TY - JOUR
T1 - Advancing the application of systems thinking in health
T2 - Exploring dual practice and its management in Kampala, Uganda
AU - Paina, Ligia
AU - Bennett, Sara
AU - Ssengooba, Freddie
AU - Peters, David H.
N1 - Funding Information:
This paper is part of the Thematic Series entitled: “Advancing the application of systems thinking in health.” The Series was coordinated by the Alliance for Health Policy and Systems Research, World Health Organization. The publication of the Series and the associated capacity building and dissemination activities were carried out with the aid of a grant from the International Development Research Centre, Ottawa, Canada. The authors would also like to give thanks to Ms. Taghreed Adam and to the two reviewers of the paper, for their insightful suggestions. Support for Sara Bennett and David Peters was provided through the Future Health Systems Research Programme Consortium, funded by the United Kingdom’s Department for International Development (DFID).
Publisher Copyright:
© 2014 Paina et al.; licensee BioMed Central Ltd.
PY - 2014/8/18
Y1 - 2014/8/18
N2 - Background: Many full-time Ugandan government health providers take on additional jobs - a phenomenon called dual practice. We describe the complex patterns that characterize the evolution of dual practice in Uganda, and the local management practices that emerged in response, in five government facilities. An in-depth understanding of dual practice can contribute to policy discussions on improving public sector performance.Methods: A multiple case study design with embedded units of analysis was supplemented by interviews with policy stakeholders and a review of historical and policy documents. Five facility case studies captured the perspective of doctors, nurses, and health managers through semi-structured in-depth interviews. A causal loop diagram illustrated interactions and feedback between old and new actors, as well as emerging roles and relationships.Results: The causal loop diagram illustrated how feedback related to dual practice policy developed in Uganda. As opportunities for dual practice grew and the public health system declined over time, government providers increasingly coped through dual practice. Over time, government restrictions to dual practice triggered policy resistance and protest from government providers. Resulting feedback contributed to compromising the supply of government providers and, potentially, of service delivery outcomes. Informal government policies and restrictions replaced the formal restrictions identified in the early phases. In some instances, government health managers, particularly those in hospitals, developed their own practices to cope with dual practice and to maintain public sector performance. Management practices varied according to the health manager's attitude towards dual practice and personal experience with dual practice. These practices were distinct in hospitals. Hospitals faced challenges managing internal dual practice opportunities, such as those created by externally-funded research projects based within the hospital. Private wings' inefficiencies and strict fee schedule made them undesirable work locations for providers.Conclusions: Dual practice prevails because public and private sector incentives, non-financial and financial, are complementary. Local management practices for dual practice have not been previously documented and provide learning opportunities to inform policy discussions. Understanding how dual practice evolves and how it is managed locally is essential for health workforce policy, planning, and performance discussions in Uganda and similar settings.
AB - Background: Many full-time Ugandan government health providers take on additional jobs - a phenomenon called dual practice. We describe the complex patterns that characterize the evolution of dual practice in Uganda, and the local management practices that emerged in response, in five government facilities. An in-depth understanding of dual practice can contribute to policy discussions on improving public sector performance.Methods: A multiple case study design with embedded units of analysis was supplemented by interviews with policy stakeholders and a review of historical and policy documents. Five facility case studies captured the perspective of doctors, nurses, and health managers through semi-structured in-depth interviews. A causal loop diagram illustrated interactions and feedback between old and new actors, as well as emerging roles and relationships.Results: The causal loop diagram illustrated how feedback related to dual practice policy developed in Uganda. As opportunities for dual practice grew and the public health system declined over time, government providers increasingly coped through dual practice. Over time, government restrictions to dual practice triggered policy resistance and protest from government providers. Resulting feedback contributed to compromising the supply of government providers and, potentially, of service delivery outcomes. Informal government policies and restrictions replaced the formal restrictions identified in the early phases. In some instances, government health managers, particularly those in hospitals, developed their own practices to cope with dual practice and to maintain public sector performance. Management practices varied according to the health manager's attitude towards dual practice and personal experience with dual practice. These practices were distinct in hospitals. Hospitals faced challenges managing internal dual practice opportunities, such as those created by externally-funded research projects based within the hospital. Private wings' inefficiencies and strict fee schedule made them undesirable work locations for providers.Conclusions: Dual practice prevails because public and private sector incentives, non-financial and financial, are complementary. Local management practices for dual practice have not been previously documented and provide learning opportunities to inform policy discussions. Understanding how dual practice evolves and how it is managed locally is essential for health workforce policy, planning, and performance discussions in Uganda and similar settings.
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U2 - 10.1186/1478-4505-12-41
DO - 10.1186/1478-4505-12-41
M3 - Review article
C2 - 25134522
AN - SCOPUS:84906824226
SN - 1478-4505
VL - 12
JO - Health Research Policy and Systems
JF - Health Research Policy and Systems
IS - 1
M1 - 41
ER -