Regulating physician dual practice to advance Universal Health Coverage in low- and middle-income countries. A study to assess existing policies and identify effective regulatory options in Mozambique and South Africa

Background. Doctors in low- and middle-income countries (LMICs) often work simultaneously in public and private clinical services, a phenomenon known as ‘dual practice’. Although such practice is credited with increasing doctors’ income and retention in the public sector, it is also accused of compromising availability of services in public hospitals.

The implications of dual practice for the achievement of universal health coverage (UHC) depend on the balance of these opposing effects in different contexts. Regulating the practice is a complex health system issue, and little evidence exists on the effectiveness of regulatory options.

Research approach. We base this proposal on our previous research in Mozambique and South Africa, and investigate physician dual practice within the context of urban and rural public hospitals. Our research questions focus on assessing the impact of current regulation in the two countries, as well as on identifying regulatory options to help achieve UHC in LMICs.

We take a number of vantage points to understand how interactions between stakeholders determine forms of the phenomenon and compliance with regulation, and to develop a model predicting how different policy options will influence retention and services.

Methods. First, a mixed methods enquiry will help us understand the current forms of dual practice, doctors’ distribution of time across public and forms of dual practice, compliance with regulation, and interactions of relevant stakeholders. We will use a combination of interviews, analysis of hospital service data, and doctors’ diaries to develop a metrics of dual practice and construct a picture of its impact on UHC.

Second, we will use discrete choice experiments (DCE) to reveal doctors’ preferences among public sector jobs with attributes including opportunities for forms of dual practice (outside, beside, inside and integrated) and freedoms to take up those opportunities. The DCE surveys will be conducted face to face in six urban and rural hospitals and include between 300 and 350 individuals.

Third, we will use Agent-Based Modelling to develop a theoretical model of the interactions of doctors and hospital managers in hospital contexts. Informed by the mixed-methods enquiry and DCE conclusions, we will model the influences on doctors’ job choices among alternative hospitals and the factors shaping managers’ decisions regarding stringency of regulation.

The model will explain and predict doctors’ time allocations across public and private services, and their implications for the availability of services under alternative policy scenarios.

The research team. Our proposal includes researchers and policy makers from the National Institute of Health of Mozambique, the University of Witwatersrand of South Africa, the Nossal Institute for Global Health, Australia, and Queen Mary University of London. The project will rely on national community engagement advisory committees to provide inputs for the development of the study, and will include government officials, medical associations, civil society organisations, and patients’ representatives.

Expected impact. We expect our project will: develop health system research capacity in Mozambique and South Africa; contribute to understanding the implications of different forms of regulation of human resources and health labour markets for the achievement of UHC, and; engage with the development of local policies to regulate the phenomenon.