Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine Health Policy

cy and Planning 2014;29:703–716

ß The Author 2013; all rights reserved. Advance Access publication 21 October 2013 doi:10.1093/heapol/czt053

Dual practice by doctors working in South and

East Asia: a review of its origins, scope and
impact, and the options for regulation
David Barry Hipgrave* and Krishna Hort

Nossal Institute for Global Health, University of Melbourne, Carlton, Vic. 3010, Australia
*Corresponding author. Box 1049, Brighton Rd RPA, Elwood, Vic. 3184, Australia. E-mail: dhipgrave@gmail.com

Accepted 14 June 2013

Health professionals often undertake private work whilst also employed by
government. Such dual practice (DP) is found in both high-income and lower-
and middle-income countries (LMIC) around the world, with varying degrees of
tolerance. This review focuses on DP in South and East Asia in the context of
the rapidly expanding mixed health systems in this region. Although good data
are lacking, health service uptake in South and East Asia is increasing,
particularly in the private sector. Appropriately regulated, DP can improve health
service access, the range of services offered and doctors’ satisfaction. By contrast,
weakly regulated DP can negatively affect public health service access, quality,
efficiency and equity, as doctors often pursue the balance of public and private
work that maximizes their income and other benefits. The environment for
regulation of DP is changing rapidly, with improved communications opportu-
nities, increasing literacy and rising civil society, particularly in this region.
Currently, the options for regulating DP include (1) those which restrict the
opportunities for dual practitioners to prioritize income and other benefits over
their responsibility to the public; these require a level of regulatory capacity
often missing in LMIC governments; and (2) those which not only tolerate
public-sector doctors’ private work but also encourage adequate health services
for the general public. Growth of the private sector and weak regulation in
South and East Asia increases the risk that dual practitioners will ignore the
poor. Responsive and decentred regulation of doctors involving professional
associations, civil society and other stakeholders is increasingly recommended.
Moreover, as governments in LMIC strive for universal health coverage, market
and financing opportunities for regulation of DP may arise, particularly involving
insurers. This may also help to improve the current imbalance in the urban–rural
distribution of doctors.

Keywords Dual practice, health sector, public/private, lower- and middle-income countries,
South and East Asia, regulation

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704 HEALTH POLICY AND PLANNING

KEY MESSAGES
 Dual practice (DP) is most likely to have negative consequences in lower- and middle-income countries, where regulation
of doctors’ behaviour is often weak. Weak regulation of DP threatens equitable, universal access to healthcare.

 As uptake of healthcare rises in South and East Asia’s mixed health systems, the scale of DP is likely to be increasing, but
most countries lack current analysis of the problem.

 New options for regulation of DP are emerging, including roles for newly empowered civil society groups; independent,
non-government agencies; professional associations; and health insurers implementing financial mechanisms.

 Improved regulation of DP has the potential to harness its potential benefits for increasing access to health services,
including for rural communities in South and East Asia.

