Dual practice by doctors working in South and East Asia: a review of its origins, scope and impact, and the options for regulation.

Health professionals often undertake private work whilst also employed by government. Such dual practice (DP) is found in both high-income and lower- and middle-income countries (LMIC) around the world, with varying degrees of tolerance. This review focuses on DP in South and East Asia in the context of the rapidly expanding mixed health systems in this region. Although good data are lacking, health service uptake in South and East Asia is increasing, particularly in the private sector. Appropriately regulated, DP can improve health service access, the range of services offered and doctors' satisfaction. By contrast, weakly regulated DP can negatively affect public health service access, quality, efficiency and equity, as doctors often pursue the balance of public and private work that maximizes their income and other benefits. The environment for regulation of DP is changing rapidly, with improved communications opportunities, increasing literacy and rising civil society, particularly in this region. Currently, the options for regulating DP include (1) those which restrict the opportunities for dual practitioners to prioritize income and other benefits over their responsibility to the public; these require a level of regulatory capacity often missing in LMIC governments; and (2) those which not only tolerate public-sector doctors' private work but also encourage adequate health services for the general public. Growth of the private sector and weak regulation in South and East Asia increases the risk that dual practitioners will ignore the poor. Responsive and decentred regulation of doctors involving professional associations, civil society and other stakeholders is increasingly recommended. Moreover, as governments in LMIC strive for universal health coverage, market and financing opportunities for regulation of DP may arise, particularly involving insurers. This may also help to improve the current imbalance in the urban-rural distribution of doctors.