Public health doctors in some developing countries earn at best only 20% of what their colleagues in private practice do, a recent study reports. In rural areas they suffer additional disadvantages. Most health staff naturally do all they can to avoid these hardships. "The brain drain is not merely a matter of Congolese doctors moving to South Africa or Philippine nurses to the United States; it also means migration from public to private practice and from rural to urban areas," Wim Van Lerberghe and colleagues report in this month's Bulletin of the World Health Organization.
Those who do not migrate in one of these three ways compensate with "coping strategies". Demanding under-the-counter fees, pressurizing patients to attend private consultations, and selling drugs that are supposed to be free are examples of "predatory" approaches. More acceptable ones may simply involve staff switching between public and private practice to top up their incomes. Administrators may have fewer opportunities than clinicians, but they can also be better placed to misappropriate funds. They can also pursue legitimate alternatives such as teaching, taking other work outside office hours, or doing short-term contracts for development agencies.
"Staff struggling to make ends meet is a major difficulty faced by more than half the national health systems of the world," says Orvill Adams, WHO's Director of the Health Service Provision department. "Yet until recently it has been treated mainly as a problem of corruption rather than the systemic challenge that it is for health services."
Topping-up helps to retain valuable expertise in public service but it also raises financial barriers for access to health care, makes staff less available, and jeopardizes users' trust. In the long run, too, many of the best clinicians end up in private practice and many of the best managers in development agencies. Simple solutions will not work. For instance closing the gap between private and public sector salaries is not affordable for civil services as a whole, and politically difficult to do for only selected parts of them. Downsizing the civil service itself, even where this is achieved, is seldom followed by a narrowing of the salary gap.
An unregulated health service will not be a less predatory one. To prohibit seeking alternative income only drives the practice underground, making it harder to control its ill-effects. The first step, the authors say, is to bring the problem out into the open and recognize its complexity.
