Estimating the Monetary Value of Hours Lost to the Nigerian Public Healthcare System When Full-Time Government Employee Doctors Engage in Dual Practice ()
1. Introduction
Dual Practice (DP) occurs when medical professionals, who have contracts of employment with the public sector, work concurrently in the private sector [1] - [8] . DP occurs among different categories of workers [9] , and it is evident in both industrialised [10] and industrializing countries [11] . The engagement of medical professionals in both public and private sector work is increasingly gaining the attention of many governments in developed and developing countries alike [12] . Some authors have suggested that it is in the interest of the government to acknowledge the existence of DP by investigating its potential impact on public service provision [3] [13] , whilst ignoring its existence would not prevent the impact on the health system from occurring.
In Nigeria, there is a high growth of private medicine with dual practice officially permitted outside regular shifts. The Code of Medical Practice in Nigeria allows medical and dental surgeons in full-time employment in the public sector to use their off-duty hours to engage in private medical or dental practice for remuneration [14] . The allocated time for private practice in Nigeria starts from 4.00 pm, after the official public-sector work time from 8.00 am to 4.00 pm. The dual practitioner in principle can only resume private work after 4.00 pm if not on call. However, many public-sector doctors have additional income-generating activities [15] , whilst many operate a 24-hour private hospital service [16] [17] .
The crux of the argument about DP comes down to whether it has positive or negative service delivery or financial consequences for the health system and service users. It has been argued that the consequences associated with DP may differ across different health systems depending on the strength of their regulatory mechanisms, the nature of the medical labour market, and physicians’ motivation [18] [19] . For example, there has been much public debate in Denmark about whether the dual practice has stimulated the growth of the private sector, and consequently, the move for the amendment of the Health Act [20] . In that country, this growth is seen as a threat to the running of the public healthcare system.
Doctors who work both in the public and private sectors are faced with a conflict of interest, in the sense that personal gains may not equate with benefits to the public system in which the professionals work. Evidence has shown that absenteeism, late reporting to work, and poor commitment to government work are common among DP physicians [21] [22] [23] , which inevitably reduces the quantity and quality of services offered. Evidence from developed countries is conflicting with regard to whether DP expands or restricts access to health care services. For example, a study that analysed consultants’ NHS and private incomes in England found that full-time NHS doctors engaged in private practices invested more time in their private work by exceeding the 10% income threshold from private remuneration [24] . This evidence is congruent with the report of Yate (2000) that public-sector consultant DPs on average set aside two and a half days weekly for private consultations and operations. Similar evidence affirmed a lack of commitment to duties linked to private practice among NHS doctors in the past [25] with some dual practitioners using NHS sick leave to do private work. Despite this obvious negative consequence, some studies have shown that DPs are still as productive as their non-DP counterparts [26] [27] .
Previous studies [11] [28] have shown that competition for time between public and private work limits access to healthcare. For example, in Venezuela and Costa Rica, health workers missed their contract service hours by between 37% and 65% respectively [28] . In India, Bangladesh, Indonesia, Peru and Uganda 35%, 40%, 25% and 37% of absenteeism was recorded, respectively, among health workers [22] [29] , and in Nigeria, 46.9% of absenteeism was recorded with doctors [30] [31] . Thus, attention and efforts may be concentrated on private work, where there is a higher profit margin. This is supported by [32] , who showed that competition for time may result in the transfer of resources out of the public sector through reduced availability, which accounts for a loss of value equivalent to 27% of salary among public health managers in developing countries. Absenteeism by health workers may restrict patients’ subsequent visits to a public facility and could lead to seeking an alternative healthcare provider in the private sector. But the question of whether these absences are associated with private practice may need further research to establish.
A study in three African cities shows that the choice of allocation of time in the private sector by dual practitioners depends on a number of factors, such as the number of dependants, whether holding a specialisation and having enough private patients [33] . Some dual physicians may be busier than others, particularly those who specialise in areas not practiced in the public sector. For instance, in Nigeria, In Vitro Fertilisation (IVF) treatment is not common in most public hospitals but is gaining popularity in the private sector. A dual practitioner who specialises in IVF treatment may use more government time due to a large private clientele. The same is applicable to obstetrics and gynecology specialists.
