Paulo Ferrinho

Dual practice in the health sector: review of the evidence

This paper reports on income generation practices among civil servants in the health sector, with a particular emphasis on dual practice. It first approaches the subject of public–private overlap. Thereafter it focuses on coping strategies in general and then on dual practice in particular.To compensate for unrealistically low salaries, health workers rely on individual coping strategies. Many clinicians combine salaried, public-sector clinical work with a fee-for-service private clientele. This dual practice is often a means by which health workers try to meet their survival needs, reflecting the inability of health ministries to ensure adequate salaries and working conditions.Dual practice may be considered present in most countries, if not all. Nevertheless, there is surprisingly little hard evidence about the extent to which health workers resort to dual practice, about the balance of economic and other motives for doing so, or about the consequences for the proper use of the scarce public resources dedicated to health.In this paper dual practice is approached from six different perspectives: (1) conceptual, regarding what is meant by dual practice; (2) descriptive, trying to develop a typology of dual practices; (3) quantitative, trying to determine its prevalence; (4) impact on personal income, the health care system and health status; (5) qualitative, looking at the reasons why practitioners so frequently remain in public practice while also working in the private sector and at contextual, personal life, institutional and professional factors that make it easier or more difficult to have dual practices; and (6) possible interventions to deal with dual practice.

How African doctors make ends meet: an exploration

This paper is an attempt to identify individual coping strategies of doctors in sub‐Saharan Africa. It also provides some indication of the ‘effectiveness’ of these strategies in terms of income generation, and analyses their potential impact on the functioning of the health care system. It is based on semi‐structured interviews of 21 doctors working in the public health sector in sub‐Saharan Africa and attending in 1995 an international Masters course in Public Health in Belgium or in Portugal.

Patterns of perceptions of workplace violence in the Portuguese health care sector

This article characterizes the problem of violence against health professionals in the workplace (VAHPITWP) in selected settings in Portugal. It addresses the questions of what types of violence are most frequent and who are the most affected health professionals.Three methodological approaches were followed: (i) documentary studies, (ii) a questionnaire-based hospital and health centre (HC) complex case study and (iii) semi-structured interviews with stakeholders.Of the different types of violence, all our study approaches confirm that verbal violence is the most frequent. Discrimination, not infrequent in the hospital, seems to be underestimated by the stakeholders interviewed. Violence seems much more frequent in the HC than in the hospital. In the HC, all types of violence are also most frequently directed against female health workers and, in the hospital, against male workers.These studies allow us to conclude that violence is frequent but underreported.

Pilfering for survival: how health workers use access to drugs as a coping strategy

BackgroundCoping strategies have, in some countries, become so prevalent that it has been widely assumed that the very notion of civil services ethos has completely – and possibly irreversibly – disappeared. This paper describes the importance and the nature of pilfering of drugs by health staff in Mozambique and Cape Verde, as perceived by health professionals from these countries. Their opinions provide pointers as to how to tackle these problems.MethodsThis study is based on a self-administered questionnaire addressed to a convenience sample of health workers in Mozambique and in Cape Verde.ResultsThe study confirms that misuse of access to pharmaceuticals has become a key element in the coping strategies health personnel develop to deal with difficult living conditions. Different professional groups (mis)use their privileged access in different ways, but doctors diversify most. The study identifies the reasons given for misusing access to drugs, shows how the problem is perceived by the health workers, and discusses the implications for finding solutions to the problem.Our findings reflect, from the health workers themselves, a conflict between their self image of what it means to be an honest civil servant who wants to do a decent job, and the brute facts of life that make them betray that image. The manifest unease that this provokes is an important observation as such.ConclusionOur findings suggest that, even in the difficult circumstances observed in many countries, behaviours that depart from traditional civil servant deontology have not been interiorised as a norm. This ambiguity indicates that interventions to mitigate the erosion of proper conduct would be welcome. The time to act is now, before small-scale individual coping grows into large-scale, well-organized crime.

