Impact of Physician Dual Practices on a Pediatric-Oncology Outreach-Program

Objective: Physician dual practices (PDP) can be defined as ‘doctors combining clinical work in public and private health-sector.’ This study explores the impact of PDP on a long-term pediatric-oncology outreach-program between large referral hospitals in the Netherlands, Indonesia and Kenya. Methods: This cross-sectional descriptive study used a self-administered semi-structured survey. The most senior doctor from each partner site was interviewed in June 2022. The survey contained 70 closed-ended and 7 open-ended questions and took 30-45 minutes to complete. Closed-ended questions were evaluated on 2-5 point rating scales. Informed consent was acquired and respondents endorsed the final report. Results: In the Netherlands an estimated 0-20% of senior doctors combine work in public and private-sector, while 60-80% do so in Indonesia and Kenya according to the respondents. In Indonesia and Kenya, most of doctors are involved in PDP to augment low government salaries. Impact of PDP on pediatric-oncology care is minimal in the Netherlands, but detrimental in Indonesia and Kenya: shortage of experienced doctors, limited supervision of junior staff, slow diagnostics and delays in chemotherapy administration ultimately lead to undermining of the quality of care and adverse patient outcomes. Conclusions: PDP adversely impact patient care at the Indonesian and Kenyan partner sites of a pediatric-oncology outreach-program. Strategies addressing PDP in resource-poor settings are required to improve treatment outcomes and survival of children with cancer.


Introduction
however is more common in LMIC than HIC. The impact PDP may therefore have on healthcare delivery to the general and poor population may differ across countries and is closely related to the organization of health-systems (Hoogland et al., 2022).
Around 90% of children with cancer reside in LMIC. Whether children can effectively be treated for cancer depends significantly on where children live. Childhood cancer survival approaches 80% in HIC and is commonly below 30% in LMIC (El Salih et al., 2022;WHO, 2021). Hospitals try to close this survival gap by participating in outreach-programs. Through these programs knowledge, skills and expertise can be shared between HIC and LMIC (El Salih et al., 2022;Ribiero et al., 2016).
Limited knowledge is available about the role PDP play in pediatric-oncology outreach-programs and how it might obstruct their joint strive for better childhood cancer survival. This study explores the impact of PDP on an outreach-program between three large public referral hospitals in Netherlands, Indonesia and Kenya.

Setting
There is a long-term cooperation between Princess Máxima Center in Netherlands (HIC), Dr Sardjito Hospital in Indonesia (LMIC) and Moi Teaching and Referral Hospital in Kenya (LMIC). At the Dutch partner site, 600 children are annually diagnosed with cancer whose survival is 75%. At the Indonesian partner site, at least 180 children are diagnosed with cancer each year whose survival is 30%. At the Kenyan partner site, approximately 200 children are yearly diagnosed with cancer whose survival is also 30% (El Salih et al.,2022).

Study Design
This cross-sectional descriptive study examined the impact PDP have on a pediatric-oncology outreach-program. The following domains were explored and compared in the three participating outreach partner sites: prevalence of PDP, reasons for working in private and public-sector, positive and negative consequences, and its impact on pediatric-oncology care. The most senior doctor from each partner site was interviewed in June 2022, using a self-administered semi-structured survey. Each respondent was asked to solely report on the situation in their own country. The survey was created based on an extensive literature review. After disclosure of the purpose and content of the study, informed consent was acquired. All respondents received the same survey and were requested to fill it in at home or inside the hospital. The survey contained 70 closed-ended and 7 open-ended questions and took 30-45 minutes to complete. Closed-ended questions were evaluated on 2-5 point rating scales. The respondents endorsed the final report.

Results
During June 2022, the surveys were handed out to the most senior doctor from the Dutch, Indonesian and Kenyan partner site of the pediatric-oncology outreachprogram. All three senior doctors (response rate 100%) returned the survey.

Prevalence of Physician Dual Practices
In the Netherlands an estimated 0-20% of senior doctors combine work in public and private-sector according to the Dutch respondent, while an estimated 60-80% do so in Indonesia and Kenya according to the respondents from these consecutive partner sites. Table 1 illustrates the reasons and consequences of PDP on the health-sector according to the Dutch, Indonesian and Kenyan respondents. In the Netherlands, doctors work in the private-sector to offer less complex interventions that cannot all be dealt with in the public-sector. In Indonesia and Kenya, most doctors are involved in the private-sector to supplement low government salaries. In all three countries, doctors work in the public-sector for the following reasons: social responsibility, access to public resources, job or pension security, and ability to join a professional team or network.

