In many countries the public sector health workforce is often labelled “unproduc- tive”, “poorly motivated”, “inefficient”, “client unfriendly”, or even “corrupt”. “Unfair” salaries are presented as the justification of “inevitable” predatory behaviour and pub- lic-to-private brain-drain (64). This has eroded the implicit psychological and social contracts that underlie the public service values of well-functioning public organiza- tions (65). Most observers would agree that often public sector salaries are definitely unfair and insufficient for daily living expenses, let alone for living up to the expecta- tions of health professionals; in many countries they have been falling, in real terms, over recent decades. For example, nurses in Mozambique have seen the purchasing power of their salaries eroded by 85–90% over 15 years. In such a context, demotiva- tion, overall lack of commitment and low productivity are to be expected.
It should come as no surprise that in order to compensate for unrealistically low salaries, health workers increasingly rely on individual coping strategies to boost their income, for example by competing for access to seminars or training courses with at- tractive per diems or by engaging in dual practice (64, 66, 67). Many combine salaried public sector work with a fee-for-service private clientele. Others stay away from work to earn a living in other ways, or resort to predatory behaviour such as extracting un- der-the-counter payments or misappropriating drugs or other supplies. The problems such behaviour creates are increasingly recognized, although the subject remains taboo for many ministries of health and development agencies (68).
When health workers set up in dual practice to improve their living conditions – or merely to make ends meet – this does not necessarily interfere with their duties; it may even help to retain valuable elements in public service. Most often, however, it entails at least competition for time and a loss of resources for the public sector, while reinforcing a rural-urban and public-private brain-drain of the best-trained and most competent workers. This in turn reinforces the attraction of a job “on the side”, which quickly becomes not only more rewarding financially, but also professionally and in terms of social prestige.
There are even more serious consequences when health workers resort to predatory behaviour: financial exploitation of patients builds a barrier to access to care, and may have catastrophic effects for patients if they have to pay for care that is not needed or effective but is always expensive. In the long run, this affects the legitimacy and credibility of the public sector and harms the essential relation of trust between users and providers.
Pretending that the problem does not exist, or that it is merely a question of individual ethics, does not do justice to the nature and extent of the problem and will not make it go away. Prohibition of dual practice is equally unlikely to meet with success, certainly where salaries are patently insufficient. As an isolated measure, the use of restrictive regulations – when not blatantly ignored – only drives dual practice underground and makes it difficult to correct its negative effects. Despite this, many governments still resort to prohibition as their main means of controlling dual practice. Another disap- pointing approach is to downsize the workforce (in the hope that dividing the salary mass among a smaller number will leave a better individual income for those who remain). Such initiatives often generate so much resistance that they do not reach a stage of implementation. Where retrenchment becomes a reality it is rarely followed by substantial salary increases, so that the problem remains and the public health system is even less capable than before of assuming its mission.
On the other hand, it is remarkable that many people do remain in public service, given the gap between current salary levels and what they could earn in alternative employment. There obviously are other sources of motivation: social responsibility, self-fulfilment, professional satisfaction, working conditions and prestige (69). In fact, most health workers implicitly or explicitly condemn dual practice and predatory be- haviour, though they may attempt to explain and justify them in various ways. There is often a disconnection between health workers’ self-image as honest public servants wanting to do a decent job and the brutal facts of life that force them to betray that image. The manifest unease that this provokes offers important prospects. It suggests that, even in difficult circumstances, behaviours that depart from traditional public servant deontology have not been interiorized as a norm. This ambiguity suggests that interventions to mitigate the erosion of proper conduct would be welcomed (70).
A piecemeal approach using a combination of measures – career possibilities, pros- pects for training, and others – can go a long way towards rehabilitating the working environment. A prerequisite to dealing with these situations is to confront the problem openly. That is the only way to create the possibility of containing and discouraging income-generating activities that present conflicts of interest, in favour of ad hoc solutions that have less negative impact on the functioning of the health services. Besides minimizing conflicts of interest, open discussion can diminish the feeling of unfairness among colleagues. It can help to build a social environment that reinforces professional behaviour free from the clientelism and the arbitrariness that is prevalent in the public sector of many countries. Peer influence, for example through profes- sional societies, can be effective in improving professional accountability, particularly if it is seen as building up public reputation and status (71). It then becomes possible to manage human resources in a more transparent and predictable way. There are indications that the newer generations of professionals have more modest expecta- tions and are realistic enough to see that the market for dual practice is finite and to a large extent occupied by their elders. This gives scope for the introduction of systems of incentives that are consistent with the health system’s social goals (72).
Where, for example, financial compensation for work in deprived areas is introduced in a context that provides a clear sense of purpose and the necessary recognition, this may help to reinstate lost public service values. The same goes for the introduc- tion of performance-linked financial incentives. These can, in principle, overcome the problem of competition for working time, one of the major drawbacks of dual practice. However, such approaches require well functioning and transparent bureaucracies, so they are, a priori, most difficult to implement on a large scale in the countries most in need of them.