How and why public sector doctors engage in private practice in Portuguese-speaking African countries

Objective: To explore the type of private practice supplementary income-gen erating activities of public sector doctors in the Portuguese-speaking Afri can countries, and also to discover the motivations and the reasons why doc tors have not made a complete move out of public service. Design: cross-sectional qualitative survey. Subjects: In 1996, 28 Angolan doctors, 26 from Guinea-Bissau, 11 from Mozam bique and three from S Tome and Principe answered a self-administered quest ionnaire. Results: All doctors, except one unemployed, were government employees. For ty-three of the 68 doctors that answered the questionnaire reported an inco me-generating activity other than the one reported as principal. Of all the activities mentioned, the ones of major economic importance were: public s ector medical care, private medical care, commercial activities, agricultur al activities and university teaching. The two outstanding reasons why they engage in their various side-activitie s are 'to meet the cost of living' and 'to support the extended family'. Pu blic sector salaries are supplemented by private practice. Interviewees est imated the time a family could survive on their public sector salary at sev en days (median value). The public sector salary still provides most of the interviewees income (median 55%) for the rural doctors, but has become mar ginal for those in the urban areas (median 10%). For the latter, private pr actice has become of paramount importance (median 65%). For 26 respondents, the median equivalent of one month's public sector salary could be generat ed by seven hours of private practice. Nevertheless, being a civil servant was important in terms of job security, and credibility as a doctor. The so cial contacts and public service gave access to power centres and resources , through which other coping strategies could be developed. The expectation s regarding the professional future and regarding the health systems future were related mostly to health personnel issues. Conclusion: The variable response rate per question reflects some resistanc e to discuss some of the issues, particularly those related to income. Neve rtheless, these studies may provide an indication of what is happening in p rofessional medical circles in response to the inability of the public sect or to sustain a credible system of health care delivery. There can be no do ubt that for these doctors the notion of a doctor as a full-time civil-serv ant is a thing of the past. Switching between public and private is now a f act of life.