Variations in regulations to control standards for training and licensing of physicians: a multi-country comparison

Deconcentrating regulation in low- and middle-income country health systems: a proposed ambidextrous solution to problems with professional regulation for doctors and nurses in Kenya and Uganda

BACKGROUND

Regulation can improve professional practice and patient care, but is often weakly implemented and enforced in health systems in low- and middle-income countries (LMICs). Taking a de-centred and frontline perspective, we examine national regulatory actors' and health professionals' views and experiences of health professional regulation in Kenya and Uganda and discuss how it might be improved in LMICs more generally.

METHODS

We conducted large-scale research on professional regulation for doctors and nurses (including midwives) in Uganda and Kenya during 2019-2021. We interviewed 29 national regulatory stakeholders and 47 subnational regulatory actors, doctors, and nurses. We then ran a national survey of Kenyan and Ugandan doctors and nurses, which received 3466 responses. We thematically analysed qualitative data, conducted an exploratory factor analysis of survey data, and validated findings in four focus group discussions.

RESULTS

Kenyan and Ugandan regulators were generally perceived as resource-constrained, remote, and out of touch with health professionals. This resulted in weak regulation that did little to prevent malpractice and inadequate professional education and training. However, interviewees were positive about online licencing and regulation where they had relationships with accessible regulators. Building on these positive findings, we propose an ambidextrous approach to improving regulation in LMIC health systems, which we term deconcentrating regulation. This involves developing online licencing and streamlining regulatory administration to make efficiency savings, freeing regulatory resources. These resources should then be used to develop connected subnational regulatory offices, enhance relations between regulators and health professionals, and address problems at local level.

CONCLUSION

Professional regulation for doctors and nurses in Kenya and Uganda is generally perceived as weak. Yet these professionals are more positive about online licencing and regulation where they have relationships with regulators. Building on these positive findings, we propose deconcentrating regulation as a solution to regulatory problems in LMICs. However, we note resource, cultural and political barriers to its effective implementation.

"If You Do Not Take the Medicine and Complete the Dose…It Could Cause You More Trouble": Bringing Awareness, Local Knowledge and Experience into Antimicrobial Stewardship in Tanzania

Antimicrobial resistance (AMR) is a global health issue disproportionately affecting low- and middle-income countries. In Tanzania, multi-drug-resistant bacteria (MDR) are highly prevalent in clinical and community settings, inhibiting effective treatment and recovery from infection. The burden of AMR can be alleviated if antimicrobial stewardship (AMS) programs are coordinated and incorporate local knowledge and systemic factors. AMS includes the education of health providers to optimise antimicrobial use to improve patient outcomes while minimising AMR risks. For programmes to succeed, it is essential to understand not just the awareness of and receptiveness to AMR education, but also the opportunities and challenges facing health professionals. We conducted in-depth interviews (n = 44) with animal and human health providers in rural northern Tanzania in order to understand their experiences around AMR. In doing so, we aimed to assess the contextual factors surrounding their practices that might enable or impede the translation of knowledge into action. Specifically, we explored their motivations, training, understanding of infections and AMR, and constraints in daily practice. While providers were motivated in supporting their communities, clear issues emerged regarding training and understanding of AMR. Community health workers and retail drug dispensers exhibited the most variation in training. Inconsistencies in understandings of AMR and its drivers were apparent. Providers cited the actions of patients and other providers as contributing to AMR, perpetuating narratives of blame. Challenges related to AMR included infrastructural constraints, such as a lack of diagnostic testing. While health and AMR-specific training would be beneficial to address awareness, equally important, if not more critical, is tackling the challenges providers face in turning knowledge into action.

Impact of a multifaceted intervention on physicians' knowledge, attitudes and practices in relation to pharmaceutical incentivisation: protocol for a randomised control trial

INTRODUCTION

In settings where the private sector constitutes a larger part of the health system, profit-gathering can take primacy over patients' well-being. In their interactions with pharmaceutical companies, private general practitioners (GPs) can experience the conflict of interest (COI), a situation whereby the impartiality of GPs' professional decision making may be influenced by secondary interests such as financial gains from prescribing specific pharmaceutical brands.

METHODS AND ANALYSIS

This study is a randomised controlled trial to assess the impact of a multifaceted intervention on GPs' medical practice. The study sample consists of 419 registered GPs who own/work in private clinics and will be randomly assigned to intervention and control groups. The intervention group GPs will be exposed to emotive and educational seminars on medical ethics, whereas control group GPs will be given seminars on general medical topics. The primary outcome measure will be GPs' prescribing practices, whereas the secondary outcome measures will be their knowledge and attitudes regarding COI that arises from pharmaceutical incentivisation. In addition to a novel standardised pharmaceutical representatives (SPSR) method, in which field researchers will simulate pharmaceutical marketing with GPs, presurvey and postsurvey, and qualitative interviewing will be performed to collect data on GPs' knowledge, attitudes and practices in relation to COI linked with pharmaceutical incentives. Univariate and multivariate statistical analyses will be performed to measure a change in GPs' knowledge, attitudes and practices, while qualitative analysis will add to our understanding of the quantitative SPSR data.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Pakistan National Bioethics Committee (# 4-87/NBC-582/21/1364), the Aga Khan University (# 2020-4759-1129) and the London School of Hygiene and Tropical Medicine (# 26506). We will release results within 6-9 months of the study's completion.

