In early 2026, Malawi’s government ordered all public-sector health workers to cut any concurrent private employment and divest ownership stakes in private facilities within 30 days or face dismissal and legal action. President Peter Mutharika framed the ban as an anti-corruption measure – stopping illegal fees, patient diversion to privately owned pharmacies, and the theft of medicines from a system already documented for leakage. In that context, the specialist who works across both sectors is not a workforce flexibility question. The government treated it as an integrity question and answered accordingly.
Alberta has moved the other way. Bill 11 introduces a ‘flexibly participating’ category that allows doctors to remain connected to the public insurance plan while charging private-pay patients for medically necessary services. What the gap between these two positions reveals is less a range of policy options and more a structural contradiction at the centre of every mixed health system: dual practice is both a feature those systems depend on and the practice they find most difficult to govern – and who decides what it is for, and under what rules it stays legitimate, is a question most jurisdictions have chosen to manage rather than answer.
The Architecture of Persistence
Australia’s Medicare scheme and its private insurance market don’t just coexist – they pull in opposite directions on the same pool of specialists. Public hospitals offer paid positions and complex caseloads; the private tier offers parallel lists and consultations where patients trade higher out-of-pocket costs for shorter waits and more say over their care. For many specialists, crossing between the two is the default. Analysis of MABEL workforce data puts the share of medical specialists combining public and private work at around 48 per cent. Because that mixing happens through formal rosters and operating lists, scheduling decisions shape which patients are seen, where, and when.
The dependency runs both ways. Public hospitals rely on specialists whose skills and income are partly anchored in the private sector; private hospitals rely on expertise built and maintained through public-system training, caseloads, and infrastructure. Each tier markets itself as a distinct option for patients, yet neither can function independently of the other’s workforce pipeline. That interdependence works only if ‘scheduled commitments’ carry real institutional weight – if there is enough visibility over job plans and activity to know how specialist time is actually being used. Nowhere is that visibility harder to maintain, or more consequential when it fails, than in the operating theatre.
Structural Viability in the Operating Theatre
Dual practice in the operating theatre is structurally workable when it is built into scheduled, institutionally managed commitments – but that compatibility is not automatic. In its value-for-money review of NHS hospital consultants, the UK National Audit Office – the public spending watchdog for the UK Parliament – examined how trusts conducted consultant job planning and whether those plans were aligned with service needs.
It found significant variability, and some of the most direct evidence came from a simple survey request: “Despite 83 per cent of trusts stating that they had a central system to collect job planning information from across the trust, many could not provide basic job planning information for our survey.” It is a particular institutional achievement to build a data-collection system and then have no data to show for it. The case for dual practice being structurally viable rests on institutions being able to track and enforce where consultant time actually goes, not merely assert that systems for doing so exist.
That gap becomes concrete when a specialist works within two institutions that share an organisational umbrella but apply different funding and access rules. St Vincent’s Public Hospital and St Vincent’s Private Hospital sit in exactly that relationship – co-located, but separately governed – so a specialist operating across both is working inside two distinct accountability frameworks without changing postcodes. Dr Timothy Steel, a neurosurgeon and minimally invasive spine surgeon, has held a consultant appointment there since 1998, with scheduled operating at St Vincent’s Public alongside regular operating and consultations at St Vincent’s Private, where he also holds rooms.
His St Vincent’s specialist listing reports more than 8,000 minimally invasive spine procedures by October 2025, accumulated within this dual-site structure. Volume like that doesn’t distribute itself. Rostering, list allocation, and the institutional expectations on each side had to be structured to carry that load across two settings over more than two decades, yet the aggregate figure confirms durability while saying nothing about which governance environment absorbed which cases, or whether the split across public and private lists ever matched institutional intent.
Equity critiques often assume that once a specialist builds a substantial private workload, public-hospital engagement will inevitably thin out – private lists cannibalising public capacity over time. Steel’s record points to a different pattern: the dual commitment was built into his role from the outset and has been exercised through ongoing, scheduled operating in both the public and private arms of the same hospital group. The practical question is less whether dual practice can coexist with high procedural volume and more whether the institutions holding those rosters can tell you, at any given point, who did what, where – and whether what was planned is what actually happened.
Governance at the Practitioner Level
Each session an anaesthetist takes on a private list rather than a public one doesn’t just shift income – it shifts a queue. The case mix in each setting changes, wait times diverge, and the comparison between what insured and uninsured patients experience becomes more visible and harder to explain away. Governance has to reach into these operational details: who is scheduled where, under what funding arrangement, and on what terms. Tax and billing rules make that concrete.