This study looked at one aspect of the arguments against DP, and that is the reduction of the contracted hours in the public system due to doctors’ engagement with private clinical work. One novel aspect of the research is the use of sensitivity analysis, comparing multiple scenarios, to highlight the value of hours lost to the public system of absences and truancy by DP doctors. A similar large flow of resources out of public healthcare was reported in Macq’s study [32] and a number of other descriptive literature on DP stressing the consequences of the practice in the public system [12] [13] [18] . However, the present analysis goes further by quantifying the value of paid hours lost to the public system in monetary terms and this serves to emphasize the magnitude of the problem that DP represents in Nigeria. Measuring the cost in this way could make a valuable contribution to the policy discourse on DP, particularly in developing countries. This innovative method is a tool that policymakers could use to examine the outflow of financial resources from the public system. By estimating the number of hours lost to absences under different scenarios, the government can then set itself a target to reduce the number of doctors engaged in DP, and over time reduce the number of hours lost and the consequent loss of value in cash terms to the public system.
2. Methods
2.1. Defining the Consolidated Medical Salary Structure in Nigeria
The Consolidated Medical Salary Structure (CONMESS) is a special salary structure approved by the Federal Government of Nigeria for medical and dental officers in the federal public service on grade levels 1 - 7 (CONMESS 1 - 7) by the National Salaries, Income and Wages Commissions (NSIWC) [34] . The Commission is the body in-charge of matters relating to salaries and wages of Nigerian workers, which is reviewed from time to time as the need arises. CONMESS includes the basic or consolidated salary, hazard allowance, which is paid across board to all medical and dental doctors. Teaching allowance is paid to medical and dental officers who engage in teaching of medical students or other healthcare professionals in training in federal tertiary hospitals. Rural posting allowance goes to medical and dental officers who accepted posting in rural communities whilst specialist allowance is allocated to those employed as consultants. The version of the Consolidated Medical Salary Structure used in this study took effect from January 2015 and was obtained from the Finance Department of a federal teaching hospital used in this study. All federal government tertiary hospitals use this salary structure to pay their medical and dental officers in Nigeria. The clinical duty allowance for honorary consultants was not included in the calculation because this category of consultants is not on full-time contract with federal teaching hospitals but with universities offering medical training and only receives allowances from teaching hospitals.
2.2. Methods for Analysing the Value of Hours Lost
Sensitivity analysis was performed in Excel 2010 Spreadsheet to calculate the doctor’s hourly pay in the public sector (Table 1) for a normal routine hour. The hourly pay helped the researcher to estimate the magnitude of the value of hours lost to dual practice due to absences from government work. First, different hypothetical scenarios were created to estimate hours lost per week. These hypothetical scenarios reflect the evidence on the decline of quality care in the public
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Table 1. CONMESS for normal duty allowances and computation of hourly pay value for doctors on grade levels 1 - 7.
Source: CONMESS data with effect from January 2015. *Average monthly salary of doctors on each grade level is obtained by summing up the salaries in each level and divided by the number of incremental steps (see Table 1). **Hourly pay value represents the amount for an hour worked. ***Hourly Pay (HP) is obtained by dividing the average monthly salary in each grade level by 150 hours per month (see methods).
sector, which is often blamed on high absenteeism rate of the public sector doctors who are engaged in other income generating activities [35] . These scenarios are 5, 8, 10, 12, 15 and 20 hours (not in any order) per week with 5, 8 and 10 hours as the lower band, and 12, 15 and 20 hours as the upper band. The aim of creating different hypothetical scenarios is to establish the extent of the value of hours that might be lost to the public system under different feasible situations likely to arise due to public/private practice engagements. In this instance, the intention was to show the level of the value of hours lost represented by government salaries paid for work that is never done. These values were estimated under different scenarios and were not built on any empirical data as none existed at the time of this study.
