Transformative Education
for Health Professionals

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Key Policy Issue #2: The scope of regulation and accreditation

Typically, the following aspects of health professions that are regulated rather than left to the market are:

  1. access to education institutions;
  2. curricula;
  3. access to practice and the scope of tasks that can be performed;
  4. quality of professional education and respect of ethical norms; and
  5. continuing maintenance of competencies.

Regulatory mechanisms include accreditation, licensure (and sometimes periodical re-licensure), professional inspection and compulsory continuing education. As regards the education of health professionals, important questions are: who can set up a training/educational institution; should there be international/national standards for programmes, curricula, qualification of educators? How can regulation contribute to scaling up the quantity of health professionals and the quality and relevance of their education and training?

The most common approach to accreditation of institutions and programmes is the process model that includes: self-evaluation based on agreed standards; a peer review that usually includes a site visit; and a report indicating the outcome of the accreditation (full accreditation, conditional accreditation and no accreditation). A ministry, a professional regulatory body, a national accrediting body or a professional society may carry it out. However, in more than half the countries of the world, reviews of schools and programmes are not done at all or not adequately (Uys and Coetzee, 2012). There is only weak evidence of a causal link between accreditation and higher quality. When accreditation is voluntary, the likelihood of such an association is higher, but the explanation may be that it is only those higher quality institutions that choose to become accredited (Sutherland & Leatherman, 2006).

In low-income countries, the existence of a statutory authority for the regulation of the medical, dental, pharmaceutical, nursing and midwifery professions is common, but rare for mid-level health workers, leaving them in a legal limbo. In a small number of countries, there exists a Council for Professions Allied to Medicine, which, in certain cases, does cover clinical officers and medical assistants. In terms of effectiveness, there are sometimes grave deficiencies in the processes of determining competence to practice. Two deficiencies in particular are highlighted: the evolving roles of health workers are not adequately recognized (an example is the emergence of new prescribers in response to the HIV epidemic); and lifetime registration implying that there is a major risk of skill decay over time. This is particularly likely to occur when the regulatory body is a branch of the same entity responsible for training health workers (e.g. ministry of health) where graduates of the training programmes are automatically licensed to practice with no independent assessment of competency (Johnson, 2012). However, good practice in the shape of the shift from a single lifetime registration or licensure to a pattern of periodic re-licensure subject to evidence of continuous professional development and/or re-assessment of competence to practice is increasingly encountered.