market makes it a key health workforce issue. It draws on

Introduction
Dual practice (DP), also known as multiple job holding, is the
widespread phenomenon of government employees working
concurrently both within and outside the public-sector environ-
ment. The private work may be undertaken physically within or
outside public facilities, but is conducted either entirely for
personal profit or as part of a profit-sharing arrangement with
the relevant government authority. DP is common within but not
restricted to the health professions; teachers (who may addition-
ally offer private tuition), academics (who may consult privately),
public security staff and conceivably any salaried professional or
other public service provider may undertake private work
additional to their government employment. However, DP in
the health sector attracts the most interest because it concerns an
issue of universal importance that can be extremely costly, is
inherently unpredictable, and assumes the availability of skilled
care (Bloom et al. 2008). Moreover, with the high profile of recent
donor- and publicly funded efforts to improve population health
(Ravishankar et al. 2009), and burgeoning research interest in
human resources for health (Ranson et al. 2010), high-level
attention has been paid to DP by public-sector health workers,
doctors in particular (Kiwanuka et al. 2011a,b).
DP is common all over the world, and is found in countries
whose development and economic status, political system and
demographic and health situations vary widely. The United
States (where it is rare) and Canada (where it is officially not
permitted) are two exceptions, but even in nations or states
where it is officially banned, overt or covert DP is common. The
frequency of health sector DP varies widely; in some nations, a
majority of public-sector doctors also work privately, while in
others only senior doctors or specialists do so (Garcia-Prado and
Gonzalez 2011).
Accounts of health workforce practices in many South and
East Asian nations (including India, Bangladesh, Thailand,
Cambodia, China, Vietnam, Indonesia, Papua New Guinea, Sri
Lanka and Nepal) and also nearby Australia and New Zealand
confirm DP by doctors in this region (Berman and Cuizon 2004;
Ferrinho et al. 2004; Garcia-Prado and Gonzalez 2011), but
there is less evidence on its impact. Concerns centre on the risk
that DP may reduce health service access, quality and effi-
ciency, but there are both theoretical and practical reasons why
DP might be of overall benefit.
This article focuses on DP and its regulation in South and
East Asia, where the burgeoning, mixed public–private health
several recent reviews of the available evidence, theoretical
perspectives on DP and its regulation, and on the meagre
related original research. It contextualizes DP in the evolution
of the health systems and political economies of many South
and East Asian nations and low- and middle-income countries
(LMIC) elsewhere. It also considers the region’s rapidly
changing health markets and efforts to achieve universal
health coverage (UHC).
As there is no consensus on the overall impact of DP and its
regulation, the purpose of this article is first to summarize for
policy-makers, finance and health authorities and health
regulators the related evidence in South and East Asian
nations. Second, this article reviews and builds on suggested
options for regulation of DP in the health sector in the context
of the growing market for both public and private health
services, drawing on a recent model that accounts for the
attractiveness of DP and includes the proportion of income
from insurers; this is a key consideration as governments strive
to achieve UHC. Finally, it considers new approaches to
regulation of DP and doctors in general, involving independent
but government-sanctioned authorities, professional associ-
ations and civil society. The article closes with a brief review
of the key related research questions on this issue.
Method
This article draws on a recent systematic review (Kiwanuka
et al. 2011a), a Cochrane review (Kiwanuka et al. 2011b),
published comprehensive overviews of DP, particularly on its
regulation in LMIC (Berman and Cuizon 2004; Ferrinho et al.
2004; Garcia-Prado and Gonzalez 2007, 2011), and on a
comprehensive search of the peer-reviewed and grey literature.
We searched the terms ‘dual practice’, ‘dual job holding’ and
‘multiple job holding’ and ‘health sector’, or the former three
terms individually, in the PubMed database available at
http://www.ncbi.nlm.nih.gov/pubmed?db¼pubmed and the
three terms and ‘health sector’ in the Google internet search
engine. These searches were undertaken during the period
October–December 2012 and again in May 2013, and identified
45 more-or-less related, peer-reviewed articles through PubMed
and collectively over 8000 hits in Google. The internet searches
assessed the first 260 results for the DP and ‘health sector’
search, the first 200 results for the ‘dual job holding’ and
 DUAL PRACTICE BY DOCTORS IN SOUTH AND EAST ASIA
‘health sector’ search, and the first 70 results for the ‘multiple
job holding’ and ‘health sector’ search, after which original
sources were exhausted and Google only identified repetition.
Published articles comprised a mix of original, purposive
assessments of the scale of and reasons for DP and its impact
on health services and outcomes. Alternatively, they focused on
theoretical perspectives or models of the impact of DP, piloted
approaches to limiting or regulating it, or econometric evalu-
ation. The grey literature comprised hundreds of commentaries
on or summaries of published articles (e.g. Kiwanuka et al.
2011a), conference abstracts (e.g. Johnston and Ozaltin 2012),
academic dissertations that included discussion of DP (e.g.
Triyana 2012), items of commissioned research (e.g. Vian 2002)
or reports that mentioned DP in the context of a predominant
focus on other issues such as mixed health systems or health
service governance/regulation (e.g. Deussom et al. 2012; Mba
and Ongolo-Zogo 2011). For both the peer-reviewed and grey
literature, references cited were also carefully assessed for new
sources of information.
The origin of and influences on DP in the
health sector
Although private healthcare is an ancient profession, concerns
about the distraction from public responsibility created by
private practice have existed for at least two centuries
(Chadwick 1842; Russell 1951), and the evolution of DP is
ongoing. Its foundations vary widely, and while there is overlap
between doctors’ stated reasons for DP across nations as diverse
as the United Kingdom (Humphrey and Russell 2004),
Bangladesh (Gruen et al. 2002) and lusophone Africa (Russo
et al. 2013) the balance of reasons for public-sector doctors
taking on private work differs between developed and develop-
ing nations (Socha and Bech 2011).
In most developed nations healthcare has become highly
socialized, with governments ensuring availability of services
through the public sector, and the private sector providing an
alternative environment with different personnel or treatment
approaches, less waiting or sometimes differing degrees of care.
Most developed nations have a liberal approach to DP, with
doctors in most continental European nations, the United
Kingdom, Australia, New Zealand and Japan permitted to work
privately either within or outside their public-sector workplace,
and either outside or within their scheduled public-sector hours
of work. In the latter case, doctors’ private patients are nested
within public facilities (Garcia-Prado and Gonzalez 2011;
Kiwanuka et al. 2011a).
First-hand evidence on the factors motivating doctors to take
on extra work in higher-income countries is scant, but suggests
income enhancement, expanded or complementary use of
professional skills, clinical autonomy, broader professional
contact and peer approval, access to alternative facilities and
equipment, prestige or reputation-building, relief from the
high-pressure of and low appreciation received in the public-
sector environment, and the greater flexibility of private
practice (Garcia-Prado and Gonzalez 2011; Humphrey and
Russell 2004; Jumpa et al. 2007).
By contrast, in developing countries it is widely acknowledged
that the adverse consequences of DP are ‘embedded in the
larger setting of sub-optimal government strategies for
705
healthcare governance, financing and provision’ (Berman and
Cuizon 2004, p. 10). Absenteeism and moonlighting in LMIC
are said to reflect ‘high levels of unorganised health mar-
kets . . . , [porous] boundaries between public and private health
sectors and lack of state regulatory capacity’ (Bloom et al. 2008,
p. 2076). These authors link the pluralistic health systems
of many LMIC to the establishment and subsequent failure of
systems emulating the socialized (expensive) health sectors of
former colonial powers. These failures resulted from the various
crises—economic, political, security and structural—affecting
many developing nations since the 1960s, weakening their
public sectors and leaving a void in which non-State health
services have proliferated, including services provided by state-
employed providers working privately. Demand for healthcare
has also been lifted by the information revolution, investments
in infrastructure and education and in some countries by the
supply of new providers with limited opportunities for public
employment and low salaries. While in some countries DP is
more common among senior staff (Gruen et al. 2002), in others
it is junior doctors who are more likely to take on additional
private work (Jumpa et al. 2007). In the context of economic
growth and weak regulation, mixed health systems have grown
rapidly in many South and East Asian nations (Hort and
Annear 2012; Peters and Bloom 2012). This trend is likely to
continue, particularly with efforts to achieve UHC and the
introduction of new social health insurance schemes.
Evidence on the factors influencing DP in LMIC is again
scant. Research in South and East Asian nations (Dieleman
et al. 2003; Gruen et al. 2002; Henderson and Tulloch 2008;
Soeters and Griffiths 2003; Ying et al. 2003) emphasizes low or
unreliable salaries as the main incentive (as also documented in
Africa (Ferrinho et al. 2004; Roenen et al. 1997), but where the
perspectives of providers have been sought first-hand, other
sources of motivation (e.g. professional satisfaction, public
responsibility, better physical conditions, communication, train-
ing opportunities, prestige, etc.) also underpin the balance of
public and private work (Ferrinho et al. 2004; Gruen et al. 2002;
Ying et al. 2003).
The scope of DP in South and East Asian nations
Although most of the related reports are old and none provides
more than a glimpse based on local surveys, it is apparent
that DP in several South and East Asian Nations is widespread
and takes many different forms (Berman and Cuizon 2004;
Ferrinho et al. 2004; Garcia-Prado and Gonzalez 2011). Table 1
summarizes the evidence on DP among nations in this region
and nearby.
The information on DP in this region is incomplete and often
unreferenced. For example, the claim (in Gruen et al. 2002) that
more than 80% of government doctors in Bangladesh undertake
DP is unreferenced; despite widespread perspectives that DP is
widespread in India (Yip and Mahal 2008), some states have
banned it entirely (Berman and Cuizon 2004) and there are no
detailed studies of DP there. In Vietnam, although a 2001
health sector review estimated that only 10% of private
physicians were also working for the government (Ministry
of Health 2001), a 2003 report stated that most rural doctors
take on private work due to poor employment conditions
(Dieleman et al. 2003). A review of health service contracting to
706 HEALTH POLICY AND PLANNING

