Table 3.

The advantages and disadvantages of policy interventions for addressing physician retention in the public sector

Policy themes	Policy interventions	First author	Disadvantages (illustrative quotes)	Advantages (illustrative quotes)
Regulatory controls	Banning dual practice	Gonzalez [8], Jan [16]	“The more able ones tend to be more involved in the private sector since their ability allows them to get a higher return. The less able tend to combine both public and private activities if dual practice is allowed, or work only in public practice when this is not the case. When dual practice is forbidden, the population of physicians working the public sector for a given salary decreases” [8]. “In addition, when the public and private sectors do not share physicians, higher private sector earnings are expected to attract more highly skilled physicians, leaving those of less ability in the public sector” [8]. “In practice, bans do not prevent these activities, but instead take them outside the regulatory and policy jurisdiction of government” [16].
	Permitting dual practice	Gonzalez [21], Eggleston [4], Jan [16], Abdul Rahim [2], Gonzalez [8]	“We found that the physician’s dual practice has conflicting effects. On the one hand, his interest in curing patients and gaining prestige, generates an over–provision of health services” [21]. “These theoretical predictions stand at odds with much of the policy discussion, which tends to assume that allowing public sector physicians to earn private revenue will harm the quality of services provided in the public sector, although it may benefit private sector patients and physicians” [4]. “Since monitoring of provider time and effort is costly, often only minimal presence in a public practice is required to access the non–pecuniary benefits of public employment (eg, official salary and civil servant fringe benefits such as public housing)” [4]. “A physician with both public and private practices may use public resources to treat private patients, whether by lifting supplies (eg, gauze, medications) or treating patients at the public facilities without paying any rent or charge for such use” [4]. “Furthermore, dual practice providers may have incentives to induce demand for private practice services. The propensity of health care providers to over–refer to facilities in which they have financial interest is widely recognized” [4]. “However, dual job holding by public sector health professionals is potentially a problem because it may create inappropriate incentives as the boundaries between a public health professional’s day–to–day job and his or her private practice can become blurred” [16]. “Firstly, it can encourage the misappropriation of scare public sector resources into the private sector” [16]. “The second reason why private practice by public health workers has been posited as a problem is because it may lead to doctors diverting patients from public facilities into private services” [16]. “Also, no evidence thus far supports dual practice as a method of improving equitable delivery of healthcare” [2].	“On the other hand, if the HA is able to control these incentives to over–provide services, then it can benefit from the physician’s increased interest in doing more–accurate diagnosis” [21]. “Interestingly, some consistent results emerge from these diverse conceptualizations: (1) allowing dual practice may improve social welfare; and (2) allowing dual practice may improve the quality of public services, under specific circumstances” [4]. “Allowing dual practice may enable the government to recruit quality providers at a modest budgetary expense” [4]. “To the extent that physicians attempt to build a good reputation that will enhance future private practice revenue, allowing dual practice also gives a kind of performance–based incentive for physicians to exert effort” [4]. “From the point of view of the public sector, allowing health professionals to engage in private practice can be a means of minimizing the budgetary burden required to retain skilled staff” [16]. “In contrast to these measures, the potential value of recognizing and legitimizing dual practice is that, at one level, it enables some degree of control to be exercised over quality and safety” [16]. “The importance, therefore, of providing official recognition is that it allows policy–makers to incorporate such activity within the bounds of its regulatory and policy jurisdiction” [16]. “Practitioners would continue to enjoy the prestige of public sector positions and ongoing career development while mitigating economic opportunity costs otherwise incurred if solely servicing the government...” [2]. “This implies that dual practice might be desirable because it allows the HA to reduce the wage needed to retain physicians working in the public sector” [8].
	Limiting dual practice	Gonzalez [8], Gonzalez [21], Eggleston [4]	“Overall, profit limitations have a milder effect on the amount of dual practice performed by physicians.” [8]. “Secondly, focusing on limiting policies, we have shown that limiting income is always less effective than limiting involvement” [8]. “Therefore, our conclusion is that this sort of regulatory policy may be beneficial from a social point of view, although it can generate as a non–desired effect a reduction on physicians’ incentives to perform accurate diagnoses” [21]. “In either case, the limits on dual practice only affect behavior if physicians anticipate that the contractual terms will be enforced” [4].	“… as it only affects the high skilled physicians that are compelled to reduce private involvement in order to satisfy their earning constraint” [8]. “In contrast, policies that limit involvement directly target the intensity of dual practice and are therefore more effective in limiting its costs” [8]. “We have shown that if physicians’ payment contracts include proper incentives, then limiting physician’s private income can be optimal, whereas introducing exclusive contracts is always useless” [21]. “Better ability to monitor and contract can minimize shirking on public practice duties, appropriating supplies and using public equipment without paying rent. Transparent contractual relationships between public and private practices, such as rental of facilities and subcontracting for specific services, can offset many of the costs associated with allowing the same physicians to practice in both” [4].
