DUAL PRACTICE IN KAMPALA, UGANDA: A MIXED METHODS STUDY OF MANAGEMENT AND POLICY

Problem Statement: Dual practice is widespread in developing countries and frequently sparks discussions about its effects on service delivery and system performance. In the absence of empirical studies, policy-makers often rely on anecdotal evidence for policy discussions and planning. This thesis examines dual practice in Kampala, Uganda, where, anecdotally, almost all government health workers have dual practice. Methods: An exploratory mixed methods design included multiple case studies of government facilities with embedded units of analysis, as well as a self-administered survey containing preference elicitation and demographic questions completed by government doctors and nurses. Manuscript 1 uses interview and survey data to develop a framework for understanding dual practice. Manuscript 2 uses qualitative data and develops a causal loop diagram to describe the interactions, adaptations, and management practices related to dual practice. Manuscripts 3 and 4 use best-worst scaling to identify and elicit provider preferences on the consequences of dual practice and on dual potential practice policy options, respectively. Results: Manuscript 1 describes the heterogeneous nature of dual practice in Uganda. Manuscript 2 illustrates the historical development of dual practice in Uganda and explains informal management practices within government facilities. Manuscript3 produces a ranking of providers’ perceptions of dual practice consequences. Manuscript 4 identifies policy options linked to salary, dual practice policy, work structure, and benefits. Policy options related to salary and work structure were most important to health providers. Dual practice policy options were least important. Conclusions: This study underscores the importance of defining dual practice locally and accounting for differences between doctors and nurses and among doctors. A formal policy on dual practice should carefully consider unintended feedback in the system, the role of public and private incentives for government providers, and the costs and benefits of various policy options. Provider stated preferences point to potential policies to improve health workforce management in the short term – such as supportive supervision, while resources are secured for longer-term policies – salary increases, civil service reform. Future research should consider evaluating the effects of dual practice on service delivery and the effectiveness of policy initiatives