Table 1 Evidence for DP in South and East Asian and nearby nations

Country Available evidence

Australia Among 4571 specialist physicians surveyed in 2003, 79% of the 87% with patient care in public hospitals also had private
practice (Dent 2004)
Bangladesh Widely cited but unreferenced data cited in 2002 suggest that 80% of government doctors engage in private practice (Gruen
et al. 2002)
Cambodia Without providing figures, two reports suggest that DP in Cambodia is ‘deep-rooted’, ‘widespread’ (Soeters and Griffiths
2003) and ‘ubiquitous’ (Ferrinho et al. 2004); 90% of dual-practitioners’ income is said to come from private work
(Langenbrunner and Somanathan 2011)
China DP is theoretically legal but heavily restricted (Yang 2006). Informal payment of doctors by patients is widespread, tacitly
approved by doctors’ employers (Fan 2007; Lim et al. 2004; Yang 2006)
India DP, especially combining western with allopathic or other medicine is widely believed to be common (Berman and Cuizon
2004; Yip and Mahal 2008), and was inferred from high rates of absenteeism observed during 32 500 public clinic visits
(Chaudhury et al. 2006)
Indonesia DP is again widely believed to be common (Berman and Cuizon 2004). A rate of 80% was reported in one survey in 1993
(Bir and Eggleston 2003). An overview of Indonesia’s health sector cites research estimating that 70% of publicly-
employed puskesmas physicians and 93% of midwives undertake permitted private practice (Rokx et al. 2012). Virtually all
public-sector specialists engage in DP (Meliala et al. 2013)
Nepal One report suggests that up to 75% of doctors and 50% of nurses working in the public sector also maintain a private
practice [cited in Ensor (2007)]
New Zealand Among 2626 public-sector specialists, 38% reported secondary private employment. Conversely, among 781 private
specialists 40% reported working in a public hospital (Roche 2009)
Papua New Guinea A report from 1994 describes a trial of private practice in public hospitals (Thomason 1994). A draft World Bank report on
health human resources notes a dearth of reliable new information, particularly on the private sector
Sri Lanka DP is legal and considered to be widespread, but is poorly monitored. There is no information on the proportion of
government doctors engaged in private practice (Ministry of Healthcare and Nutrition 2009)
Thailand A 2001 survey of 1808 government doctors revealed that 69% of them engage in DP, and that most of the 2000 private
clinics in Bangkok are run by public-sector doctors (Garcia-Prado and Gonzalez 2011; Prakongsai et al. 2003). Medical
tourism may drag urban public-sector specialists away from government service (Pocock and Phua 2011). A 2011 report
states that most private clinics are run by public-sector doctors (Supakankunti and Herberholz 2011)
Vietnam The majority of rural doctors (84% of public health staff) is forced to take on private work due to their poor employment
conditions (Dieleman et al. 2003). Many doctors in rural areas open private pharmacies to increase their income
(personal observation based on 7 years of field work)