Reasons and Consequences of Physician Dual Practices
Positive consequences of PDP are higher professional satisfaction according to the Dutch senior doctor, and additional income for doctors according to the Indonesian and Kenyan respondents. Negative consequences of PDP on the health-sector are minimal in the Netherlands, but significant in Indonesia and Kenya: demoralized and unmotivated staff in public hospitals, hindrance of Universal Health Coverage implementation, and limited access to care in public hospitals. Table 2 presents the impact of PDP on pediatriconcology care according to the Dutch, Indonesian and Kenyan respondents. Impact of PDP on pediatric-oncology care is minimal in the Netherlands, but detrimental in Indonesia and Kenya: shortage of experienced doctors, limited supervision of junior staff, slow diagnostics and delays in chemotherapy administration ultimately lead to undermining of the quality of care and adverse patient outcomes.

Impact of Physician Dual Practices on Pediatric-Oncology Care
In the Netherlands, PDP are not an issue, and therefore need not be prohibited according to the Dutch senior doctor. He explains that if PDP are clearly discussed and agreed upon formally, the experience of working in a private-practice may even be positive. In Indonesia, addressing the specialist shortage through pediatriconcology training programs is preferred to an outright PDP ban according to the Indonesian senior doctor. In Kenya, PDP also do not have to be prohibited, but need to be addressed by building a culture of self-regulation and accountability according to the Kenyan senior doctor. Hereby, doctors should take responsibility for the care of patients in public hospitals and be held accountable by authorities if they do not provide necessary care.

Discussion
Although PDP are evidently a global practice, (McPake et al., 2016;Ferrinho et al., 2004;Egglestone and Bir, 2006;Moghri et al., 2016) knowledge on its impact on pediatric-oncology outreach-programs is scarce. Our study findings highlight PDP in three hospitals that are geographically and socio-economically diverse. More doctors are involved in PDP in Indonesia and Kenya, than in the Netherlands. In Indonesia and Kenya, doctors primarily work in the private-sector to augment low government pay. In all three settings, doctors work in public hospitals to meet societal expectations and benefit from shared responsibilities in professional networks. The impact of PDP on pediatric-oncology care is minimal in the Netherlands, but profound in Indonesia and Kenya. Nevertheless, both Indonesian and Kenyan doctors think innovative PDP regulation rather than prohibition is the best approach to mitigate the overriding negative impact of PDP on healthcare.
When weighing whether PDP positively or negatively impact health-systems, a tilt towards the negative consequences is the norm irrespective of the settings. All our respondents reported staff shortages and time Impact Physician Dual Practices on Outreach-Program   (Moghri et al., 2016;Garcia-Prado and Gonzalez, 2007;Socha, 2010;Garcia-Prado and Gonzalez, 2011). Ferrinho (2004) argues for instance that PDP enhance private-practices at the cost of public healthcare provision. This might be particularly true for highly specialized niches like pediatric-oncology where outcomes are highly dependent on access, quality and promptness of medical interventions (WHO, 2021;Ribiero et al, 2016) Limited work hours or absenteeism by public-sector doctors may culminate in prolonged waiting time for services in the public-sector (Tranparency International, 2006;Mostert et al., 2015). The latter may provide opportunity for doctors to cream skim affluent patients or those needing less complex interventions from public-sector 'wait lists' to their private-practices. This propagates inequity in access and increases the cost of care within the health-system negating the core principles of universal healthcare for all (Hoogland et al., 2022;Transparency International, 2006;Mostert et al., 2015). Pediatric-oncology outreach-programs are purposed to narrow the inequity in survival gaps between HIC and LMIC through bidirectional exchange of knowledge, skills and expertise. The two critical elements in success and sustainability of such a program are firstly, patients' guaranteed access to quality treatment irrespective of their ability to pay and secondly, a devoted experienced workforce providing full-time  While it is generally accepted, that all governments have to invest in regulation of PDP, the line between restrictive and accommodating interventions is thin. The current absence of social consensus on PDP regulation can partially be explained by the watered down media publicity and cost implications of banning PDP (Hoogland et al., 2022). Various authors proposed a need to intervene particularly in LMIC settings (McPacke et al, 2016;Hoogland et al., 2022;Garcia-Prado and Gonzalez, 2007;Garcia-Prado and Gonzalez, 2011). Optimum regulation depends on a nation's healthcare system (McPacke et al., 2016;Hoogland et al.,2022;Mostert et al., 2015). If monitoring systems, punishments, rewards, and proper government salaries are available, then public and private-sector can sufficiently be monitored to permit PDP (Hoogland et al., 2022;Mostert et al., 2015). But if these elements are absent, then PDP may lead to medical neglect of patients in the public-sector and should be prohibited (Hoogland et al., 2022;Mostert et al., 2015).
This study has several limitations. Caution with generalizability is needed as solely one representative of each partner site was interviewed. The effect of PDP on a single outreach-program between three countries on three continents is explored, which may not be representative for international collaborations in other world regions.
In conclusion, PDP are detrimental to pediatriconcology care in LMIC particularly if left unregulated. It is evident that prevailing health-market dynamics in such settings place the private-sector in competition rather than complementary to the public-sector. Within pediatric-oncology outreach-programs PDP lead to undue competition for the two scarce yet invaluable resources of human expertise and time with cancer patients. An open debate about the role PDP play in pediatric-oncology