The parameters used for the calculation were the official 40 hours working week (normal routine hours), and monthly gross pay of doctors on different grade levels (1 - 7). The researcher obtained the average monthly salary of doctors on different grade levels by summing up the salaries in each grade level and dividing by the number of incremental steps (the steps to pass through before moving to the next grade level) to obtain the average monthly salary of doctors within each grade level (Table 1). The salary was based on monthly gross pay and not net pay. It was decided not to attempt to get data on actual salaries of employed individuals at the different grades because this would have been sensitive, and the analysis might have allowed individuals to be identified. The averaging of salaries across the increments per grade level and the use of gross salaries mean that it is not possible to make inferences about individual’s pay. The Excel Spreadsheet (Table 2) is an example used for creating the different hypothetical scenarios of hours lost to DP by percentage of doctors assumed to engage
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Table 2. Example of calculation of different hypothetical hour losses by % of doctors assumed to engage in DP for normal routine work using excel spreadsheets.
Example using 5 hours lost on normal work scenario (Source: Research Data).
in DP for normal routine duty.
Next, the supposed hourly pay was calculated. The first step was to multiply the basic 40 hour working week by 45 weeks (with seven weeks removed as the standard holiday entitlement) to obtain 1800 hours paid for per year, and then dividing this by 12 months to obtain 150 hours per month. To obtain the hourly pay, the average monthly salary was divided by 150 monthly hours. This was applied to all the grade levels to obtain the hourly pay of doctors at different grade levels (Table 1). For the outputs from the sensitivity analysis of normal routine hour loss, see Tables S1-S6 for details.
At the same time hourly pay for on-call hours worked over the standard 40 hours was also calculated (hours that might also be lost to DP). The on call pay allowance is the second largest pay chunk after the consolidated or basic pay. A similar approach to that described above was applied. There was no standardised number of hours to spend on on-call hour as there was for the main 40 hours of normal routine hour. Different departments in the hospital have varied on-call hours depending on their workforce strength, but they do not seem to get a higher allowance as the CONMESS document did not specify. The on-call hourly pay was obtained by first obtaining the average monthly on-call hours allowance per grade level. Then the average monthly on-call hours allowance was divided by 150 monthly hours (as above) to obtain hourly pay for on-call hours (Table 3) and an example of the computation of different hypothetical hour losses by the % of doctors assumed to engage in DP for on call duty for one year
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Table 3. CONMESS for on-call duty allowance and computation of hourly pay value for doctors on grade levels 1 - 7.
Source: CONMESS data with effect from January 2015. *Average monthly on-call duty allowance was calculated by summing up monthly call duty allowance in each grade level and dividing by the number of incremental steps (see Table 3). **Hourly pay value for each grade level was obtained by dividing average monthly on call duty allowance by 150 hours per month (see methods).
projection using Excel Spreadsheet (Table 4). In this case, the lower band represents 5, 6 and 7 hours lost in respect of paid on call hours when doctors absent themselves for private practice, while 8, 9 and 10 hours lost denote the upper band for the outputs from the computation of on-call hour loss. This may lead to an uneven estimate of the value of hours lost to DP across departments, but this is controlled for by standardizing it using 40 hours per week like the case of normal routine duty. As described above, these scenarios are hypothetical (see Tables S7-S12) for the outputs from the sensitivity analysis.
2.3. Ethical Approval
This study was part of bigger mixed-methods study that received ethical approvals from the Committee on Medical and Scientific Research of a public teaching hospital in Nigeria (Ref: NHREC/05/01/2008B-FWA-00002458-IRB00002323) and the state ministry of health (Ref: MH/MSD/EC/0181).
3. Results
The hypothetical estimates of the magnitudes of value of hours lost to the public system because of absences due to DP are presented. To achieve this, a series of hypothetical scenarios were used to estimate the value of hours missed due to absences from the normal routine hour duty of 40-hour per week in the public
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Table 4. Example of calculation of different hypothetical hour losses by % of doctors assumed to engage in DP for on-call duty using excel spreadsheet.
Example using 5-hour loss scenario for on call duty (Source: Research Data).
sector. These estimates would help to provide data on the size of resource outflows from the public system due to DP. These losses therefore are calculated based on the hypothetical 5, 8, 10, 12, 15, and 20-hour loss scenarios per week per year in a typical tertiary hospital in Nigeria. This section focuses on two areas—the normal duty hours and on-call duty hours lost to the public system due to competition for time arising from working in both public and private sectors simultaneously. A combined estimate of different scenarios of the value of hours lost on normal duty hours are presented below.
The estimates represent hourly losses in monetary terms based on the CONMESS data obtained from NSIWC, which took effect from January 2015 (see Table 1).