non-government providers in Cambodia describes extensive
informal private work by government health workers (Soeters
and Griffiths 2003). Secondary data also describe DP in
Cambodia as ‘ubiquitous’ and conclude that in Indonesia and
Vietnam ‘most doctors . . . complement public sector work’ with
private practice (Ferrinho et al. 2004, p. 5). In many LMIC, the
private work includes doctors opening private pharmacies to
sell drugs. Unlicensed pharmacies are a major part of the
unregulated health market in LMIC (Peters and Bloom 2012,
and, based on our observations, in most LMIC in South and
East Asia).
In China, private practice has theoretically been allowed for
decades (Lim et al. 2004; Yang 2006), but with such unattract-
ive limits that most doctors are unaware of the related
regulations (Ying et al. 2003). Moreover, both formal DP and
informal payment of physicians in public facilities are common
(Yang 2006; Ying et al. 2003). While informal payments differ
from DP, they often have the same motivation and adverse
impact on service access. China’s Medical Practitioners Law of
1998 prohibits doctors ‘from utilising their professional pos-
itions to solicit funds and/or goods from patients and receive
illegal funds and/or goods from patients’ (Yang 2006, p. 19).
However, as the price for health services is set artificially low
(Blumenthal and Hsiao 2005; Tian et al. 2008), most doctors
both receive formal payment (salaries and/or a share of hospital
income) and accept informal payment from patients (Fan 2007;
Lim et al. 2004; Yang 2006). Informal payments (red packets)
remain very common in China and are even defended by
consumers (Yang 2006).
Although evidence is lacking, it is almost certainly true that
the scale of DP in South and East Asia is increasing. Total
health spending is rising and health systems are increasingly
characterized by mixed public and private practice (Hort et al.
2011; Hort and Annear 2012; Peters et al. 2001; Ramesh and Wu
2008). Moreover, in their efforts to improve access or achieve
UHC, governments in many nations have committed to
increasing health sector spending and social health insurance
coverage/benefits (High Level Expert Group 2011; Ministry of
Health 2012; State Council 2009; The Economist 2012). More
funding and broader insurance coverage may increase uptake of
not only public-sector healthcare but also private healthcare
among those who can afford it. The balance and hence the
impact on levels of DP will probably vary according to patients’
and insurers’ willingness to pay for private health services.
Moreover, notwithstanding the commitment to UHC, it is not
apparent that regulation and governance of health providers or
commitment to health financing by local authorities in South
and East Asia’s decentralized environments will improve (e.g.
Hipgrave et al. 2012). In such circumstances, it is likely that the
trend which sees public providers undertaking more parallel
private practice with minimal regulation will continue (Ensor
and Weinzierl 2007; Peters and Bloom 2012). In this context,
 DUAL PRACTICE BY DOCTORS IN SOUTH AND EAST ASIA
identifying and funding feasible options for regulation of DP
are increasingly imperative. The options for such regulation are
reviewed below.
Theory and evidence on the outcomes of DP
A considerable amount of theoretical modelling and policy,
practice and economic analysis has been undertaken in relation
to the implications of DP, and options for its regulation
(Berman and Cuizon 2004; Biglaiser and Ma 2007; Bir and
Eggleston 2003; Brekke and Sorgard 2007; Eggleston and Bir
2006; Gonzalez 2004; Gonzalez and Macho-Stadler 2013;
Kiwanuka et al. 2011a). The different models applied in desktop
research on DP have been summarized elsewhere (Berman and
Cuizon 2004; Biglaiser and Ma 2007; Eggleston and Bir 2006).
Moreover, the models based on theories relating to labour
supply, employment satisfaction, bureaucracy, work–leisure
incentives, the healthcare market, principal–agent relationships,
rational profit-maximization and others are usually studied
without reference to context, particularly the different levels of
incentive and regulation in various settings (Berman and
Cuizon 2004; Garcia-Prado and Gonzalez 2011; Kiwanuka
et al. 2011a). These models may therefore be somewhat
removed from many nations’ health systems which, even
within the various income levels, vary widely in the amount
of public–private segmentation and regulation (Bloom and
Standing 2008). However, a recent exception with implications
for the regulation of DP is considered below (Gonzalez and
Macho-Stadler 2013).
Implications of DP for health service equity, quality
and efficiency
The literature is reasonably consistent on the possible broad
impacts of DP, both positive and negative. A recent compre-
hensive review analysed its impact on health service access and
equity, quality of care and efficiency of use of health resources
(Garcia-Prado and Gonzalez 2011) (Table 2). These impacts are
highly simplified and will not apply everywhere. Moreover, the
balance of positive and negative effects will vary widely, and
perspectives on this balance may vary between health autho-
rities and providers, rich patients and poor patients (Berman
and Cuizon 2004).
For example, the incentives will vary widely according to
whether doctors are salaried or receive fee for service payments,
and whether a system of capitation applies. The benefits and
costs will also differ by country, as priorities will be different.
The balance between countries’ desires to improve access and
equity, efficiency and quality of care will vary widely according
to income level and many cultural, political and other factors.
Institutions or agencies such as professional bodies, health
bureaucracies, regulatory frameworks and public feedback will
influence dual practitioners’ behaviour. ‘The implications of DP
that are important to one country are not necessarily important
to others; likewise, the response of each country . . . should be
individually tailored’ (Garcia-Prado and Gonzalez 2011, pp.
271–2).
Overall it seems that in market economies with limited
public-sector capacity, well-regulated DP probably improves
health service access and possibly its efficiency. Much depends
on how similar are the services offered by the public and
707
private sectors (Brekke and Sorgard 2007), the level of incentive
for public-sector workers to also work privately (or the
disincentives to commit to the public sector), the cost of
private healthcare to consumers and the ability of government
to regulate the behaviour of dual practitioners.
DP outcomes among LMIC in South and East Asia
Notwithstanding the above, it is very difficult to write with
confidence about the impact of DP among LMIC in South and
East Asia. This is not only because we lack information from
studies at country level and the tendency of new reports to cite
old reviews and secondary data. It is also because in the rapidly
evolving socio-economic, demographic and political context in
many such nations, the health market is also changing rapidly,
possibly invalidating previous conclusions.
Nonetheless, several studies of dual practitioners in this
region imply that the impacts tabulated above are highly
relevant. In Bangladesh, tolerance of DP was felt to expand
health service availability, including in rural areas where it is
difficult to attract doctors to work in the public sector. It also
enabled workers to minimize the opportunity costs and
economic losses associated with public employment (Gruen
et al. 2002). However, also in Bangladesh, in several states in
India and in Indonesia, rates of absenteeism are high among
public-sector health staff, especially doctors and especially those
known to have a private practice. In India, there was a strong
and direct inverse relationship between rates of absenteeism
and income (Chaudhury et al. 2006).
A study in Cambodia found that DP enhanced the profes-
sional reputation, job security, training opportunities and career
progression of public health workers, as well as increasing their
extremely low public-sector income (Henderson and Tulloch
2008; Soeters and Griffiths 2003).
On the other hand, a study at public hospitals in Thailand
noted opportunistic behaviour among dual practising obstetri-
cians, particularly in relation to rates of operative delivery, and
manipulation of treatment choices for doctors’ convenience
(Hanvoravongchai et al. 2000). DP was tolerated to the extent
that the care of public patients was not compromised. While it
is possible that the observed ‘sorting’ of patients enhanced
overall access to care, it was not clear that public patients had a
voice in demanding appropriate care from ‘absent’ obstetricians,
nor that the care of private patients was optimal.
Thailand, Malaysia and India are also known to receive many
foreign tourists for medical procedures—so-called medical
tourism. There is concern that government tolerance of DP by
state-sector specialists encourages them to prioritize high-
paying foreigners over local public-sector patients (Pocock and
Phua 2011).
China’s laissez-faire approach to regulating public-sector
doctors’ formal or informal payments is a difficult problem
for health authorities. For decades, doctors and hospital
administrators in China have circumvented low, state-estab-
lished fees for healthcare by charging patients for additional
drugs, investigations, procedures and services not covered by
the fee schedule or various other regulations (Blumenthal and
Hsiao 2005; Eggleston et al. 2008; Hu 2010; Lim et al. 2004; Tian
et al. 2008). While private care in public facilities is not
uncommon, additional and informal payments in China often
708 HEALTH POLICY AND PLANNING

Table 2 The impacts of DP on health service access and equity, quality and efficiencya

Potential negative impacts Potential benefits

Health service access Absenteeism and shirking during official work hours. Provides incentives for doctors to stay in the public sector
and equity Patients are forced into the private sector by dual
practitioners preferring private work Reduces the incentive for doctors to request informal payments

Patient diversion from the public to private sector to
increase income
Manipulation of quality of care or wait-times to
encourage private care
Cream-skimming: doctors refer healthier or wealthier
patients to the private sector, leaving the poor with
less access to better care
Decreased service access in rural areas, as dual
practitioners are incentivized to live in urban areas
Technical and cost Free-riding or outright theft of supplies from public
efficiency in use of facilities (drugs, dressings, etc.), or use of public
public resources administration or nursing staff or equipment for
private patients
Treating private patients in public wards
Absenteeism or shirking
Quality of care For a given level of ability, doctors provide better care
(technical, in the private sector; this assumes doctors do not
interpersonal and overwork and provide poor care in both sectors
amenity)
Doctors may provide poorer care in the public sector
to incentivize patients to go private
Absenteeism of senior doctors working in private
leaves public patients to be managed by junior staff
Provides an alternative to crowded public facilities and long
waiting lists
Some types of private work involve public-sector doctors
working in poor rural areas lacking even public facilities
Uptake of private services by the wealthy or the formal sector
reduces pressure on the public system; more effective public-
sector targeting of the poor (although evidence shows
frequent use of private services by the poor, even in urban
areas)
Allowing DP provides incentives for doctors to stay in the
public sector, avoiding staff shortages and non-use of service
capacity
Allowing DP provides incentives for good doctors to stay in the
public sector; however, adequate incentives are needed to
ensure good service
Dual practitioners may provide better care in the public sector
so patients will self-refer to their private practice
Provides a health service alternative to poor public facilities
with old or absent equipment
Enables doctors to learn from a broader range of practice
experience and colleagues

Note: aBased on a recent review (Garcia-Prado and Gonzalez 2011).

