The study was conducted with a population composed of 41 MPs, former Health Ministers, Heads of Medical Sciences schools, Hospital Managers and Heads, Ministry of Health officials, Insurance and Social Security Organization officials, general practitioners, specialists, university professors, and experts. All interviewees were men. The highest work experience was 11-20 years (41.6%) with the most abundant education for Ph.D. (48.8%). In terms of individual positions, the highest positions were for academics (26.8%), and the lowest positions for heads of medical schools (5%).
Upon data analyzed, factors affecting the physicians' dual practice in Iran were classified into three main themes: "individual motivational factors", "structural factors," and "historical and cultural factors." individual motivational factors consist of three categories. One of the most important factors affecting the tendency to work in the public and private sectors at the same time was the desire of most people to get the most benefits from different sectors.
Individual motivational factors affecting physicians' dual practice consist of three categories:
1) Individual motivational factors
1-1) Motivation for work in the public sector
1-1-1) Gaining Faculty Position
"Those who are faculty members in public sector use thethis sector as a credit and the private sector as a way to improve their income. Being a faculty member at public universities indicates that the person is of high quality, high in knowledge, and trusted by the scientific community. If such a person works in the private sector, his position in the public sector contributes to his progress in the private sector and consequently gaining a very high income. The most important thing that encourages physicians to work in the public sector at the same time is that the public sector can help them be more successful in the private sector. This means that the public sector is not only an obstacle to their progress in the private sector, but it also helps them"(P8).
"In addition, there are social incentives. For example, one of the social motives is that a university professor can improve the social aspect of her/his character and can get the deserved respect from people" (P11).
1-1-2) Creating Demand for Private Sector Services
"The reason why both sectors are selected is that the public sector is a launching pad for physicians. They get their patients from there. They (patients) come from the public sector, not the private sector. The doctor comes from the public sector to tell the patient that if you stay here, you will lose your foot, you will be blind, you will die, but if you go to the private sector, you will survive. That is why all doctors prefer to keep the public sector as their gateway and patient entrance gateway" (P10).
1-1-3) Interest in education and research
"A large part of the scientific community in the country includes motivated individuals who wish to contribute to the country's scientific progress, increase the science production, and to play an effective role in educating the younger generation. They are intrinsically interested in education and research" (P8).
1-1-4) Job security and earning a secure income
Working in the private sector creates a long-term job security margin, and in any case, makes it easier to get guaranteed income or so-called hand-to-mouth income" (P15).
1-1-5) Using the other benefits of working in the public sector
"In addition to being motivated to work in the academic environment, working with colleagues, the other motivation may be that there are challenges and tensions, for example, in dealing with patients, which can be better managed. For example, if the patient complains about a procedure, the doctor might be better able to handle the problem if he has a position in the government system and therefore prefers to have a role in the public sector" (P34).
1-2) Motivation for work in the private sector
1-2-1) Financial incentives and earning more
"The most important motivation is material incentives. We have no income threshold in our country, so, everyone wants to earn as much money as possible without any predefined threshold for internal specialists, surgeons, etc. There is no limit to monetization. So, she/he counts on it considering her/his potential, and as much energy as she/he can put into it. Let she/he get as much revenue as possible" (P7).
"Because they want money, and the fixed salary does not satisfy their needs" (P21).
1-2-2) Insufficient capacity in the public sector
"Suppose Dr. X, a professor who also works as a subspecialty in my specialized center in this country, has to visit 10 patients in his clinic. However, when it hits 140 patients and his work ends at 4 pm, do I have to keep he/she until 9 pm? I have no clinic, no space, no staff, and no money to give her/him."(P1)
"The surgeon wants to hospitalize her patient, but the state hospital capacity is full. If she/he does not work in a private hospital, where does she want to hospitalize her/his patient?" (P30)
1-2-3) Increasing job independence and reducing restrictions
"There are no restricting public sector laws in the private sector. You want to apply the very strict and restrictive employment laws and regulations to a physician who is a member of the elite community. When do you come? When are you going? You don't even have to come half an hour late. You really cannot force a doctor to visit a large number of patients from the time he/she gets to the hospital until he/she leaves the hospital, and overall, he/she works less than one hour. Finally, some of this character should be respected. These restrictions are less in the private sector" (P22).
1-2-4) Timely Payment
"... Unlike the public sector, the private sector tries to pay wages on time to keep doctors, especially invited physicians. Well, this could be a motivating factor for doctors to be interested in this sector" (P21).
