Key messages

• It is not clear whether interventions to reduce the negative consequences of dual practices in the health system are effective because the certainty of the available evidence is very low.

What is the evidence.
See evidence matrix  in Epistemonikos later

We found three systematic reviews [1], [3], [4] that included 23 primary studies [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28] of which, all correspond to observational studies.

What kind of countries were included*

The 23 studies were carried out in countries from different income levels, analyzing physicians or heterogeneous groups that included all types of health professionals.
Eight studies were conducted in high-income countries [5], [6], [13], [16], [17], [18], [20], [24], seven studies in low- and middle-income countries [7], [10], [11], [12], [15], [25], [26] and three studies in countries in both categories [8], [9], [14].
Seventeen studies focused exclusively on physicians [5], [6], [7], [8], [9], [10], [11], [13], [14], [16], [17], [19], [20], [24], [25], [26], [27] and three in any health professional [12], [18], [15].

What types of interventions were included*

All the studies evaluated the effect on the public sector of regulatory policies at a national level.
Three studies evaluated the total prohibition of dual practices [7], [10], [13], five financial restrictions [5], [6], [17], [22], [25], three restrictions on licenses of professional practice [11], [12], [17] and six total liberalization (absence of regulation) [9], [15], [24], [19], [20], [26].

What types of outcomes
were measured

The outcomes, as grouped by the systematic reviews, were the following: migration of professionals to the private sector, quality of care and migration of patients to the private sector.

To whom this evidence does and does not apply

• The identified evidence comes from countries of different income levels and organization of their health system. Therefore, these results may be applicable to different realities of health systems.
• The conclusions apply essentially to the regulation of dual practices in physicians, given that the information in the group of health workers or other subgroups of professionals is very scarce. However, it is not clear that there are a priori reasons to assume a different behavior of non-medical workers in the regulation of dual practices. Therefore, in the absence of direct evidence, it is reasonable to use the available evidence to inform decisions about these regulations.

• The selected outcomes are those considered critical for the decision making, according to the opinion of the authors of this summary.
• In general, the selected outcomes coincide with those used in the main systematic reviews analyzed. The lack of report of measurements related to the costs for the health system and for the patients must be highlighted.

• The absence of regulation of dual practices in low- and middle-income countries could reduce the quality of care of the public system and increase the migration of professionals to the private system, although the certainty of the available evidence is very low.
• It is not possible to make an adequate balance between benefits and risks of the regulation of dual practices, due to the associated uncertainty.
• A common limitation in the reviews found is the absence of an adequate description of the comparator adopted when reporting the effects of the intervention.

• Dual practice has a negative effect on health systems, but it is generally poorly recognized as a problem, which generates a low level of regulation by countries [2].
• It is not possible to make an adequate balance between costs and benefits of the potential regulations due to the existing uncertainty.

• Most physicians and health professionals are inclined against the regulation of dual practices, especially in low- and middle-income countries where the remuneration gap between the public and private systems is greater [1].
• Although most countries do not have regulation of dual practices due to the difficulties of implementation, especially in low- and middle-income countries, international organizations such as the World Health Organization recommend addressing these practices and their possible regulatory alternatives, in order to implement optimal human resources’ health policies guarantee sufficient coverage [2].

Differences between this summary and other sources

• Within the systematic reviews analyzed, the need to address the dual practices in the countries is mentioned as a common element, but it is necessary to have more and better studies regarding the effect of the interventions for their regulation.
• On the other hand, in a publication of 2016 [2], it is considered as a relevant factor to achieve the Sustainable Development Goals (SDG) of the World Health Organization and achieve universal coverage, including protection against financial risks and access to basic quality health services. This would be particularly necessary in low- and middle-income countries, which are more affected by the problem. It is important to recognize the challenges of implementation for these countries in contexts where institutions might lack the strength to incorporate effective regulations.
• This publication also points out to the lack of evidence regarding the effectiveness of the regulatory mechanisms, which is consistent with the conclusions of the systematic reviews analyzed.

• The probability that future evidence changes the conclusions of this summary is high, due to the uncertainty that the existing evidence provides.
• No ongoing studies or reviews were identified in PROSPERO or in the International Clinical Trials Registry Platform (ICTRP) of the World Health Organization.