benefit the doctor or hospital administration, not the public
purse. Recent reforms aimed at improving equity by improving
access to insurance (Meng et al. 2012), controlling drug profits
(Xiao et al. 2012; Yang et al. 2013) and introducing capitation or
other forms of price control (Yip et al. 2012) are not directly
addressing the need to separate doctors from hospital manage-
ment and financing, and to price services appropriately
(Eggleston et al. 2008; Ying et al. 2003). Moreover, tolerance
for doctors’ opportunism and poor practice standards (Lim et al.
2004) appears to be waning (Li and Zhang 2012; Yang and Fan
2012). Regulating the financing of China’s hospital sector and
doctors’ incomes in particular is proving the most difficult
element of its current health reform (Yip et al. 2012; Barber
et al. 2013).
The most recent evidence on the impact of DP in this region
comes from a comprehensive World Bank review of health
service provision in Indonesia (Rokx et al. 2012). Whilst
recommending further study, its conclusion on DP is reasonably
positive, particularly on the improvement of access to health
services at community level: ‘Indonesia’s impressive gains in
access to health services are explained, in part, by DP. Coupled
with removal of financial barriers, DP has increased the use
both of services at public facilities, puskesmas and pustu, and of
services provided privately by physicians, midwives, and
nurses . . .’ (p. 10). Moreover, although again citing the dearth
of information available, the review is also cautiously positive
on the issue of efficiency: ‘More understanding is needed about
the impacts of the so-called sorting of patients in which the
poor make more use of public services while the more affluent
seek care at private facilities. The initial indication is
that . . . dual practice contributes to the sorting of patients.
‘That may have a positive effect on efficiency, as long as the
non-poor continue to support the public system’ (p. 10). Use of
the public system by the poor has declined. However, the
review speculates that legalized DP may influence doctors to
favour working in urban areas where opportunities for private
work are greater, as identified elsewhere (Hort et al. 2011;
Meliala et al. 2013). And like most of the literature, it also fails
to address quality of care and the relative amount of time spent
by dual practitioners with their public and private patients.
Context and options for regulating DP
The context for regulation of DP in LMIC
The context for regulation of DP in LMIC is well summarized as
follows: ‘Since the early 1980s, economic and structural crises
have exposed the weak institutional capacity of the public sector
in many countries . . . . [Growing] demands and structural reform
policies have left the State overworked and underfunded . . . [re-
sulting in] the rapid growth of non-State provision to fill gaps in
supply. This has been both a formal process, sanctioned by the
State through contracts with not-for-profit providers and legis-
lation allowing development of the private healthcare market, and
an informal process with burgeoning numbers of unlicensed
practitioners, pharmacists and drug pedlars increasingly
 DUAL PRACTICE BY DOCTORS IN SOUTH AND EAST ASIA
providing services. In addition, public-sector providers have
emerged to sell their services in an unorganised market. The
balance between State and market has undergone a radical shift
with interpenetration between market-type transactions and
State institutions, operating to a large extent through informal
arrangements.’ (Bloom et al. 2008, p. 2079)
Concern about the regulation of DP is so great that it was
recently rated second among priorities for research into human
resources for health in LMIC (behind how to encourage health
workers to stay in rural areas) (Ranson et al. 2010). Regulation
of practitioners’ activities does indeed constitute the major
problem with DP in LMIC, mainly because of the weak capacity
of governments, health authorities and professional bodies to
undertake regulation in such locations (Ensor and Weinzierl
2007; Garcia-Prado and Gonzalez 2011), including in South and
East Asia (Hort et al. 2011; Hort and Annear 2012; Peters and
Bloom 2012; Peters et al. 2001; Ramesh and Wu 2008). As
a result, there is a high risk for the negative aspects of DP
(Table 2) to predominate.
Options for regulation of DP
Several reviews of DP have paid attention to its regulation
(Garcia-Prado and Gonzalez 2007, 2011; Kiwanuka et al.
2011a), and noted major differences between developed and
other nations. However, as was noted earlier in relation to the
qualitative impact of DP in LMIC, there is little evidence to
recommend any particular strategy. Indeed, not one article has
reported research on the relative benefit of one approach to
regulation of DP in LMIC over another, or has even evaluated
any such approaches (Kiwanuka et al. 2011b), although a new
article compares approaches to DP in three disparate health
markets in Africa (Russo et al. 2013).
The options described for regulation of DP are summarized in
Table 3. They may be divided into those which place limits on
providers, or incentivize or reward them. An early review of DP
summarized the authors’ perspectives on its regulation: ‘The
real issue is what types of private practice should be allowed in
order to minimize conflicts of interest, and what . . . regulatory
mechanisms can be introduced to isolate [behaviours] asso-
ciated mostly with lack of regulation rather than just with low
income . . . . Efforts should be undertaken to ensure multiple
and independent channels of accountability, by means of
penalties for not satisfying contractual obligations, through
channels of accountability to professional councils and associ-
ations and to the public’ (Ferrinho et al. 2004, p. 13).
A recent report models options for regulation of DP in the
context of varying levels of private income, and considers both
developed and developing economy contexts (Gonzalez and
Macho-Stadler 2013). The authors assessed the costs of three
policy approaches: banning DP, providing incentives to pro-
viders to work exclusively in the public sector, and limiting DP
income or activity. The model suggested that banning DP is
uneconomical, as allowing it reduces public salaries and
theoretically enables health authorities to purchase additional
services. Equally, offering exclusive contracts is not as finan-
cially effective as allowing limited DP. Finally, limiting DP is
more effective than limiting income, as the latter impacts
mainly high-earning practitioners, while the former impacts all
providers.
709
In LMICs, the results of the model depend heavily on the
relative appeal of work in the private sector. Where it is very
attractive (offers much higher income), the costs of limiting or
banning DP for the health authority will be high; but where
private practice has low appeal, it is more cost effective for
health authorities to induce practitioners to operate exclusively
in the public sector. This is evident in the comparison of
salaries, patterns of private practice and the availability of
exclusivity contracts in three African countries (Russo et al.
2013), although the ability to regulate exclusivity may be low in
the poorest LMIC.
While the model focuses on economic outcomes, including
minimizing the cost of production (i.e. providing healthcare) for
the health authority, it provides a basis for the consideration of
policy and regulatory options in the LMIC context. A framework
for such options may be developed, but it should be acknowl-
edged that even among high-income nations there is definitely
no one-size-fits-all approach. Differences in local institutional
frameworks and public service values pertaining to the health
sector and providers will influence the available choices.
Three broad options are available:
(a) Taking no action. This is equivalent to allowing unregu-
lated DP, and is likely to allow proliferation of the negative
outcomes and abuses of both public and private practice
that have been noted in the literature. It is not
recommended.
(b) Banning or limiting DP. Both the regulatory literature and
modelling (Gonzalez and Macho-Stadler 2013) suggest
that this is difficult to enforce and more costly to
government for a given level of service provision.
However, if feasible, limitation of DP (income, location
or time spent) is an option for consideration.
(c) Allowing DP with regulation of behaviour in the public
and private spheres, as appropriate to the situation and
local capacity to enforce. This requires consideration of
local context which varies by location (demands and
opportunities for private practice), local regulatory capacity
and practitioner category (demands and income opportu-
nities vary for different types).
In Table 4, two measures are used to categorize different
contexts for DP, and the resulting options for regulation. The
first adapts the concept of ‘attractiveness’ of private practice, a
key determinant in the recent modelling exercise (Gonzalez and
Macho-Stadler 2013), and uses the proportion of private income
as the indicator. Higher proportions of private sector income
indicate higher opportunities for private practice, and higher
demand for the practitioner type. Data from Indonesia (Meliala
et al. 2013) and elsewhere indicate that the proportion of
doctors’ income from private practice can exceed 75% of the
total. The second key factor is the proportion of private sector
income from insurance payments. While still low in most Asian
LMIC, this is likely to increase with gradual introduction of
UHC, providing new opportunities for regulatory control.
Broader issues related to regulation of physicians in LMIC
The regulation of DP is only one example of the broader issue
of regulation and stewardship of physicians in LMIC. Despite
their evident weak capacity to do so, governments in LMIC

