The Institute for Global Health and Development
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Item How do dual practitioners divide their time? The cases of three African capital cities(Elsevier, 2014-10-18) McPake, Barbara; Russo, Giuliano; Tseng, Fu-MinHealth professionals dual practice has received increasing attention, particularly in the context of the universal health coverage movement. This paper explores the determinants of doctors' choices to become a dual practitioner and of dual practitioners' choices to allocate time to the private sector in the capital cities of Mozambique, Guinea Bissau and Cape Verde. The data are drawn from a survey conducted in 2012 among 329 physicians. We use a two-part model to analyse the decision of both public and private practitioners to become dual practitioners, and to allocate time between public and private sectors. We impute potential earnings in public and private practice by using nearest-neighbour propensity score matching. Our results show that hourly wage in the private sector, number of dependents, length of time as a physician, work outside city, and being a specialist with or without technology all have a positive association with the probability of being a dual physician, while number of dependents displays a negative sign. Level of salaries in the public sector are not associated with dual practice engagement, with important implications for attempts aimed at retaining professionals in the public sector through wage increases. As predicted by theory that recognises doctors' role in price setting, earnings rates are not significant predictors of private sector time allocation; personal characteristics of physicians appear more important, such as age, number of dependents, specialist without technology, specialist with technology, and three reasons for not working more hours in the private sector. Answers to questions about the factors that limit working hours in the private sector have significant predictive power, suggesting that type of employment in the private sector may be an underlying determinant of both dual practice engagement and time allocation decisions.Item Negotiating markets for health: An exploration of physicians' engagement in dual practice in three African capital cities(Oxford University Press, 2014-09) Russo, Giuliano; McPake, Barbara; Fronteira, Ins; Ferrinho, P.Scarce evidence exists on the features, determinants and implications of physicians' dual practice, especially in resource-poor settings. This study considered dual practice patterns in three African cities and the respective markets for physician services, with the objective of understanding the influence of local determinants on the practice. Forty-eight semi-structured qualitative interviews were conducted in the three cities to understand features of the practice and the respective markets. A survey was carried out in a sample of 331 physicians to explore their characteristics and decisions to work in public and private sectors. Descriptive analysis and inferential statistics were employed to explore differences in physicians' engagement in dual practice across the three locations. Different forms of dual practice were found to exist in the three cities, with public physicians engaging in private practice outside but also inside public facilities, in regulated as well as unregulated ways. Thirty-four per cent of the respondents indicated that they worked in public practice only, and 11% that they engaged exclusively in private practice. The remaining 55% indicated that they engaged in some form of dual practice, 31% 'outside' public facilities, 8% 'inside' and 16% both 'outside' and 'inside'. Local health system governance and the structure of the markets for physician services were linked to the forms of dual practice found in each location, and to their prevalence. Our analysis suggests that physicians' decisions to engage in dual practice are influenced by supply and demand factors, but also by how clearly separated public and private markets are. Where it is possible to provide little-regulated services within public infrastructure, less incentive seems to exist to engage in the formal private sector, with equity and efficiency implications for service provision. The study shows the value of analysing health markets to understand physicians' engagement in professional activities, and contributes to an evidence base for its regulation.