Epidemiological aspects of hepatitis C in Portugal.

During 1998, from a total of 1513 notified cases, 44.6% (n = 676) had hepatitis C, 34.7% (n = 526) had hepatitis B, 17.5% had hepatitis A (n = 265) and 3.0% (n = 46) had other virus (delta hepatitis, Epstein–Barr, cytomegalovirus). In 1998, the rate of all notifiable cases was 7.1/10. The number of notified hepatitis C cases was, for the first time, higher than the cases of hepatitis B. This is consistent with a downward trend in the notified incidence of all forms of hepatitis, except for hepatitis C, which has been steadily increasing (Fig. 1). For the period from 1993 to 1997, 79.9% (1723/2155) of hepatitis C cases were males and 34% and 42%, respectively occurred in the 15–24-year-old (n = 748) and the 25–34-year-old age groups (n = 915). A decade ago, hepatitis C was known as non-A, nonB and responsible for more than 90% of posttransfusional hepatitis. It was only in 1989 that the hepatitis C virus was isolated and described, allowing the commercialization of a first generation of serological diagnostic tests in the early 1990s. Greater availability of this test has dramatically reduced the incidence of post-transfusional hepatitis, resulting in an almost zero risk today. Because the prevalence of anti-HCV in the general population is not easy to assess, seroepidemiological studies have been conducted in healthy blood donors, and in certain population subgroups.The prevalence in blood donors is in general 25–50% less than that which occurs in the general population. The data gathered by us from 1991 to 1992 were obtained from the first Portuguese donors screened, mostly by the use of a secondEPIDEMIOLOGICAL ASPECTS OF HEPATITIS C IN PORTUGAL

A randomised, double-blind, placebo-controlled clinical trial of vitamin A in severe malaria in hospitalised Mozambican children

Summary This paper reports a randomised, double-blind, placebo-controlled clinical trial of the effect of routine vitamin A supplementation given on admission to children with severe malaria with regard to survival, recovery during hospitalisation and outcome 6 weeks after discharge. Children aged between 6 and 72 months admitted to the paediatric wards of the Central Hospital of Maputo (CHM), Mozambique with a diagnosis of severe malaria were randomly assigned either to a control group (placebo) or an experimental group (vitamin A) and were followed up 6 weeks after discharge. There were 280 children in the experimental and 290 in the placebo group. Seven (2.5%) and 13 (4.5%) children died in the experimental and the placebo groups, respectively, a relative risk of death of 0.56 (95% CI 0.23–1.38, p = 0.201). During the 1st 5 hours of admission, the relative risk of death in the vitamin A-supplemented group was 2.54 (0.50–12.96); after 5 hours of admission it was 0.19 (95% CI 0.04–0. 85; p = 0.015). In the supplemented group, 4/82 (4.9%) of the children developed neurological sequelae vs 2/78 (2.6%) in the placebo group (RR= 1. 90; 95% CI 0.36–10. 09; p = 0.682). Although the overall reduction in the risk of death observed for all children receiving vitamin A is not statistically significant, it might be clinically important. This finding cannot, however, be accepted as a firm conclusion and requires validation by future trials.

A randomized double-blind placebo-controlled clinical trial of vitamin A in Mozambican children hospitalized with non-measles acute lower respiratory tract infections.

Summary objective The objective of this study was to test the potential of routine vitamin A supplementation at admission to speed up recovery during hospitalization for acute lower respiratory tract infections (ALRI) and to decrease the levels of morbidity at 6 weeks after discharge. The study was conducted in the Central Hospital of Maputo (CHM), Mozambique, from 1995 to 1997.