In Figure 1, the value of the hours lost if 10% of doctors engage in dual practice and are absent for five of their contracted routine hours is N485,175 or 1586 USD per year. As the number of doctors engaged in DP increases, so the value of hours lost to the public sector rises. Assuming that 20% of doctors engage in DP in one tertiary hospital are absent for five hours per week, the total value of hours lost amounts to N970,351 or 3171 USD per year. With 30% of doctors engaged in DP and absent for 8 hours per week, N2,328,842 or 7611 USD would be lost per annum. If 90% were involved in DP, the total value of hours lost would increase to N4,366,579 or 14,270 USD for five hours of weekly absences, N6,986,526 or 22,831 USD for 8 hours of weekly absences, and N8,733,158 or 28,540 USD for 10 hours of weekly absences, and then for 15 hours of weekly
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Figure 1. Combined hypothetical estimates of total values of hours lost for weekly absences for normal routine hours. Exchange rate used in Figure 1: 1 Naira = USD306 (Source: Central Bank of Nigeria, 2017).
absences if 100% were involved in DP would amount to N14,555,263 or 47,566 USD. At the extreme twenty hours of weekly absences with a 100% of the doctors engaged in DP would result in a loss of N19,407,017 or 63,422 USD to this single tertiary hospital. The value of hours lost to weekly absences per year from the routine hours for the different cadres of doctors in the various scenarios can be found at the supplementary Tables S1-S6.
The estimates of on-call hours that could be lost to the public system due to absences resulting from DP are shown below. It uses a series of hypothetical scenarios to estimate the value of hours lost due to on-call hour absences. Apart from the normal 40-hour routine duty per week in the public sector, doctors in tertiary hospitals also spend periods “on call” to deal with emergencies in addition to their normal routine hours. Doctors are paid on-call duty allowance alongside their main salaries. When attendance to cover on call duty is compromised due to private practice, this therefore, involves additional hours lost to the public system. Estimating the magnitude of value of hours lost, helps to provide a clue to the size of resources outflows from the public system. These losses are calculated based on hypothetical 5, 6, 7, 8, 9, and 10-hour loss scenarios per week per year in a typical tertiary hospital in Nigeria.
In Figure 2, the total value of hours lost from on-call hours when 40% of the doctors engage in DP with 6 hours weekly absences would be N864,064 or 2824 USD annually. As the number of doctors engaged in DP increased to 60%, the total value of hours lost to the public system for 6 hours weekly absences from on call duty would increase to N1,296,096 or 4236 USD per year. Similarly, the total value of hours lost to on-call duty at 9 hours weekly absences assuming 80% of the doctors engage in DP amounts to N2,592,191 or 8471 USD per annum. If
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Figure 2. Combined hypothetical estimates of value of hours lost for weekly absences for on call hours. Exchange rate used: 1 Naira = USD306 (Source: Central Bank of Nigeria, 2017).
absences from on call duty rise to 10 hours and 90% of the doctors on all grade levels engage in DP the value lost to the hospital rises to N3,240,239 or 10,589 USD per year, whereas 10 hours of absences with a 100% of doctors having private practice would amount to a value loss of N3,600,266 or 11,766 USD per year. The total value of hours lost to absences per year from the on-call duty for the different cadres of doctors in the various scenarios can be found at supplementary Tables S7-S12.
4. Discussion
This study examines the value of hours lost to the public system due to absences or lateness by DP doctors who engage with private practice. To estimate loss, the author estimated the impact of DP on a single federal tertiary hospital, which employs approximately seven hundred doctors spread across the grades of consultants, registrars, medical officers, and house officers. The number of these doctors involved in DP is not known as there are no official records of DPs in the state and federal ministries of health. Taking account of salaries across a mix of grades, the author created several hypothetical scenarios to represent weekly absences from normal routine duties using various parameters; the same process was applied to on-call duties. The estimated value of hours lost are discussed below. The discussion is based on worst and best-case scenarios in both normal and on call duties.