TRIAL REGISTRATION NUMBER

ISRCTN12294839.

An overview of health workforce education and accreditation in Africa: implications for scaling-up capacity and quality

BACKGROUND

For countries to achieve universal health coverage, they need to have well-functioning and resilient health systems. Achieving this requires a sufficient number of qualified health workers and this necessitates the importance of investments in producing and regulating health workers. It is projected that by 2030, Africa would need additional 6.1 million doctors, nurses, and midwives. However, based on the current trajectory, only 3.1 million would be trained and ready for service delivery. To reduce current shortages of the health workforce, Africa needs to educate and train 3.0 million additional health workers by 2030. This study was conducted to describe the distribution and ownership of the health training institutions, production of health workers, and the availability of accreditation mechanisms for training programmes in the WHO African Region.

METHODS

A cross-sectional study was conducted using a standardized questionnaire from January 2018 to April 2019. All the 47 countries in the Region were invited to complete a structured questionnaire based on available secondary information from health sector reports, annual HRH reports, country health workforce profiles, and HRH observatories and registries.

RESULTS

Data from 43 countries in the World Health Organization African Region in 2018 show that there were 4001 health training institutions with 410, 1469 and 2122 being medical, health sciences, and nursing and midwifery schools, respectively, and 2221, 1359 and 421 institutions owned by the public, private for-profit and private not-for-profit sectors, respectively. A total of 148 357 health workers were produced in Region with 40% (59, 829) being nurses and midwives, 19% (28, 604) other health workers, and 14% (20 470) physicians. Overall, 31 countries (79%) in the Region have an accreditation framework for the health training institutions and seven countries do not have any accreditation mechanism.

CONCLUSION

To achieve universal health coverage, matching of competencies with population needs, as well as increasing capacities for health worker production to align with demand (numbers and skill-mix) for improved service delivery should be prioritized, as this would improve the availability of skilled health workforce in the Region.

Type of Findings Generated by the Occupational Therapy Workforce Research Worldwide: Scoping Review and Content Analysis

Occupational therapists are needed to meet the health and occupational needs of the global population, but we know little about the type of findings generated by occupational therapy workforce research conducted worldwide. We aim to synthesize these findings and their range of content to inform future investigations. A scoping review with content analysis was used. Six scientific databases, websites of official institutions, snowballing, and key informants were used for searches. Two independent reviewers took selection decisions against the eligibility criteria published a priori in the review protocol. Of the 1246 unique references detected, 57 papers were included for the last 25 years. A total of 18 papers addressed issues of attractiveness and retention, often in Australia, and 14 addressed the issues of supply, demand, and distribution, often in the US. Only these two categories generated subtopics. Many workforce issues were rarely addressed as a main topic (e.g., race/ethnic representation). Cross-national, cross-regional, or cross-professional studies generated more actionable findings. Overall, we found few discernable trends, minimal evidence of research programs, and various gaps in content coverage or in the use of contemporary research approaches. There is a need for a coordinated strengthening of the occupational therapy workforce research worldwide.

Which Contributes to Clinical Performance: Academic Output or Person–Environment Fit?

Background

The measures put in place by health authorities to ensure the professionalism of doctors are important. Hospitals in China have included academic outputs in the promotion criteria to incentive medical clinicians to engage in scientific research so that to improve job performance (JP). However, such practice disproportionally focuses on academic outputs but ignores the force of needs fulfilled brought by intrinsic incentive. This study aims to discuss the realistic problem regarding the promotion mechanism and the potential drivers to clinical JP.

Methods

This study was based on multi-source data collection on clinical performance from electric medical record (EMR), person-environment (P–E) fit from the survey, and academic output from personnel files of ward clinicians (n = 244) of general public hospitals who sought for career progression in Shanghai in 2020. Independent-Sample t-test and chi-square test were used for comparison of two sample means or constituent ratio between promoted and not promoted clinicians. Linear multilevel regression was conducted to examine the relationship between clinical performance and academic outputs and P–E fit.

Results

Clinicians who were promoted were more productive in producing academic outputs than those who were not (t = −5.075, p < 0.001). However, there was no difference in clinical performance between the two groups (t = −1.728 to 0.167, p > 0.05). The regression showed that academic outputs were not related to clinical performance, while higher P–E fit was associated with the improvement of various clinical performances.

Conclusion

This study shows that P–E fit plays a more important role in facilitating clinical performance than academic performance and highlights the importance of intrinsic motivation of clinicians in achieving clinical performance.