	Self–regulation	Jan [16]	“Indeed, in certain circumstances, this could lead to an incentive to “overprovide” quality in the public sector, particularly, in high–income settings, because the health facility rather than the individual doctor bears the cost of providing additional quality” [16]. “Consequently, there is a certain trade–off between quality and access to health care because higher–quality services will tend to be more costly, and thus specific measures addressing financial access need to be considered when proposing such forms of self–regulation” [16].	“Self–regulation of this nature works because significant weight is given to an individual’s reputation as a doctor in public practice, which influences his or her income–generating capacity in private practice” [16]. “The role of such regulation could be viewed as addressing the uncontrolled proliferation of private providers and, in a sense, establishing barriers to entry” [16]. “The rationale for professional self–regulation is that it recognizes the collective interest in instituting some form of cooperative behavior among individual agents” [16].
	Compulsory services	Abdul Rahim [2]	“The evidence base on effectiveness of compulsory services to date remains lacking” [2].
Incentives	Offering exclusive contracts	Eggleston [4], Gonzalez [21], Gonzalez [8]	“The problem with this measure is that in the context of the strict resources constraints that often exist within low– and middle–income countries, such payments can be prohibitively costly–particularly if incomes in the private sector are high and thus there is a need for greater levels of compensation” [4]. “We have shown that if physicians’ payment contracts include proper incentives, then limiting physician’s private income can be optimal, whereas introducing exclusive contracts is always useless” [21].	“Exclusive contracts, however, are shown to be a useful tool for cost–containment when physicians are paid on a salaried basis” [21]. “This illustrates how exclusive contracts offer greater flexibility for the HA to mitigate loss of productivity associated with dual practice, which makes the HA less interested in banning dual practice when rewarding policies are available” [8].
	Offering rewarding contracts	Gonzalez [8], Abdul Rahim [2], Jan [14]	“Rewarding policies, ie, those that pay an extra amount to physicians who give up their private practice, are only desirable when limitations are difficult to enforce” [8]. “The Commission determines salaries for public sector workers and hence deems it unfair to selectively raise wage of health employees and exclude other sectors” [2]. “The most immediate and overriding constraint on the feasibility of this option however is the cost to the public sector. In circumstances where there are tight resource constraints in the public sector, this option is unlikely to be feasible” [14].	“Remuneration should reflect the level of work responsibility and be deemed fair vis–à–vis other sector counterparts to ensure continued attraction and retention of staff” [2]. “Furthermore, a mix of payment mechanisms such as time–based, service–based and population–based is linked with enhanced provider performance” [2]. “On this basis, the incentive to shift effort from public–sector to private–sector work would be offset by making remuneration for public practice, like that of private practice, related to effort or output” [14].
	Providing professional development opportunities	Abdul Rahim [2]		“Continued education, interactive training and professional development geared towards the priority health conditions and needs of the local population improves health worker competency and motivation” [2].
Management reforms	On–boarding programs	Heponiemi [22]	“Organizational justice was not able to buffer the association between being or becoming a new public GP and turnover intentions” [22]. “Our results showed that new public GPs had 2.6 and those who stayed as public GPs both times had 1.6 times higher likelihood of having turnover intentions compared to those who stayed at other positions both times” [22].	“Our results suggest that by improving organizational justice primary care organizations could improve GP’s job satisfaction and involvement and consequently maybe increase GP work’s attractiveness as a career option. For example, organizations could invest in supervisor training, particularly because previous studies have shown that leaders can be trained to act in a more just manner and this in turn improves subordinates’ attitudes and behavior” [22].
	Organizational justice	Cohn [23]		“One year after the on–boarding program was initiated, not a single new physician left BMG, which is a sharp turnaround from the 10 percent loss the group experienced previously” [23]. “Since the onboarding program began, however, everyone who has worked with the new physicians (including allied health professionals) has noted an improvement in physician morale and in the practice environment” [23].