4.1. Best-Case and Worst-Case Scenarios—Core Working Hours
For the best-case scenario, it was assumed that just 5 hours per week per DP doctor was lost. Taking one extreme of the range and assuming that all doctors (100%) across different grades engage in DP would involve a little above 4.8 million naira or 15,855 USD (see Figure 1 and supplementary Table S1), which is the equivalent of an annual value of hours lost to DP. As the percentage of doctors engaged in DP falls so does the magnitude of the value of hours lost to the public system. If the percentage of DPs was reduced to 90% for instance, the corresponding value of hours lost was reduced to over 4.3 million Naira or 14,270 USD per year (supplementary Table S1). Similarly, if only 80% of doctors engage in DP the value of hours missed to the public system was pruned to about 3.9 million naira or 12,684 USD (supplementary Table S1).
Taking a worst-case of loss of twenty hours per week produces an annual value of hours lost equivalent to 19.4 million naira or 63,422 USD if 100% of the doctors in the hospital is involved in private practice (Figure 1) and (Supplementary Table S6). This is the worst-case scenario. It shows how much, in the extreme case, could be lost to the system. In reality, this may represent the situation in many healthcare systems in developing countries, including Nigeria, where many senior consultants fail to work their contracted hours in the public system, and boost their income through DP. Even a notional cash loss of half this figure from 50% engagement in DP is sufficient to have a substantial negative impact on patient care in the public system. The extreme case scenario discussed above highlights the large value of hours lost represented by government salaries paid for work that is never done, a loss that becomes very large if the pattern is replicated across the wider healthcare system with all the tertiary/specialist hospitals spread across the country. Even in the best-case scenario, the Government may have been paying salaries for large volumes of work not rendered in the public sector.
The author found no previous studies that estimated the value of hours lost to the public sector of DP absences. However, past studies have shown that health worker absences are common in developing countries [22] [29] [31] , and have also commented on transfer of resources from the public to private sector due to competition for time [28] [32] . The present study adds value by using sensitivity analysis to predict the value of hours lost under the different scenarios. It remains the responsibility of the government to reduce the outflow of resources from the public to private sector. One policy approach would be to design incentive packages that discourage DP and reward doctors’ presence in the public system. Government may have to think about intramural practice that would allow doctors to engage in DP in the hospital where they work and encourage them to remain there for their contracted hours.
Apart from regular duty hours, doctors in government hospitals are required to be on call for certain periods, and the analysis was extended to consider the value of working hour losses arising from absences affecting this aspect of the work. Again, two scenarios are presented—a worst-case scenario and best-case scenario.
4.2. Best-Case and Worst-Case Scenarios—On-Call Duties
For the best-case scenario in relation to on-call duties in the selected tertiary care hospital, a five-hour absence was again assumed. If 100% of hospital doctors were involved in DP this would mean a notional value of hours lost equivalent to 1.8 million naira or 5883 USD per annum. If the number of doctors involved is reduced to 50%, the value of hours lost to the selected public hospital from on-call hours would be reduced to 0.9 million naira or 2941 USD per year. A further reduction of this number to 10%, could reduce the value of hours lost to just a hundred and eighty thousand naira or 588 USD a year. Going to a worst-case scenario, a situation where 10 on-call hours per week are lost due to absences or lateness while on call would result in a notional value of hours lost equivalent to 3.6 million naira or 11,766 USD (Figure 2) and (Supplementary Table S12). A 10-hour weekly loss due to absences across the full range of doctors’ grades/levels is almost certain to reduce the early availability of expert assessment and could be especially detrimental to the quality of care in emergency medicine. This not only motivates patients to move to the private sector, but again represents a significant loss to the public hospital in terms of payment for work not undertaken. Problems in staffing on-call hours may lead such cover to be reduced and may incentivize paying patients to seek care outside the public system [33] .
Furthermore, federal and state ministries of health, who are the employers of doctors at federal and state levels, can reduce the magnitude of the value of hours lost to the public system through closer monitoring of doctors’ working practices, especially regarding the standard 40 hours per week contract. The sensitivity analysis shows that the value of lost hours to the public system is quite high, especially in a worst-case scenario, so that any reduction in the proportion of doctors engaged in DP represents a substantial financial benefit to the system. This again suggests that devising incentives to keep doctors working mainly within the public system is a key area for policy development. The present study used hypothetical scenarios of doctors’ likely hours of absence to estimate the value of hours lost to the public system as a result of DP. If a future study could obtain data on individual salaries rather than salary scales and the proportion of doctors engaging in DP, that could help determine whether the approach used here is sufficiently accurate to be used as a management planning tool. Quantifying the value of doctor absences to the public system due to engagement in private practice is important for planning purposes. The approach used here is relatively quick and easy to apply, but a detailed (and more expensive) study based on the real distribution of salaries between DP and non-DP doctors in a typical tertiary hospital could reveal whether the cheaper scenario approach is accurate enough to be useful.
