Background
Physician dual practice refers to full-time salaried public sector medical doctors practicing simultaneously in the private, for-profit sector [
1,
2]. Also termed “public-on-private,” “moonlighting,” or “multiple job holding,” physician dual practice is present in almost all countries [
1‐
3], but the extent to which physicians engage in dual practice, their motives for doing so, the consequences of dual practice, and the regulatory options depend highly on the local context [
1‐
5].
Public-on-private dual practice is often promoted as a means to supplement low government salary rates, thus encouraging physician retention in the public sector and increasing healthcare access, particularly in low- and middle-income countries (LMICs) [
5‐
8]. It has also been argued to reduce public sector waiting times by stimulating additional effort from physicians with profit incentives [
9]. Additionally, dual practice can allow for provision of additional and/or higher quality services that are excluded from the public health service bundle due to low demand or low cost-effectiveness [
9].
On the other hand, dual practice has been criticized as reducing the quality of public sector services by incentivizing physicians to divert time, attention, and resources to their private practices [
1,
2,
6,
9]. Physicians have also been accused of patient diversion either by direct referral or by more subtle means, like manipulating increased public sector waiting times in order to stimulate demand for their private services [
1,
2,
6,
9]. In most LMICs, regulations to reduce the negative effects of dual practice are either completely lacking or poorly implemented because of low enforcement capacity [
4].
In Ethiopia, a low-income country in sub-Saharan Africa, the public health sector has long been suffering from a shortage of medical doctors [
10]. The number of physicians in the country working in the nation’s public hospitals suffered a sharp decline from 1658 in 1989 to only 638 in 2006 [
10] and in Tigray region(in which this study was conducted) the number of physicians continued to decline from 84 in 2006 to 77 in 2010. Due to high physician attrition rates, rapid population growth, low production, and increased post-graduate enrollment, the country’s physician-to-population ratio of 1:36,158 is far below the World Health Organization (WHO) recommendation for developing countries of 1:10,000 [
10,
11].
As is the case with physicians in many other low-income countries, the major reason Ethiopian physicians leave the public sector is believed to be unmet salary expectations coupled with higher earning potential in the domestic private sector or in the international market [
10,
12]. Therefore, allowing dual practice is one of the major physician retention strategies of the Tigray government endorsed in 2010 in Tigray region [
13]. Its job allocation system is yet another strategy for retaining new medical graduates. Most students’ education is funded by the government, and in exchange for free training, health workers are required to serve a fixed number of years in a randomly selected public facility (3 years for GPs, 4 years for specialists) before receiving their license. Only after completing their service obligation or paying a large fee are they “released” from the public sector with their credentials [
12].
Tigray National Regional State (TNRS), the northernmost of Ethiopia’s nine regions, officially introduced private-on-public dual practice in 1993. The region faces a critically poor physician to population ratio of 1:58,000 with 77 physicians working in the public sector in 2010 [
13]. After the introduction of DP this number steadily increased and doubled by 2015(153) [
13]. There are 15 general hospitals and 1 referral hospital in the public sector, while there are 127 privately owned clinics (26 higher-level clinics, 35 medium clinics, and 66 small clinics). Physicians working at public hospitals own 26 (20.5%) of the region’s private health facilities.
The new health financing strategy introduced in 1998 increased governmental health expenditure and dramatically shifted the financing structure of public sector health facilities, enabling them to retain revenue collected from user fees in addition to the annually allocated governmental budget [
13,
14]. Nevertheless, public health facilities still struggle with tight budgets as government spending on healthcare remains far below the average in the rest of Africa, and many patients qualify for fee-waivers or exemptions [
15‐
17].
Strengthening the public-private partnership is stated as part of the Tigray Regional Health Bureau’s agenda [
13]. Private facilities provide selected fee-exempt services (DOTS, HCT, ART, PMTCT, reproductive health services, malaria services, etc.) through service provision contracts with the government [
13]. Public hospitals are also encouraged by the government to operate “private wing” services which use the public hospital facilities outside of working hours [
11]. In the “private wing,” patients pay a fee higher than that applicable in the main public facility in order to avoid waiting, and a fixed proportion is transferred to the public facility [
8].
According to routinely reported data, the average bed occupancy rate in Tigray’s public hospitals hovers around 47% [
18], yet many patients complain of long waiting times and other difficulties accessing public sector services [
12,
16]. A study conducted on health workers’ performance in Ethiopia reported that absenteeism of health workers, pilfering of resources, illicit charging, and diversion of patients to the private sector are major problems [
12]. However, the role of dual practice among physicians is not well studied in the Ethiopian context. Therefore, the objectives of this study were (1) to assess the extent of dual practice among physicians, (2) describe the situation of DP in Tigray region/Ethiopia (3) to assess the positive and negative consequences of dual practice on public sector service from the perspectives of physicians, patients, and hospital managers in TNRS, Ethiopia.
