Coping Strategies

This policy brief highlights results from unannounced visits made to a sample of public health facilities in Machakos District with the intention of documenting the proportion of critical health care workers who were absent from their stations of operation. It also presents policy options to address the problem of absenteeism of critical health providers in the health sector. [from author]

District health systems in Africa depend largely on public funding. In many countries, not only are these funds insufficient, but they are also released in an untimely fashion, thereby creating serious cash flow problems for district health managers. This paper examines how the untimely release of public sector health funds in Ghana affects district health activities and the way district managers cope with the situation. [from abstract]

Insufficient attention has been paid to understanding what determines the performance of health workers and how they make labor market choices. This paper reports on findings from focus group discussions with both health workers and users of health services in Ethiopia. We describe performance problems identified by both health users and health workers participating in the focus group discussions including absenteeism and shirking, pilfering drugs and materials, informal health care provision and illicit charging, and corruption.

This presentation describes the issues faced and the measures employed by the Provincial Government Western Cape Department of Health regarding nursing shortages. It describes the issue of contracting with private agencies for nurses and details how the PGWC Department of Health managed this challenge.

The two main objectives of this study were to examine aspects of the acculturation of overseas-born and Australian-trained health professionals in the Australian health discourse and identify key coping strategies used by them when in working in the rural context. [from abstract]

This issue focuses on the health workforce and contains the articles: Could health worker migration bring benefits to Malawi?; Removal of childbirth delivery fees: the impact on health workers in Ghana; Regulation of dual job-holding public sector doctors in Peru; Health worker responses to health sector reforms; and Motivating Tanzanian primary health care workers. [adapted from author]

This article presents the results of a 2002 social audit of the health sector of three Baltic States. Comparisons were made of perceptions, attitudes and experience regarding unofficial payments in the health services of Estonia, Latvia and Lithuania. The findings can serve as a baseline for interventions and to compare each country’s approach to health service reform in relation to unofficial payments. [adapted from abstract]

It is common for doctors working in the public sector to hold second jobs in private practice. Dual medical practice occurs in virtually all countries regardless of income. [author’s description]

Coping strategies have, in some countries, become so prevalent that it has been widely assumed that the very notion of civil services ethos has completely – and possibly irreversibly – disappeared. This paper describes the importance and the nature of pilfering of drugs by health staff in Mozambique and Cape Verde, as perceived by health professionals from these countries. Their opinions provide pointers as to how to tackle these problems. [from abstract]

Work capacity correlates weakly to disease concepts, which in turn are insufficient to explain sick leave behavior. With data mainly from Sweden, a welfare state with high sickness absence rates, our aim was to develop an explanatory theory of how to understand and deal with work absence and sick leave. In this paper we present a theory of work incentives and how to deal with work absence. [from abstract]

This resulted in a collection of papers with very different viewpoints and formats, reflecting the different professional and geographical backgrounds of the participants. We have grouped them under three headings. First a set of papers describes the performance of health personnel in a number of countries and attempts to improve it. A second part looks more closely at the various coping strategies health care workers, medical and paramedical, clinical and managerial, actually apply to deal with difficult working and living conditions.

The objective of this article is to examine in Peru the nature of dual practice (doctors holding two jobs at once - usually public sector doctors with private practices), the factors that influence individuals decisions to undertake dual practice, the conditions faced when doing so and the potential role of regulatory intervention in this area. [from abstract]

This report presents results from the Egypt Health Care Providers Surveys, the objectives of which were to: provide a comprehensive picture of all sources of health care services; provide policy relevant data on critical issues for health sector reform; and create a database on health care providers for use by the Ministry of Health and Population in developing policy reform proposals. Five separate surveys were conducted on health care institutions, private clinics, pharmacies, dayas (traditional birth attendants), and other practitioners. The sample of 10,048 providers was developed from a complete enumeration of all health care providers in sampling areas and data from the 1986 national census.

This presentation was part of the ECSA Workforce Observatory Meeting in Arusha. It describes an evaluative study to determine issues and causes of health worker problems and shortages done in Rwanda to aid in informing policy reform.


