Table 4 Facility-level management practices for dual practice, by case
| Â | Facility-level management practices | Attitude for dual practice | 1-on-1 consultations | Discussion in staff meetings | Incentives/support supervision | Effect on the supply of government providers |
|---|---|---|---|---|---|---|
Case A | Dual practice allowed after government duties completed | Negative | Yes | No | No | Associated misunderstandings potentially create feedback that decreases the supply of government providers. Providers interviewed had a different interpretation of the in-charge’s version of "completeness," and reported leaving government work early. The misunderstandings associated with this approach were perceived to result in absenteeism |
Case B | Motivate providers to perform at their public sector job (e.g., supportive supervision; tea, purchased in health manager’s personal funds); non-interference with health workers lives outside government duties | Cautious | Yes | No | Yes | Potentially promotes desirable feedback, by creating conditions to improve public sector performance and retain government providers |
Case C | Discourage dual practice; emphasize priority for government duties and high public sector performance | Negative | Yes | No | No | Potentially promotes undesirable feedback by reducing the number of government providers; alternatively threats of disciplinary action could support improved performance in public sector |
Case D | Priority for government duties; non-interference with time outside government duties | Positive | Yes | No | No | Potentially does not affect government supply of doctors, but creates tensions among staff |
Although the Case D – the smaller hospital’s leadership had a positive attitude towards dual practice, they did not report a specific management strategy, except non-interference. Doctors reported to cope with dual practice through individual negotiations among their colleagues; however, this was not without pitfalls, as nurses were perceived to compensate for the absence of doctors. Furthermore, doctors appeared to have difficulty responding to emergencies, given that they juggled two or sometimes more places of work | ||||||
Case E | Formal policies | Mixed, depends | Yes | No | Yes, in the context of flexible scheduling; N/A for other policies and practices | Potentially effective at reducing the number of nurses working two full time jobs. According to respondents, also improved attendance among nurses. Probably no effect on those with part-time dual practice |
Policy preventing nurses to sign up for only night duties (which typically means they have a full-time day job) | ||||||
A memorandum of understanding with externally funded research projects, to stop the active recruitment of government staff to fill full-time positions on projects | Effective at reducing active recruitment by research and NGO projects, therefore reducing internal dual practice opportunities. According to respondents, also improved attendance among nurses | |||||
Private wing | Ineffective – mild effect on government providers, but has potential if more efficient. | |||||
Informal policies | Sustains retention among government providers, particularly specialists. Flexible scheduling creates friction among non-physicians | |||||
Flexible scheduling |