Factors Associated with Dual Practice in Surgery Specialists: Application of Multi-Level Analysis on National Registry Data

  • Mahboubeh BAYAT 1. Center for Health Human Resources Research & Studies, Ministry of Health and Medical Education, Tehran, Iran 2. Gerash University of Medical Sciences, Gerash, Iran
  • Roghaye KHALILNEJAD Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
  • Ali AKBARI-SARI Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
  • Iraj HARIRCHI Department of Surgery, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
  • Gholamhossein SALEHI ZALANI Gerash University of Medical Sciences, Gerash, Iran
  • S. Elmira MIRBAHAEDDIN Telfer School of Management, University of Ottawa, Ontario, Canada
  • Mahmoud KHODADOST 1. Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2.Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
  • Ebrahim JAFARI POOYAN Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
  • Mehdi YASERI Department of Epidemiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
  • Azad SHOKRI Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sci-ences, Sanandaj, Iran
Keywords: Surgery specialists; Dual practice; Multiple jobs holding; Iran


Abstract Background: Dual practice by surgery specialists is a widespread issue across health systems. This study aimed to determine the level of dual practice engagement and its related factors among Iran’s surgery specialists. Methods: A pre-structured form was developed to collect the data about surgery specialists worked in all 925 Iran hospitals in 2016. The forms were sent to the hospitals via medical universities in each province. The data were merged at the national level and matched using medical council ID codes, national ID codes and eventually a combination of the first name, surname and father's name. Multilevel logistic regression was used to assessing the association between dual practice with study variables. Results: Overall, 14931 surgeons were participated (93% response rate) and 6405 (57% of) engaged in DP on total. Urinary tract & genital and neurosurgery specialties had the highest rank with 69%. DP was more frequent in specialists with higher age and experience, populated provinces, higher deprivation, and share of private hospitals. Faculty physicians (OR=0.69), full-time geographic physicians (OR=0.17), specialists with more than 25 years’ experience (OR=2.59) and age more than 40 yr (OR=1.3) had significant association with dual practice. Conclusion: Multi-approach strategy is needed to control dual practice through tax regulations, income cap, and limitations in work hours and number of visits in private sector.      


1. Shrime MG, Bickler SW, Alkire BC, Mock C (2015). Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health, 2:S8-S9.
2. Groen RS, Samai M, Stewart KA et al (2012). Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet, 380:1082-7.
3. Kushner AL, Cherian MN, Noel L et al (2010). Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anesthesia in 8 low-and middle-income countries. Arch Surg, 145:154-159.
4. BC Ministry of Health, Provincial Surgical Executive Committee (2015). Future directions for surgical services in British Columbia. ed., Victoria, BC.
5. Popovic JR (2001). 1999 National Hospital Discharge Survey: Annual Summary with detailed diagnosis and procedure data. National Center for Health Statistics. Vital Health Stat, 13(151). (151):i-v, 1-206.
6. Zalani GS, Khalilnezhad R, Mirbahaeddin E et al (2018). Human resources for health strategies: the way to achieve universal health coverage in the Islamic Republic of Iran. East Mediterr Health J, 24:846-854.
7. Johannessen K-A, Hagen TP (2014). Physicians’ engagement in dual practices and the effects on labor supply in public hospitals: results from a register-based study. BMC Health Serv Res, 14:299.
8. Jan S, Bian Y, Jumpa M, Meng Q et al (2005). Dual job holding by public sector health professionals in highly resource-constrained settings: problem or solution? Bull World Health Organ, 83:771-776.
9. Bayat M, Shokri A, Khalilnezhad R et al (2018). Effect of dual practice on service delivery time by surgeons in the Islamic Republic of Iran: multi-level analysis of a national survey, 2016. East Mediterr Health J, 24(9):866-876.
10. Ferrinho P, Van Lerberghe W, Fronteira I et al (2004). Dual practice in the health sector: review of the evidence. Hum Resour Health, 2(1):14.
11. Humphrey C, Russell J (2004). Motivation and values of hospital consultants in south-east England who work in the national health service and do private practice. Soc Sci Med, 59(6):1241-1250.
12. Iversen T (1997). The effect of a private sector on the waiting time in a national health service. J Health Econ, 16:381-396.
13. Armstrong W (2000). The consumer experience with cataract surgery and private clinics in Alberta: Canada's canary in the mine shaft. ed. Alberta Chapter of Consumers Association of Canada.
14. Berman P, Cuizon D. Multiple public-private jobholding of health care providers in developing countries. An exploration of theory and evidence Issue paper-private sector London: Department for International Developmnent Health Systems Resource Centre Publication; 2004.
15. Christen P (2012). Data matching: concepts and techniques for record linkage, entity resolution, and duplicate detection. ed. Springer Science & Business Media.
16. Cheng TC, Joyce CM, Scott A (2013). An empirical analysis of public and private medical practice in Australia. Health Policy, 111(1):43-51.
17. Bayat M, Shokri A, Khodadost M et al (2018). Factors influencing medical specialists' dual practice in the Islamic Republic of Iran. East Mediterr Health J, 24(9):877-887.
18. Ashmore J, Gilson L (2015). Conceptualizing the impacts of dual practice on the retention of public sector specialists-evidence from South Africa. Hum Resour Health, 13:3.
19. Morris S, Elliott B, Ma A et al (2008). Analysis of consultants' NHS and private incomes in England in 2003/4. J R Soc Med, 101(7):372-380.
20. Iran IPo: Administrative recruitment regulations for non-faculty members. Tehran: Islamic Parliament of Iran; 2012;54:17.
21. Bloor K, Maynard A, Freemantle N (2004). Variation in activity rates of consultant surgeons and the influence of reward structures in the English NHS. J Health Serv Res Policy 9:76-84.
22. González P, Macho-Stadler I (2013). A theoretical approach to dual practice regulations in the health sector. J HEALTH ECON, 32:66-87.
23. Wibulpolprasert S, Pengpaibon P (2003). Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Hum Resour Health, 1:12.
24. Sherr K, Mussa A, Chilundo B et al (2012). Brain drain and health workforce distortions in Mozambique. PloS one, 7:e35840.
25. Spiegel DA, Gosselin RA (2007). Surgical services in low-income and middle-income countries. Lancet, 370(9592):1013-1015.
26. Bayat M, Salehi Zalani G, Harirchi I et al (2018). Extent and nature of dual practice engagement among Iran medical specialists. Hum Resour Health, 16:61.
27. Russo G, McPake B, Fronteira I, Ferrinho P (2013). Negotiating markets for health: an exploration of physicians’ engagement in dual practice in three African capital cities. Health Policy Plan, 29(6):774-783.
28. McPake B, Russo G, Tseng F-M (2014). How do dual practitioners divide their time? The cases of three African capital cities. Soc Sci Med, 122:113-121.
29. Salehi Zalani G, Bayat M, Shokri A et al (2016). Affecting Factors on the Performance of Community Health Workers in Iran's Rural Areas: A Review Article. Iran J Public Health, 45(11):1399-1410.
How to Cite
BAYAT M, KHALILNEJAD R, AKBARI-SARI A, HARIRCHI I, SALEHI ZALANI G, MIRBAHAEDDIN SE, KHODADOST M, JAFARI POOYAN E, YASERI M, SHOKRI A. Factors Associated with Dual Practice in Surgery Specialists: Application of Multi-Level Analysis on National Registry Data. Iran J Public Health. 48(5):882-892.
Original Article(s)