Exploration of Policy and Regulatory Frameworks for Dual Clinical Practice toward Universal Health Coverage: Evidence from South Sudan

Abstract

Background: Dual clinical practice (DCP) is prevalent among healthcare workers in South Sudan, yet no specific, legally binding regulatory framework governs the practice. This study assessed the socio-demographic profiles of participants, examined existing policy frameworks, and proposed context-appropriate regulatory options for managing DCP in Juba, South Sudan. Methods: A mixed-methods, cross-sectional, sequential study was conducted in Juba, South Sudan, from March to April 2026 among 288 healthcare workers selected through multistage stratified random sampling from 20 public and private health facilities. Qualitative data were obtained through 22 purposively selected key informant interviews and three focus group discussions involving policymakers, academics, professional bodies, health service users, and community members. Quantitative data were analysed using descriptive statistics (frequencies, proportions, and 95% confidence intervals), while qualitative data were analysed thematically using ATLAS.ti version 7. Results: Among the participants, 52.8% were male, and approximately 40% were aged 20–29 years. Regulatory awareness was critically low: only 15.6% (95% CI: 11.5–20.1) reported knowledge of existing DCP policies, 33.7% (95% CI: 28.5–38.9) reported no awareness, and 50.7% (95% CI: 44.8–56.3) were uncertain. Only 14.9% believed that the current framework adequately regulated DCP, while 66% considered DCP acceptable under appropriate regulation. Qualitative findings consistently indicated strong opposition to outright prohibition, with participants advocating a regulatory approach incorporating salary reform, improved working conditions, conflict-of-interest management, and accountability mechanisms. A desk review of South Sudanese policy documents further indicated that, although the 2011–2015 human resources for health policy recommended establishing a DCP governance framework, subsequent national health policies remain silent on the practice and provide no explicit regulatory guidance. Conclusion: South Sudan faces a substantial health-policy and regulatory gap in governing DCP. The findings support the development of a permissive, context-specific, and politically feasible regulatory framework that combines financial incentives for healthcare workers, improved working conditions, conflict-of-interest disclosure, and accountability mechanisms rather than prohibition. Policymakers should prioritise multisectoral stakeholder involvement in co-designing and implementing evidence-informed DCP governance policies that strengthen health-worker performance and support progress towards Universal Health Coverage (UHC).