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The objective of this article is to explore the type of private practice supplementary income-generating activities of public sector doctors in the Portuguese-speaking African countries, and also to discover the motivations and the reasons why doctors have not made a complete move out of public services. [objective]

The migration of health professionals from southern Africa to developed nations is negatively affecting the delivery of health care services in the source countries. Oftentimes however, it is the reasons for the out-migration that have been described in the literature. The work and domestic situations of those health professionals continuing to serve in their posts have not been adequately studied. The present study utilized a qualitative data collection and analysis method. This was achieved through focus group discussions and in-depth interviews with health professionals and administrators to determine the challenges they face and the coping systems they resort to and the perceptions towards those coping methods. [author’s description]

Many health service managers are familiar with the problem of absenteeism in district hospitals. It affects the running of the hospital and can seriously compromise the quality of care which patients receive. For the purpose of this Kwik-Skwiz absenteeism is defined as staff taking time off that has not been scheduled or staff taking more leave than is necessary or reasonable. Clearly there are many legitimate reasons for taking sick or other types of leave. It is often debatable how much leave is reasonable. It often depends on the pattern and circumstances, rather than the actual total amount of leave that an individual takes. Managers have a responsibility to balance the rights and needs of individual staff members, with the needs of the hospital. High levels of absenteeism, both on the part of individuals or in the whole hospital, are often symptomatic of underlying problems. Addressing these issues can result in lower absenteeism levels that benefits staff, managers and patients. [author’s description]

The broad objective of this paper is to contribute to the retention of health workers in Malawi by providing an enhanced understanding of health workers’ coping strategies, together with the identification of possible strategies that could impact on their retention. [from author]

To explore the extent, characteristics, incentives, effects and possible regulation of private medical practice in public facilities this study undertook a cross sectional quantitative – qualitative analysis. Results from the survey and focus groups reveal that DP is mainly a strategy to obtain better incomes in the face of low public salaries. Furthermore this situation is influenced by the Peruvian macroeconomic environment characterised by an oversupply of doctors caused by the deregulation medical practice and education. DP is common in all types of health facilities and working institutions, and it is closely associated to clinical practices.

There are four types of health providers at present in China. These are defined in terms of differences in ownership. Private practice in the health sector was reintroduced from 1980, when China began its economic reform from a planned economy to a market economy. Dual practice (DP) is quite common and a major concern from the point of view of health policy-making as little is known about it. The aim of this study was to describe policies and regulations of DP, the current situation, its impact on access to services and physician behaviour, and to provide evidence for future policy decisions. This study was conducted in two provinces, Shandong and Sichuan.

This paper examines the policy options for the regulation of dual job holding by medical professionals in highly resource-constrained settings. It draws on the limited evidence available on this topic to assess a number of regulatory options in relation to the objectives of quality of care and access to services, as well as some of the policy constraints that can undermine implementation in resource-poor settings. [from abstract]

The authors report on a study in which unannounced visits were made to health clinics in Bangladesh with the intention of discovering what fraction of medical professionals were present at their assigned post. This survey represents the first attempt to quantify the extent of the problem on a nationally representative scale. [from abstract]

Health sector workers respond to inadequate salaries and working conditions by developing various individual coping strategies; some, but not all, of which are of a predatory nature. The paper reviews what is known about these practices and their potential consequences (competition for time, brain drain and conflicts of interest).

The Chinese government has found it impossible to maintain uniform pay levels, particularly in the face of a radical devolution of its own financial management. Health workers have increasingly resorted to informal methods of earning an income. The government considers this to be unprofessional behavior and has used a combination of moral pressure and loss of professional privileges to discourage it.

This paper reports on income generation practices among civil servants in the health sector, with a particular emphasis on dual practice. It first approaches the subject of public-private overlap. Thereafter it focuses on coping strategies in general and then on dual practice in particular. In this paper dual practice is approached from six different perspectives: what is meant by dual practice; typology of dual practices; prevalence; impact on personal income, the health care system and health status; reasons; and possible interventions. [adapted from author]

We report on income generation and work mix among 100 civil servants who manage public health services in developing countries. Their salary puts these managers among the better-off in their countries. However, 87% of the respondents complement their salaries with other income-generating activities.

This review examines the systemic and individual causes of multiple job holding (MJH) and evidence on its prevalence. MJH should be seen as resulting initially from underlying system-related causes. These include overly ambitious efforts by governments to develop and staff extensive delivery systems with insufficient resources. Governments have tried to use a combination of low wages, incentives, exhortations to public service, and regulation to develop these systems. In many countries, these strategies are not sufficient to outweigh the motivations of and incentives faced by individual health workers in mixed public private labour markets.

We develop a principal-agent model to analyze how the behavior of a physician in the
public sector is affected by his activities in the private sector. We show that the physician will have incentives to over-provide medical services when he uses his public activity as a way of increasing his prestige as a private doctor. The health authority only benefits from the physician’s dual practice when it is interested in ensuring a very accurate treatment for the patient. Our analysis provides a theoretical framework in which some actual policies implemented to regulate physicians’ dual practice can be addressed.