Multiple Job Holding Among Public Sector Medical Doctors, Professional Nurses and Rehabilitation Therapists in Gauteng and Mpumalanga

Abstract

Background Multiple job holding (MJH), defined as public sector health professionals having a second job in the private sector, is a ubiquitous practice across health systems globally. In South Africa, MJH is legally permissible, albeit with clear stipulations in the Remunerative Work Outside the Public Service (RWOPS) policy. This PhD addresses knowledge gaps on the extent, forms and determinants of MJH among South Africa’s public sector health professionals, their preferences for different MJH regulations, and the perspectives of stakeholders on the RWOPS policy. Aim The aim of the PhD study was to examine multiple job holding and its regulation among public-sector health professionals. The specific objectives of the study were to: 1. Explore the perspectives of stakeholders on the implementation of the RWOPS policy. 2. Explore the experiences of public sector medical doctors, professional nurses, and rehabilitation therapists concerning MJH. 3. Describe the extent of different forms of MJH among public sector health professionals. 4. Determine the factors influencing MJH among public sector health professionals. 5. Investigate the relative trade-offs between different incentives and restrictions to influence MJH in the public sector. Methods Between 2021 and 2022, a sequential mixed-methods study was conducted in 29 public sector hospitals in the Gauteng and Mpumalanga provinces of South Africa. Drawing on the health labour market approach, MJH framework, as well as labour, organisational, and regulatory compliance theories, the study consisted of three components: 33 key informant interviews; 30 in-depth interviews with health professionals; and a survey that incorporated a discrete choice experiment (DCE) involving 486 medical doctors, 571 professional nurses, and 340 rehabilitation therapists. Thematic analysis and MAXQDA PLUS 2022 were used for qualitative data analysis, while Stata® 17 was used for quantitative analysis. Results The MJH prevalence differed significantly across the three professions: 38.7% among rehabilitation therapists; 33.7% among medical doctors; and 8.6% among professional nurses. Across all professional groups, income supplementation was the primary driver for MJH, but secondary drivers included job variety and professional fulfilment. MJH was significantly more likely among medical specialists (OR 4.3, p<0.001), married professional nurses (OR 2.4, p=0.022) and male rehabilitation therapists (OR 2.4, p=0.005). vi In the discrete choice experiment doctors, nurses, and rehabilitation therapists were strongly opposed to banning MJH, requiring salary increases of 45.7%, 20.0%, and 42.8%, respectively, to accept a ban. However, non-financial incentives were also influential, with doctors, nurses, and rehabilitation therapists willing to forgo 57.9%, 54.8%, and 38.9% of their salaries, respectively, for an improved clinical practice environment. An improved practice environment and facility management could improve public sector retention, even if MJH is prohibited. Ambiguity about the RWOPS policy, initially adopted as a retention strategy in the public health sector, affects its compliance and management which varied in the two study provinces. Doctors (84.7%) and rehabilitation therapists (87.4%) were more likely to obtain RWOPS approval, compared to professional nurses (19.2%). However, health professionals generally supported the implementation of mandatory RWOPS approval, but this differed by category and engagement in MJH. Conclusion This PhD study advances the scientific discourse on the extent, forms, and drivers of MJH among public sector health professionals and provides novel insights into MJH regulatory preferences among health professionals. The high reported prevalence of MJH could adversely affect the care of public-sector patients. The ambiguity about the RWOPS policy influences its perceived legitimacy, compliance and enforcement. The DCE demonstrates the importance of positive practice environments and competent management for MJH mitigation. The study findings have global relevance but should inform the review and possible revision of existing MJH policies in South Africa.