The training and expectations of medical students in Mozambique

BackgroundThis paper describes the socio-economic profile of medical students in the 1998/99 academic year at the Universidade Eduardo Mondlane (UEM) Medical Faculty in Maputo. It aims to identify their social and geographical origins in addition to their expectations and difficulties regarding their education and professional future.MethodsThe data were collected through a questionnaire administered to all medical students at the faculty.ResultsAlthough most medical students were from outside Maputo City and Maputo Province, expectations of getting into medical school were already associated with a migration from the periphery to the capital city, even before entering medical education. This lays the basis for the concentration of physicians in the capital city once their term of compulsory rural employment as junior doctors is completed.The decision to become a doctor was taken at an early age. Close relatives, or family friends seem to have been an especially important variable in encouraging, reinforcing and promoting the desire to be a doctor.The academic performance of medical students was dismal. This seems to be related to several difficulties such as lack of library facilities, inadequate financial support, as well as poor high school preparation.Only one fifth of the students reported receiving financial support from the Mozambican government to subsidize their medical studies.ConclusionMedical students seem to know that they will be needed in the public sector, and that this represents an opportunity to contribute to the publics welfare. Nevertheless, their expectations are, already as medical students, to combine their public sector practice with private medical work in order to improve their earnings.

Negotiating markets for health: an exploration of physicians’ engagement in dual practice in three African capital cities

Scarce evidence exists on the features, determinants and implications of physicians’ dual practice, especially in resource-poor settings. This study considered dual practice patterns in three African cities and the respective markets for physician services, with the objective of understanding the influence of local determinants on the practice. Forty-eight semi-structured qualitative interviews were conducted in the three cities to understand features of the practice and the respective markets. A survey was carried out in a sample of 331 physicians to explore their characteristics and decisions to work in public and private sectors. Descriptive analysis and inferential statistics were employed to explore differences in physicians’ engagement in dual practice across the three locations. Different forms of dual practice were found to exist in the three cities, with public physicians engaging in private practice outside but also inside public facilities, in regulated as well as unregulated ways. Thirty-four per cent of the respondents indicated that they worked in public practice only, and 11% that they engaged exclusively in private practice. The remaining 55% indicated that they engaged in some form of dual practice, 31% ‘outside’ public facilities, 8% ‘inside’ and 16% both ‘outside’ and ‘inside’. Local health system governance and the structure of the markets for physician services were linked to the forms of dual practice found in each location, and to their prevalence. Our analysis suggests that physicians’ decisions to engage in dual practice are influenced by supply and demand factors, but also by how clearly separated public and private markets are. Where it is possible to provide little-regulated services within public infrastructure, less incentive seems to exist to engage in the formal private sector, with equity and efficiency implications for service provision. The study shows the value of analysing health markets to understand physicians’ engagement in professional activities, and contributes to an evidence base for its regulation.

Task-shifting: experiences and opinions of health workers in Mozambique and Zambia.

BackgroundThis paper describes the task-shifting taking place in health centres and district hospitals in Mozambique and Zambia. The objectives of this study were to identify the perceived causes and factors facilitating or impeding task-shifting, and to determine both the positive and negative consequences of task-shifting for the service users, for the services and for health workers.MethodsData collection involved individual and group interviews and focus group discussions with health workers from the civil service.ResultsIn both the Republic of Mozambique and the Republic of Zambia, health workers have to practice beyond the traditional scope of their professional practice to cope with their daily tasks. They do so to ensure that their patients receive the level of care that they, the health workers, deem due to them, even in the absence of written instructions.The “out of professional scope” activities consume a significant amount of working time. On occasions, health workers are given on-the-job training to assume new roles, but job titles and rewards do not change, and career progression is unheard of. Ancillary staff and nurses are the two cadres assuming a greater diversity of functions as a result of improvised task-shifting.ConclusionsOur observations show that the consequences of staff deficits and poor conditions of work include heavier workloads for those on duty, the closure of some services, the inability to release staff for continuing education, loss of quality, conflicts with patients, risks for patients, unsatisfied staff (with the exception of ancillary staff) and hazards for health workers and managers. Task-shifting is openly acknowledged and widespread, informal and carries risks for patients, staff and management.