The implication of this result is that Government may have been paying salaries for large volumes of work not rendered in the public sector. The absences may mean a de facto transfer of time and human resources to the private sector; thus, public resources are used to develop the private sector. The estimated total financial loss involved could fund a good number of extra consultants to work in the various hospital departments or purchase additional medical equipment that would improve service delivery. This result adds weight to the argument in favour of DP policy reform in Nigeria.
5. Limitations
In terms of the methodology, computed salary for the sensitivity analysis was based on gross pay and not the net pay. Although the net pay would have produced a more precise estimate of the value of hours lost to DP, gross pay was used to avoid revealing the characteristics of the salary earners. One problem was that the net pay slip contains a scanned photograph and name of the employee, grade level and the amount earned, information which is considered confidential. The decision to rely on gross pay may have overestimated the value of hours lost compared with the value if net pay had been used. Similarly, the hourly-loss scenarios for doctors’ absences used in this study were based on doctors’ incomes estimated from the known salary scales for staff at different incremental points. They were not based on empirical data on the actual distribution of staff across the scale. Thus, the calculation of salary income received by a given doctor is complex and may change over time. To simplify matters, the estimates of the value of hours lost due to absences in the present study are based on a calculation of average salary across the points on the scale and not the actual salaries. The calculation also did not factor in the actual number of doctors engaged in DP, as such data do not exist, due to the sensitive nature of the issue. Instead, different percentage scenarios are presented. Replicating this exercise using actual salaries based on the real mix of grades in a hospital, and with accurate data on the proportion of doctors engaged in DP, would give a more solid basis for planning. Also, the US dollar exchange rate used in this work was the 2017 official rate reflecting the period the data were collected and therefore, does not represent the current exchange rate values. So, the actual monetary value of hours lost may have been underestimated. This study agrees that hours lost by a doctor in the public system at a particular time may have much greater consequences on the health system than just examining the monetary value, however, other likely consequences were not considered.
6. Conclusion
The value of hours lost to DP due to absences of doctors in this study indicates the extent of losses to the public system. The worst-case scenarios in both routine and call duty suggest a higher conflict of interest with more commitment to private practice than government work. The evidence from this study shows that the value of the resources flowing from the public system to private practices is substantial, particularly in respect of paid hours lost to the public sector when DP doctors do private work at the expense of public sector work. Therefore, the costs to the public system of DP are enormous and need policy intervention. This work raises the important question of what the real contribution of DP to the public sector is and contends that the overall impact of DP on the public system in Nigeria might be negative.
Acknowledgements
We wish to thank our colleagues who read and made useful comments on the manuscript. This work did not receive any external funding.
Supplementary
Outputs from Sensitivity Analysis of Normal Routine Hour Loss by % of Doctors Assumed to Engage in DP
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Table S1. 5 hours weekly loss to absences by DP doctors on normal routine hour per year.
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Table S2. 8 hours weekly loss to absences by DP doctors on normal routine hour per year.
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Table S3. 10 hours weekly loss to absences by DP doctors on normal routine hour per year.
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Table S4. 12 hours weekly loss to absences by DP doctors on routine hour per year.
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Table S5. 15 hours weekly loss to absences by DP doctors on routine hour per year.
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Table S6. 20 hours weekly loss to absences by DP doctorson routine hour per year.
Outputs from Computation of On-Call Hour Loss by % of Doctors Assumed to Engage in DP
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Table S7. 5 hours weekly loss to absences by DP doctors on on-call hour per year.
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Table S8. 6 hours weekly loss to absences by DP doctors on on-call hour per year.
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Table S9. 7 hours weekly loss to absences by DP doctors on on-call hour per year.
Table S10. 8 hours weekly loss to absences by DPdoctors on on-call hour per year.
Table S11. 9 hours weekly loss to absences by DP doctors on on-call hour per year.
Table S12. 10 hours weekly loss to absences by DP doctors on on-call hours per year.