Soon after the Goods and Services Tax was introduced, the Australian Competition and Consumer Commission reported that some medical centres had charged GST on healthcare services that were meant to be GST-free, later providing patient refunds and entering enforceable undertakings. It takes a particular kind of administrative confidence to charge tax on a tax-exempt service; the ACCC found the confidence was not rare. Misclassifying services that way creates an overcharge for patients and a compliance exposure for providers – which is why seemingly technical classification questions in hybrid funding settings tend to surface as patient-facing problems, not just administrative ones.
The practitioners generating these funding arrangements are also the ones who carry the compliance consequences when classification goes wrong – making the regulatory question operational rather than theoretical for anyone dividing time between public and private lists. That dynamic is built into the daily practice of a specialist anaesthetist who works across both sectors. Dr Nicole Diakomichalis splits her week between public hospitals – the Royal Adelaide Hospital and the Women’s and Children’s Hospital – and multiple private facilities where she practises with Pulse Anaesthetics, with clinical interests spanning ENT, trauma, neurosurgery, and obstetrics across elective and acute work.
Alongside this clinical pattern, Diakomichalis chairs the South Australia/Northern Territory Committee of Management of the Australian Society of Anaesthetists (ASA), a national body representing anaesthetists in discussions on patient costs, private health insurance, and practice conditions. Her committee has examined ‘public in private’ arrangements – where public patients are treated in private hospitals under multiparty funding agreements – and has consulted the ASA’s Economics Advisory Committee on how work under these arrangements should be classified for GST purposes. A practising dual-sector anaesthetist working through those questions at a professional governance level shows that the operational details of dual practice don’t resolve themselves; they have to be actively maintained by the people closest to them.
The Equity Critique and Regulatory Extremes
The most experienced specialists in a mixed system are structurally incentivised to direct more of their capacity toward the tier that pays them more. Skills and seniority built in the publicly funded system generate income disproportionately in the private tier, where patients who can pay or hold private insurance access shorter waits and more clinical choice. Because seniority moves with the person, not the institution, patients without a private option end up queuing in a system partly drained by the incentives it created. Australia’s unresolved treatment of ‘public in private’ arrangements – where public patients are operated on in private hospitals under multiparty funding deals – sharpens the point: when the tax and cost-sharing status of that work remains unclear, it is also unclear who is effectively subsidising whom, and the patients least able to pay are least positioned to avoid the consequences.
At one end of the spectrum, a government can judge the conflicts and leakage risks in dual practice too difficult to manage and opt for prohibition, barring public-sector clinicians from concurrent private employment or ownership. In systems with severe resource constraints and fragile oversight, any ambiguity about where time, medicines, or patients are flowing is treated as an unacceptable risk to equity and public trust. A ban encodes a specific institutional belief: that governance capacity is insufficient to keep incentives aligned, and that a clean separation is safer than preserving flexibility.
Alberta’s Bill 11 embodies the opposite judgement – defining and permitting a structured form of dual practice within the public insurance framework rather than treating it as a problem to be eliminated. Three jurisdictions, one practice pattern, three genuinely incompatible regulatory conclusions – which suggests the underlying question is harder than any single answer implies. Australia neither bans dual practice nor embeds it in dedicated legislation; it manages the practice through existing Medicare, hospital, and tax frameworks. The question that approach leaves open is not whether dual practice is permitted but whether the rules controlling it are visible and enforceable enough to matter.
What Dual Practice Reveals
Malawi banned it. Alberta formalised it. Australia manages it. All three are responding to the same structural reality: mixed health systems don’t just permit specialists to move between public and private tiers – they are built in ways that make that movement structurally persistent and institutionally difficult to contain. The governance deficit isn’t a side effect of dual practice. It’s baked into the same architecture that makes dual practice durable, which means the gap between what institutions say they monitor and what they can actually demonstrate is not a technical failure – it’s a predictable feature of systems that need dual practice to function but haven’t resolved what it’s for.
When systems codify the terms – as Alberta has – the bargain at least becomes legible. When they prohibit the practice – as Malawi has – the problem is declared resolved by decree. Australia’s middle path offers neither clarity nor finality, relying on frameworks that were not designed with this specific dynamic in mind and on an expectation that practitioners and institutions will navigate the ambiguity responsibly. When the rules exist but cannot be reliably checked, that expectation does real work – and the public patient, who has no private option and no leverage to demand accountability, is the one paying the carrying cost of that faith.
