Interventions to manage health worker dual practice (holding more than one job)

Researchers in The Cochrane Collaboration set out to conduct a review of studies on the effect of interventions to stop or to regulate the practice among health workers of having more than one job (dual practice). However, after searching for all relevant studies, they were unable to find any studies that met their requirements for inclusion in the systematic review.

Interventions to regulate dual practice

Many health professionals have two or more jobs. This is referred to as dual practice. In many low- and middle-income countries, low pay and difficult working conditions lead many health workers in the public health sector to add to their income by taking on private patients who pay for the services that they receive. In addition to this extra income, work in the private sector may also offer advantages such as higher status, more control over working hours and better professional opportunities.

By allowing public sector health workers to supplement their income, it may be easier for the public sector to keep their skilled health workers. This type of dual practice may also lead health workers to spend less time in their public sector job, and may also encourage some health workers to be inefficient and corrupt. For instance, they may take time off without permission to go and work in their private positions; they may lower the quality of their services in the public sector in order to drive patients to their private practice; or they may take resources such as transport and drugs from their public sector workplace to use in their private sector jobs.

In some countries, governments have imposed a ban on dual practice, or have attempted to regulate how many hours their health workers are allowed to conduct a private practice or how much they are allowed to earn from this practice by imposing mandatory licenses and private sector price ceilings. In other countries, health workers are given special incentives such as higher salaries and promotions if they agree to only work in the public sector, while other countries have allowed limited private practice (health workers seeing private patients) within public facilities.

What happens when efforts are made to regulate dual practice?

These efforts to regulate health worker dual practice have not been properly evaluated, therefore the review authors were not able to find any studies that met their stated requirements for types of study designs. The review shows that there is a huge gap in our knowledge about the effectiveness of policy interventions that attempt to regulate health worker dual practice.

A summary of this review for policy-makers is available here

Authors' conclusions: 

There is a need to rigorously evaluate the effects of interventions implemented to manage dual practice among health workers. However, there is still much that is unknown about dual practice itself. The designing of studies to evaluate the effects of interventions to manage dual practice could benefit from prior studies to assess the various manifestations of dual practice, their prevalence and their likely impacts on health services delivery. These findings would then inform the design of studies to evaluate interventions to manage dual practice.

Read the full abstract...

Dual practice, whereby health workers hold two or more jobs, is a common phenomenon globally. In resource constrained low- and middle-income countries dual practice poses an ongoing threat to the efficiency, quality and equity of health services, especially in the public sector. Identifying effective interventions to manage dual practice is important.


To assess the effects of regulations implemented to manage dual practice.

Search strategy: 

Databases searched included: The Cochrane Central Register of Controlled Trials (CENTRAL) 2011, Issue 4, part of The Cochrane Library., including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 26 May 2011); MEDLINE In-Process & Other Non-Indexed Citations May 24, 2011 (searched 26 May 2011); MEDLINE, Ovid (1948 to May week 2 2011) (searched 26 May 2011); EMBASE, Ovid (1980 to 2011 week 20) (searched 26 May 2011); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 04 December 2009); LILACS (searched January 2010); and AIM (December 2009) (searched 18 December 2009).

Selection criteria: 

Randomized controlled trials, non-randomized controlled trials, controlled before-and-after studies and interrupted-time-series studies. Dual practice was defined as holding more than one job. Studies for inclusion were those focusing on interventions to manage dual practice among health professionals employed in the public health sector.

Data collection and analysis: 

Two review authors independently applied the criteria for inclusion and exclusion of studies when scanning the identified titles and abstracts. The same two review authors independently screened full reports of selected citations. At each stage, results were compared and discrepancies settled through discussion.

Main results: 

No studies were found which were eligible for inclusion in this review.