Methods
Study area
The study was conducted in TNRS, northern Ethiopia; its capital city (Mekelle) located 783 km from Addis Ababa, capital city of Ethiopia.TNRS is one of the nine regional states of the Federal Democratic Republic of Ethiopia located in the northern part of the country. It is bordered by Eritrea to the north, Sudan to the west, Afar Region to the east and Amhara Region to the south. The total area of the region is about 54,569.25 km2 and the elevation ranges from 600 to 2700 m above sea level. There are 6 administrative zones including one special zone, Mekelle Zone(western zone, north west zone, central zone, eastern zone, south east zone, southern zone and Mekelle zone). The region has 52 Woredas (34 rural and 18 urban) and 814 Kebeles (753 rural and 61 urban). According to the 2007 EC census projection, the region has a total population of 5,055,999 (49.2% male and 50.8% female).
The region had 13 governmental hospitals of them 6 where zonal and 7 were districts. (Kahsay-abera hospital is found in the western zone, Sihul hospital in north west,St Mary hospital in central, Adigrat in eastern zone, Mekelle hospital in Mekelle zone and Lemlem-karl in southern zone) since the southeastern zone is found to adjacent to Mekelle has no zonal hospital. Among these hospitals there were 56 physicians, of which 42 worked in the zonal hospitals where we undertook our study.
Study design and period
A cross-sectional study was conducted from February to March 2011 in six public hospitals in TNRS (Kahsay Abera Hospital, Shul Hospital,St Mary Hospital, Adigrat Hospital, Mekelle Hospital, and Lemlem Karl Hospital).
Inclusion and exclusion criteria
All patients admitted for at least two days in the six study hospitals during the study period were included to this study whereas too ill patient and unable to respond verbal communication were excluded from the study. All physicians who gave informed consent and work in the study hospitals were included to this study.
Sample size and technique
Purposive sampling was used to select geographically representative hospitals for inclusion in the study. These hospitals represent all parts of the region.
Since the number of patient admitted in the zonal hospital were small in number and manageable all admitted patients were surveyed using the consecutive sampling method. All physicians who work in the study hospitals during the study period were also included to the study.
Data collection
A self-administered, semi-structured, pre-tested questionnaire in English was distributed to all physicians working in the study hospitals during the study period. Physicians were asked about their medical specialization, number of years served in the public sector, monthly public sector salary, and type of employment in the public sector using a structured questionnaire. They were also asked to describe their level of involvement in dual practice if any, their reasons for engaging in dual practice, their opinions regarding its effect on public hospital service provision, and their recommendations to improve physician retention by using open ended questions. For this study Dual practitioner was operationally defined in two categories including (1) a full-time salaried public sector medical doctors practicing simultaneously in the private, for-profit sector outside the public hospital (2) physicians who work in the private wing of a public hospital [private practice ‘within’ public practice facilities]. Completed questionnaires were sealed by the respondents and collected by the study supervisors.
Admitted patients were interviewed using a structured, pre-tested questionnaire translated into Tigrigna, the local language. Data were collected on patients’ socio-demographic characteristics, their referral history and prior visits to private clinics, and their opinions on dual practice. High school graduates trained on the data collection tools conducted the interviews.
At each study hospital, a focus group discussion (FGD) was held with six members of the management committee, excluding the medical directors to avoid bias or undue influence. The participants discussed their reflections on the positive and negative effects of dual practice on public hospital services.The FGD included the following questions: what positive side do you observe from dual practice; what drawbacks did you observe in your hospital related to dual practice; how do you manage when problems occurred associated with dual practice and what is your opinion if the government bans dual practice?
Data analysis
Quantitative data were cleaned and entered, and frequencies and descriptive statistics were computed using SPSS Version 16.0. Audio recordings of the FGDs were transcribed to text, coded, and analyzed according to thematic areas. Qualitative data from the FGD and open ended questions were summarized into categories based on the common thematic area that respondents reply. Small sample size precluded formal content analyses; a few key responses are reported here for context. Data from the three sources were triangulated to determine the extent of dual practice, the reasons physicians engage in it, and its impacts on public sector services.
Ethical approval and consent to participate
Prior to the study, ethical clearance was obtained from Ethical Review Committee of the College of Public Health and Medical Sciences of Jimma University. All study participants including hospital administrators, physicians and patients were informed about the purpose of the research and how responses will be reported. Confidentiality and anonymity were maintained.
Acknowledgements
Our sincere thanks go to Atakelti Abraha, Sr. Liat Woldu, Hagos Godefay, Tirhas Gebremedhin, Solomon Abay, Hayelom Gebrekirstos, Hanna S.Yang, Haregeweyni Alemu,Tigray Regional Health Bureau, Jimma University, and Yale University, Adwa Hospital staff and governing board. Thanks to all my family especially Zerabruk Gigar and Hagos Gigar for their varied support and encouragement. We would also like to thank all the study participants, data collectors and CEOs of the study hospitals for their support.