Table 1. Dual practice typology: examples of local conditions, consequences for UHC goals and policy options.
| Local conditions | Types of dual practice observed | Country example | Potential negative consequences for UHC goals | Type of regulatory options |
|---|---|---|---|---|
| – Limited ability and willingness to pay for health services – Limited private sector development – Blurred boundaries between public and private, large informal private sector – Poor regulation and enforcing capacity |
Pervasive and unregulated dual practice, present in all its forms – outside, beside, within, as well as integrated to public services24 |
Bangladesh,21 Guinea Bissau,24 Nepal, Peru19 |
– Reduced provision of free-of-charge services – Absenteeism and shirking by public sector health workers – Illegal charges in public facilities |
– Introduce top-down regulation limiting health workers’ dual practice – Inform public patients about fees and charges, including free-of-charge services – Separate public and private services |
| – Rising incomes and ability to pay for health services – Improved governance, regulatory and implementation capacity – Incipient formal private sector clearly separated from the public sector |
Dual practice to some extent regulated, and present outside and beside and at times within public services, but not in its integrated form |
Cabo Verde, China,31 Mozambique,24,25 South Africa,22 Thailand27 |
– Poor quality public services – Diversion of public patients to private practices – Public sector personnel disproportionally distributed in facilities or locations in which dual practice is possible – Limited range of public health services |
– Allow regulated dual practice outside and inside public facilities in specific places and times – Monitor the implementation of regulation – Offer exclusivity contracts – Encourage self-regulation by professional bodies |
| – High-income – Sophisticated health systems and regulatory capacity – Established private sector |
Regulated dual practice, allowed outside, and in some instances, beside public services | Australia, Canada,8 Italy, Portugal,12 Spain,16 United Kingdom15 | – Poor quality public services – Diversion of public patients to private practices – Public-sector health workers move to the private sector |
– Market-based or financial interventions – Provide incentives for positive behaviour – Regulation by professional bodies – Provide incentives to the private sector when outsourcing services – Establish contracts with private providers |
UHC: universal health coverage.