highlights the importance of crafting flexible policies that consider the motivations of health professionals, such as income gaps and professional development opportunities while ensuring that public health goals are met.

Ultimately, WHO recommends that governments adopt a nuanced, context-specific approach to regulating dual practice. For countries grappling with shortages of healthcare workers or the challenge of retaining them in the public sector, strict bans may not be feasible. Instead, governments should focus on creating balanced policies that align the interests of health professionals with national health goals.

The Path Forward: Building Evidence for Better Governance

One of the key takeaways from the WHO report is the need for more empirical evidence on the governance of dual practice. While case studies provide valuable insights, the effectiveness of various governance tools remains largely unexplored in the literature. More research is needed to understand how different regulatory, financial, and monitoring mechanisms can be tailored to local contexts to maximize positive outcomes.

As the global push toward UHC continues, governments need to manage dual practice effectively. By ensuring that dual practice operates within the regulatory framework, governments can harness its benefits while minimizing its negative effects on healthcare equity and quality.