1-2-5) Using the other benefits of working in the private sector
Some respondents pointed other issues that are important in the tendency of physicians to the private sector. These include the desire to acquire private hospital stocks, attractive working environments, and dealing with the upper-middle classes of society.
1-3) Motivation to work in the office
1-3-1) Office as a physician's identity and prestige
"... Besides these, some might say that working in the private sector such as her/his own office is an identity and if we do not have our own office, then the path we started is incomplete. That is, at first, we step into the clinical practice aimed at having an independent office, and our work would be incomplete if we could not achieve that goal …" (P7).
The results of this study showed that structural factors are most important ones in the tendency of physicians to dual practice in the public and private sectors.
1) Structural factors
1-1) Inappropriate service tariffs in public and private sectors
"The question posed by university professors in the public sector is why her wage differs from that of a private practitioner, for example, she/he gets 100 Rial for an operation while her/his counterpart in the private sector gets 1000 Rial?" (P1).
"Dual Practice occurs where there is a class gap. The gap between sectors is particularly high in terms of revenue. This is where dual practice makes sense ..." (P21).
1-2) Problems governing the Public Sector
“See dual practice means a major flaw in the public sector. This is a sign indicating the poor performance of the government. The one says to himself that they are getting a person injured in a road traffic accident, I do her surgery, I stop her bleeding, I am in the operating room for three hours, and finally, I get a merit pay of 1,200,000 Rial six months later. He/she doesn't satisfy, but when she/he steps into the private sector, she finds there a better world, it feels better, it makes him/her less nervous ... "(P15).
"When we give the wage of someone who's doing well in the government system six or seven months later in a quarter yet abject him/his, and then his/her student earns his/her mater's six-month income just in one day. What do you expect? " (P20).
1-3) Integrated Ministry of Health and medical schools
"In my opinion, one of the consequences of the integrated Ministry of Health and medical schools and introducing a faculty member whose main work is not providing health services, is dual practice. They temporarily entered the Ministry of Health, neither of them had an idea of entering the sector, and then they returned to their original job, which was not again the university but the private sector. So, you have loosened the foundation of the country's health system management. One consequence of this integration was the weakened foundation of health system management. Well, here are the consequences" (P33).
1-4) Private sector development
"... You see, until a few years ago that private hospitals had not grown like mushrooms in big cities, the dual practice was not so popular among public sector doctors, and many of these pests didn't exist (...). Well, that is what the private sector is hoping for. That means all the hope of the private sector is for patients to be sent from the public sector to the private sector" (P5).
1-5) Income inequality and the absence of proper tax mechanism
"You see, in the developed countries such as the US, if a doctor wants to do a lot of work, they are allowed to do, but at a rate that goes up, the tax he has to pay goes up a proportion to his increased income and eventually he gets to point where he says to himself that I am just working for the government, at the expense of losing the peace in my life, and staying away from studying and training, to gather wealth for the government. So, she/he does not do this and gets convinced to some extent to work less. The satisfaction limit is not set in our country. Where is your saturation point? So, it is a race that doesn't have a end line and everybody wants to get ahead in this race. Well, this is an issue that doesn't justify working only in the public sector at all" (P2).
Third main factor affecting the physicians' dual practice in Iran corresponds to historical and cultural factors and consists of three classes.
1) Historical and cultural factors
1-1) The importance of the office for the physician from the public's viewpoint
"... The culture of our country, the view that people have on are all influential. For example, I am a doctor who does not have an office, I do not do clinical work, but for example, relatives who do not know what we are doing and are not very familiar with health policy, when we say we do not have an office, they say hopefully you will set up an office (laughing). That is, they look at it as a deficiency. Well, such a look imposes much pressure on someone who is doing a normal task that he may not even enjoy it and doesn't get high wages for doing that" (P3).
1-2) The desire of the majority of society to have alternative revenue sources
"... There is something in our culture that is being reinforced, and doctors benefit from it like everybody, which is rooted in our economic system and is not just about the health sector. Now you see, many people who work at several jobs are out of the health sector. In our economic system, people have learned that they should not put all their eggs in one basket. Because if all of their eggs are in one basket and the basket is broken their wealth will be lost. That is to say, someone who is already an employee is looking for a way to have another revenue resource. Now, if his/her finance is low he works as a taxi driver, or invests somewhere like a stock exchange to have some extra income because he knows it will not to subsistence with employee wages. The doctor thinks the same ... "(P9).
1-3) The historical record of physician' dual practice in the country
"Doctors have been active in two or more medical centers in the country from the past, which has a very long history and we cannot prevent this multifaceted context just with a very simple law" (P14).