Table 3 Options described for the regulation of DP, with reference to LMIC
Regulatory option
Restrictions
Banning DP
Restricting doctors’ private
activities or earnings
Self-regulation by the pro-
fession and regulation by
peers and the public
Rewards or incentives
Incentivizing doctors to
work exclusively in the
public sector
Allowing or tolerating pri-
vate practice or informal
payments in public
facilities
Raising public-sector salaries
Global experience
Canada, the USA, Greece, certain states in India and
for certain practitioners in some other nations
(Berman and Cuizon 2004; Garcia-Prado and
Gonzalez 2011; Kiwanuka et al. 2011a,b)
Several European nations including the UK, France,
Austria and Italy (Garcia-Prado and Gonzalez 2011)
In developed countries, professional associations and
peer pressure, accreditation and other means of
performance management can impact public-sector
activity and doctors’ engagement in DP
Reported in European nations, the UK, Thailand,
India and Cambodia through salary supplements or
promises of promotion (Garcia-Prado and Gonzalez
2007, 2011); now being piloted in Indonesia
Common in Australia and some European countries
(Garcia-Prado and Gonzalez 2011). Piloted in
Malaysia (Ramesh and Wu 2008) and known in
some places in Africa (Russo et al. 2013). Legal for
some doctors in Indonesia. In LMICs, informal
payments are widespread
In two surveys doctors said that they would drop DP
for more salary (Garcia-Prado and Gonzalez 2007;
Gruen et al. 2002); a model suggests the same thing
(Brekke and Sorgard 2007)
710
Commentary
Only feasible where government or professional regulation is independent and effective. This does
not apply in many LMIC nor in some developed nations where bans were attempted. Banning may
also lead to brain drain as doctors leave the public sector for more lucrative private work, limiting
public access to their services; or it may encourage corrupt and informal payments to public
physicians (Garcia-Prado and Gonzalez 2007)
The government restricts the maximum amount of private services doctors can provide or private
income they can earn. This demands a high level of accountability and effective regulation,
including of hours worked and services provided. No experience with this has been reported from
HEALTH POLICY AND PLANNING
LMIC (Garcia-Prado and Gonzalez 2007, 2011)
In LMIC, especially in South and East Asia, unregulated growth of the private sector has not been
matched by improved regulation (Balarajan et al. 2011; Gruen et al. 2002; Sheikh et al. 2011) and
professional associations have been unhelpful (Hort et al. 2011; Hort and Annear 2012). Laws to
regulate marketized health sectors are weakly implemented (Bloom 1998; Yang 2006; Ying et al.
2003), and there is a risk of regulatory capture (Ensor and Weinzierl 2007). However, moves to
improve accreditation in LMIC are being introduced (Anand et al. 2008; Garcia-Prado and Gonzalez
2007). Peer review and pressure from civil society are effective in regulating provider behaviour
and standards in developed countries (Ferrinho et al. 2004), but again rely on the independence of
the review and the availability of effective channels for complaint (Peters and Bloom 2012)
These schemes are reported difficult to implement and to have resulted in negotiations between
provider associations and government which either favoured or were simply ignored by doctors
(Garcia-Prado and Gonzalez 2007). They also require well-functioning and transparent health
financing (Ferrinho et al. 2004), and so are not widely reported from LMIC. However, where
salaries are very low and incentives are weak, they may be effective (Johnston and Ozaltin 2012;
Soeters and Griffiths 2003)
Apart from informal payments, this has the advantage of being convenient and easier to supervise,
but may yield conflict of interest and competition between public and private patients for doctors’
time and hospital resources. Transparent supervision is required and reports from LMIC are lacking
(Garcia-Prado and Gonzalez 2007) although examples exist in Africa (Russo et al. 2013) and
Malaysia (Ramesh and Wu 2008). Experience in Indonesia suggests that it improves access (Rokx
et al. 2012)
Intuitively effective, particularly if non-financial incentives are provided in parallel. The Greek
experience reportedly failed because the salary remained insufficient (Garcia-Prado and Gonzalez
2007). Estimates of the costs of ‘buying off’ dual practitioners with higher salaries have been
calculated in some LMIC (including Cambodia) (Garcia-Prado and Gonzalez 2007; Soeters and
Griffiths 2003), but were prohibitive. However, another report from Cambodia suggests that it can
be effective (Johnston and Ozaltin 2012)
 DUAL PRACTICE BY DOCTORS IN SOUTH AND EAST ASIA 711

