Methods: We used a qualitative approach to identify the factorsaffecting DP in medical specialists in 2016. We used a purposive and outliersampling method to conduct semistructured deep interviews with 14 keyinformants. The data analysis was performed simultaneously with datacollection using thematic content analysis by MAXQDA (version 10.0).Interviews continued up to data saturation. The quality of the study wasensured by addressing the criteria of Guba and Lincoln.
According to the World Health Organization (WHO), the globalshortage of physicians, midwives and nurses was estimated to be 11.6 millionin 2013 (1). Dual practice (DP) is defined as performing several differentjobs at the same time, and it has emerged as a reason for the workforceshortage, especially in low- and middle-income countries (2,3). Thisphenomenon occurs in most countries, even where it is banned. For example,nearly all highly skilled medical professionals in Austria, 90% of generalphysicians in Ireland, and 60% of general physicians in the United Kingdom ofGreat Britain and Northern Ireland work in private and public hospitals (4).Physicians work in both public and private hospitals and clinics to raisetheir income in most countries (5). Other factors that attract physicians toDP include greater flexibility of private practice, more opportunities forpatient contact and more self-management (6,7).
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We used a purposive and outlier sampling method (29) to select keyparticipants from three groups of universities with high, middle and lowrates of DP (23) to cover all the Iranian provinces. Key informants ofuniversities were determined in a focused discussion group with someadministrative and academic experts familiar with the university sector. Thefocused discussion group selected the deputies for curative affairs ofmedical universities as key informants for interview. A letter were sentinviting them to participate and interviews continued until the saturationstage based on the researchers' ongoing and cumulative judgement, usinga hybrid saturation model (inductive thematic saturation and data saturation)(30,31).
With regard to the control mechanisms, in low-income countries,many health workers tend towards DP because of nonflexible mechanisms in thepublic sector (13,48). In fact, the contradiction between bureaucracy and theprinciples of professionalism in the public sector drives the specialistsaway from the public sector. This is because, in the public sector, they areexpected to perform a series of specific tasks at determined hours.Practically, this rigidity has a negative effect on their autonomy andprofessional creativity (20). In order to increase the effectiveness ofcontrol mechanisms, different countries should act in accordance with theparticular conditions of the country (40,49,50). In low-income countries suchas the Islamic Republic of Iran, with low payments and poor workingconditions in the public sector, a complete ban on DP might not be feasible,and any such regulations may be ignored by medical specialists and result inthem shifting to the private sector (16). Therefore, governments should seekmechanisms to compensate the difference in income and other conditionsbetween the sectors and reinforce the competitive power of the public sector(13). These mechanisms could include: the financial monitoring of doctors;setting a ceiling for private practice income for public sector physicians;tax-based or insurance-based services; limitation of issuing occupationallicenses for private work by specialists; and improving the environment inthe public sector by offering nonfinancial incentives such as professionalrecognition and development opportunities (20,49). The implementation of eachof these strategies requires strengthening the role of the Ministry of Healthas a steward of the health sector. 2ff7e9595c
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