Who do physicians work for?

This paper presents a thorough analysis of the issue of dual job holding among physicians. As the causes and implications of this phenomenon may well depend on the specific form of dual practice under consideration, we first introduce a typology of dual practice in the health sector based on the public versus private nature of the activity and the work regime involved. Our primary focus is on public on private practice, since it is more prevalent and poses greater adverse welfare effects than do other forms. We commence our analysis with a review of the theoretical and empirical economic literature on public on private dual job holding among physicians in developing and developed countries and analyze its underlying motives and economic effects. We find that economic motives are not the only reason why physicians engage in dual practice. Other non-pecuniary factors such as job complementarities, and institutional, professional, structural and personal variables play a relevant role and, hence, should also be taken into account when regulating dual practice. Furthermore, while dual providers may be tempted to skimp on time and effort in their main job, to induce demand for their private services, or to misuse public resources, the legalization of dual practice may also contribute to recruit and retain physicians with less strain on the budget and improve access to health services, especially in developing countries. Finally, the paper highlights the lack of evidence regarding the extent and effects of this phenomenon. Given its implications for the equity, efficiency and quality of health care provision, dual practice among physicians warrants more attention from researchers and policy makers alike.