often overestimate their ability to regulate physicians’ and other Annear 2012; Rokx et al. 2012; Yip et al. 2012). It is very likely
providers’ behaviour, particularly in decentralized settings; that much of this private work will be undertaken by public-
there are many examples of the result of weak regulation of sector physicians who prefer the benefits of working in both
physicians in South and East Asian nations (Ensor and sectors. As changes to the provision of healthcare evolve, the
Weinzierl 2007; Teerawattananon et al. 2003), with major options for regulation of DP described above may be considered
implications for population health. Moreover, regulation by in the context of new approaches to the governance and
professional associations is usually lacking in LMIC, or captured stewardship of the health sector overall.
by individual or collective self-interest (Ensor and Weinzierl
2007; Teerawattananon et al. 2003). Notwithstanding recent
Responsive and de-centred regulation
moves by Indonesia (Indonesian Medical Council 2007) and
In one such approach, the regulatory strategies required vary
other national authorities to improve the behaviour of phys-
according to the engagement of providers, as represented by the
icians’ associations, calls for a greater role of such bodies in
pyramid shown in Figure 1.
LMIC (Jan et al. 2005) may be premature.
At the top, providers are either least compliant or least
Factors that may change this include increasing democratiza-
engaged and old-style command and control are required,
tion and press freedom, education and literacy rates, exploding
assuming of course, there is capacity to implement it. Further
options for social discourse and the rise of civil society, and formal
down, meta-regulation (oversight by independent authorities
models not dominated by professionals (such as public participa-
which can draw on reports on provider behaviour from
tion on regulatory bodies). These factors are likely to have a major
professional associations, consumer groups, auditors and other
impact on the ability of the public to judge and inform others
sources) broadens the options for oversight. Reports by meta-
about the behaviour of individual practitioners, and also the
regulators are integral elements of another regulatory concept
agencies representing them and the facilities where they work.
which ‘de-centres’ responsibility for regulation from govern-
Engagement of the public was a major strength of Thailand’s
ment (Black 2002). Participation in self-regulation and market
health reforms (Ramesh and Wu 2009), and patient advocacy
mechanisms are further down the pyramid, and require that
organizations elsewhere have influenced right-based approaches
providers can be trusted to behave in ways that meet both
to health service provision (see www.patientsorganizations.org/).
population health needs and professional standards and
It is too early to measure the influence of these changes in South
expectations. Currently, the ability of LMIC to implement
and East Asia, and in poor rural areas communities may still lack
either meta-regulation or the more responsive regulation at
both provider choice and the ability to communicate. However,
the bottom of the pyramid is weak, but with the rise of civil
recent incidents in China (Li and Zhang 2012; Yang and Fan 2012)
society and strengthened professional associations, this may
and the rise of medical lawsuits in the region (Ensor and Weinzierl
change.
2007; Teerawattananon et al. 2003) imply that expectations of
De-centring replaces the notion of a regulatory state with one
physician behaviour may be rising with population health literacy.
of a regulatory society. Community associations, advocacy
Indeed, an increasing role for the public and other groups in
groups, etc. act as both regulators and the regulated, involved
regulating physician behaviour or in health governance more
in and responding to exchange of information that influences
broadly has been recommended in several commentaries
regulatory outcomes (Akhtar 2011). The state and even profes-
(Bloom et al. 2008; Ensor and Weinzierl 2007; Ferrinho et al.
sional associations in turn are relieved of their pre-eminent
2004; Garcia-Prado and Gonzalez 2011; Jan et al. 2005;
responsibility for regulation, detecting deviations and penalizing
Kickbusch and Gleicher 2012; Nodzenski 2012), and by two
violators. At a higher level, that of governance of the health
eminent researcher/commentators on health and society:
sector, this concept has been taken up by WHO (Kickbusch and
‘Bringing order to unregulated health markets will take broad
Gleicher 2012), which recently described a ‘diffusion of
coalitions that go beyond governments and health profes-
governance from a State-centred model to a collaborative one,
sionals . . . . [including] citizen groups, pharmaceutical compa-
in which governance is co-produced by a wide range of actors
nies, information-technology and telecommunications
at the level of the State . . . , society . . . and supranationally’ and
companies, and . . . informal healthcare providers. Such coali-
‘the new governance dynamics of diffusion, democratization
tions might coordinate disease-surveillance systems, informa-
and shared value’ (p. viii). This has also been discussed
tion networks for pricing and sourcing quality drugs, and
specifically in the South and East Asian context in relation to
patient-referral mechanisms’ (Peters and Bloom 2012, p. 164).
the potential for civil society to overcome the inertia of some
However, this does not absolve governments and professional
government and inter-government processes (Nodzenski 2012).
bodies from establishing and maintaining accreditation sys-
tems, another form of regulation, examples of which are However, as implied earlier and as extensively reviewed recently
emerging in a number of LMIC, including in South and East (Mansuri and Rao 2012), these concepts assume adequate
Asia (Anand et al. 2008; Ensor and Weinzierl 2007; Garcia- representation of those with the most to gain (women, the poor
Prado and Gonzalez 2007, 2011). or the otherwise marginalized), and means to avoid regulatory
capture (Bolsewicz Alderman et al. 2013).
The concept of de-centring also overcomes problems com-
Future approaches to regulation of DP in South monly associated with state-centred regulation (Black 2002):
and East Asia weak or inappropriate laws; lack of information or knowledge
Rapid expansion of the private health sector in South and East about what is being regulated; implementation failure and
Asia is likely to continue as demand for services increases with motivation failure (the capturing of regulation by special
economic growth and the rise of the middle class (Hort and interest groups). It acknowledges the complexity and autonomy
712 HEALTH POLICY AND PLANNING

Command and control

Licence suspension or cancellaon
Threat of civil or criminal legal acon
Revalidaon of pracce standards or qualificaon

Meta-regulaon
Funding agreements
A public complaints process
Open access performance appraisal
Mandatory self-regulaon or connuing educaon
External pracce auding or clinical governance
Protecon for those reporng adverse events
Mandatory adverse event invesgaon

Self-regulaon
Commitment to connuing educaon
Voluntary accreditaon processes
Targets and benchmarking
Public and peer review of pracce
Public disclosure of related issues

Market mechanisms
Compeon
Performance-based payment or contracts
Providing consumers with performance appraisal

Voluntarism
Commitment to uptake of new technology
Parcipaon in clinical research or protocol evaluaon
Personal or personally-arranged performance monitoring or connuing educaon

Figure 1 The regulatory pyramid and examples of safety and quality mechanisms (Braithwaite et al. 2005; Healy and Braithwaite 2006)

of the systems being regulated and the variety of perspectives
on what regulation should achieve.
These approaches open up exciting new possibilities for the
regulation of DP, including in LMIC where the state often
lacks authority and capacity. They give voice to consumer
groups and legitimize a role for non-government actors. On the
other hand, they remain concepts, not governed by guidelines
or recommended processes (Bolsewicz Alderman et al. 2013),
and at risk of vague interpretation. Moreover, there remains
considerable scepticism about the ability of the public to
regulate doctors working in the private sector (Schuftan and
Unger 2011).
Regulation in the context of evolving health markets
As suggested in Table 4, regulation of physicians may evolve as
new, market-influenced options open up for government or for
those involved in provider stewardship. These alternatives may
take into account the geographical distribution of doctors;
consumer demand and ability to pay and the availability of new
incentives related to UHC and social health insurance. The
literature has not yet considered DP in this global, health
market context, but related research is imperative given the
rapid evolution of health markets in comparison to govern-
ments’ ability to incentivize physicians to attend to the public
sector.
For example, the introduction of social health insurance or
subsidies like conditional cash transfers is likely to encourage
patients back into the public sector and increase the use of
private providers, as occurred in Indonesia (Triyana 2012),
Thailand (Ramesh and Wu 2008) and Taiwan (Lu and Hsiao
2003). In these circumstances, insurance funds can assume an
important regulatory role by rewarding good quality of care or
services in underserved locations (Lu and Hsiao 2003), and
penalizing poor quality of care or absenteeism by dual practi-
tioners. As UHC increases demand, the right mix of perform-
ance or promotion incentives, and eligibility for insurance
payments and reputation-building opportunities might be
enough to counter doctors’ preference for urban private
 DUAL PRACTICE BY DOCTORS IN SOUTH AND EAST ASIA 713

Table 4 A new approach to policy and regulatory options for DP in LMIC

Proportion of private Proportion of Regulatory options

income for provider private payment
category (%)a coming from
insurance schemes
<25 High Restrict amount/category of insurance payments to public practitioners working in private
practice
Low Increase public salary/incentives to create fully public category of providers
Provide supervised environment for public providers to undertake private practice within
public facilities
25–75 High Restrict amount/category of insurance payments to public practitioners working in private
practice
Low Provide guidelines for professional conduct of dual practitioners in private practice, with
enforcement through professional associations, licensing, and complaints
Improve supervision and monitoring of professional conduct by dual practitioners in public
facilities, with salary linked to performance and actual hours worked
>75 High As above plus: impose conditions on private facilities which wish to receive insurance
payments that require them to monitor and report on abuse of dual practice
Low As above plus: consider shift to contracting of private providers to provide services in public
facilities rather than salaried arrangements

Note: aThe proportions of private income will vary by location within a country, and by practitioner type.

Box 1 Indicators informing approaches to the regulation of DP

 The balance of health service supply and demand, including influences (such as the attractiveness of private practice) on
the distribution of doctors across urban and rural areas.
 The capacity of patients to pay, and the coverage and benefit of social health insurance for those who cannot afford
public-sector fees or private care.
 The capacity of social health insurers to play a role in financial mechanisms of regulation (their independence; negotiating
power; funding and solvency, etc.).
 The role and character of professional associations in country, and the possibility of them collaborating effectively in, and
not capturing regulatory processes.
 The engagement of the public and the possibility of civil society being effectively involved in regulation of health providers
and facilities.
 The existence of independent regulatory agencies, representing government and with authority to recommend or
implement sanctions if appropriate.
 The availability or possible creation of private services within public health facilities, and agreements with doctors on their
financing and management.
 The availability of legal leverage over hospitals or doctors, through mechanisms like periodic accreditation, maintenance
of professional standards, sanctions, etc.
 The decentralization of power and financing in the health sector, and local capacity.

practice. Insurance payment mechanisms, such as capitation or
case-mix, can limit over-servicing and excessive fees, and
improve quality of care, particularly when administered by
single national insurers or other government purchasing (Evans
et al. 2012; Lu and Hsiao 2003; Ramesh and Wu 2009).
Taiwan, Thailand and also Singapore provide examples of
UHC at an affordable cost through strong regulation involving
financial mechanisms (Evans et al. 2012; Lu and Hsiao 2003;
Ramesh and Wu 2009). By contrast, in China social health
insurance has improved financial access and service uptake, but
not financial protection. Total health expenditure there is
increasing at an average of 17% per year (Meng et al. 2012;
Yip et al. 2012), and government-subsidized insurance and
other subsidies have not reduced opportunistic behaviour by
physicians. Similarly, in Indonesia, whilst government support
for the health sector is increasing, dual practitioners are
increasingly servicing the private sector (Hort et al. 2011;
Ramesh and Wu 2008). This does not rule out efficiency in
UHC, but the provider payment must be attractive enough to
encourage dual practitioners to provide services that are
affordable to the poor and to rural communities.
Controlling dual practitioners’ behaviour through market
mechanisms may be more important than engaging the public
or professional associations. Again, this will require future
714 HEALTH POLICY AND PLANNING
revisiting of the relative roles of different stakeholders on
provider regulation.
Selection, monitoring and evaluation of regulatory mechanisms
Finally, LMIC introducing new regulation of DP, in South and
East Asia and elsewhere, must select the best indicators of
progress and success. Box 1 summarizes the characteristics that
should assist decisions on which regulatory mechanisms to
pursue, or which elements to improve.
Once the balance of restrictions and incentives has been
selected and funding is assured, a system of supervision,
monitoring and evaluation is also needed. Human resource
management and administrative reporting in LMIC are typically
weak, so it is likely that improvement of this will involve mixed
qualitative and quantitative methods, and will be part of a
general strengthening of health sector oversight. These methods
might include periodic reports by the various regulatory
agencies assigned by government to monitor and evaluate
doctors’ behaviour; the establishment and reporting of a
functioning complaint service for patients; independent com-
munity surveys using cheap methods such as citizens’ score
cards (Brixi 2009) or social audits; occasional key informant
interviews or focused group discussions on doctors’ behaviour,
or requests for community input using new media; quantitative
monitoring of doctors’ case load and mix, workplace, income
and fees, hospital revenue and charges, insurance payments,
etc.; monitoring of absenteeism, opportunistic referral of public
patients to the private sector or private use of public facilities by
dual practitioners and occasional surveys of household access to
health services, including by specialists.
Suggestions for future research
The dearth of information on the scale and impact of DP in
South and East Asia, and the need for consideration thereof in
the reform of health systems among LMIC in the region
underscore the need for carefully designed prospective research
and piloting on this topic. The recent evaluation of DP in the
context of three health markets in lusophone Africa is a good
example of such research (Russo et al. 2013). Apart from
descriptions of the prevalence of DP and public–private income
profile of dual practitioners in the region, the questions of most
interest for health regulators would include the major incen-
tives for or enablers of DP; how such ‘medical entrepreneur-
ship’ could be harnessed more equitably (Ranson et al. 2010)
and the role of insurers or financial mechanisms, professional
associations and the public in regulating provider behaviour
and influencing geographic distribution. The latter is particu-
larly important in mixed systems where the private sector has
been allowed free rein (Tangcharoensathien et al. 2011). Nearly
all of the region’s health systems are in constant evolution,
with piloting and evaluation of various aspects of policy and
implementation. The regulation of DP should be no exception
to this process, but lessons from both LMICs and developed
states in the region should also be considered.
Acknowledgements
The authors are grateful for suggestions on another version of
this manuscript by Dr Matthias Nachtnebel of the Nossal
Institute.
Funding
The work reported in this article was funded by an agreement
between the Nossal Institute and the Asia Pacific Observatory
on Health Systems and Policies based at the WHO Western
Pacific Regional Office.
Conflict of interest
None declared.
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