Health workforce regulation in the Western Pacific Region

Health workforce regulation in the Western Pacific Region

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WHO Library Cataloguing-in-Publication Data

Health workforce regulation in the Western Pacific Region

1. Health manpower – organization and administration. 2. Health personnel.I. World Health Organization Regional Office for the Western Pacific

ISBN 978 92 9061 723 5 (NLM Classification: W 76)

© World Health Organization 2016

All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: bookorders@ who.int).

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All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

Cover photo: WHO

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CONTENTS

Acknowledgements iv1. Introduction 12. Terminology 33. Maturity 44. Components of health workforce regulatory systems 6

4.1. Institutional arrangements 6 4.2. Regulated professions 8 4.3. Education and accreditation 11 4.4. Licensing or registration requirements 14 4.5. Notifications,complaintsanddisciplinaryprocesses 18 4.6. Reciprocal agreements 19

5. Financing 236. Emerging issues 26

6.1. Globalmobility 26 6.2. Telemedicine 26 6.3. Private providers 26 6.4. Interprofessional practice 27

7. Conclusion 29References 32Annex1:Legislation,actsanddecreesconsultedforthisreview,

bycountryandarea 34Annex2:CountriesandareasoftheWesternPacificRegionand number of regulated professions 36Annex3:Questionstoguidethedeskreviewandlistof professionsreviewed 37Annex4:Thebestpracticeregulationmodel:principles and assessments 38Annex 5: Council of Australian Governments principles of best practice regulation 39Annex6:Right-touchregulation,CouncilforHealthcare RegulatoryExcellence 40

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ACKNOWLEDGEMENTS

ThiswaspreparedbyBrendaWraight,Director,BKWraightConsulting,Wellington,NewZealand,fortheHumanResourcesforHealthUnit,RegionalOfficefortheWesternPacific,WorldHealthOrganization,incollaborationwithGülinGedik,TeamLeader,HumanResourcesforHealth.

GratitudeisextendedtoVivianLinandMartinFletcher,whoreviewedthedraftsandprovidedinsightfulcomments.

TheviewsexpressedinthisreportarethoseoftheauthoranddonotnecessarilyreflectthepoliciesoftheOrganization.

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1. INTRODUCTION

Alongwithfiscalandmonetarypolicy,regulationhasakeyroleinshapingthewelfareofeconomiesandsociety,andisoneofthekeyleversforgovernmentinfluence(1).Governmentsregulatehealthservicesandsystemstoimprovethequalityofhealthservicesandhealthoutcomes,ensureequityandaccess,protectthepublic,promotesocialcohesionandincreaseeconomicefficiency(2).

Thecore,commonelementsofmanyregulatorysystemsincludethestandardsrequiredtobecomeregisteredorlicensed(i.e.prescribededucationalpathwaysandqualifications);standardssetforentry intoaprofession;standardsrequiredtomaintainregistration(includingcontinuingprofessionaleducation);andmechanismsfordealingwithpeoplewhobreachthestandards(e.g.howfitnesstopractiseisassessed,andcomplaintsandnotificationsaremanaged).Thearrangements,approachesandprocessesthatareestablishedtoimplementthesesystemsmayvaryconsiderably,accordingtothelegislation(Annex 1),thepurposeoftheregulationitself,andwhetherregulationisprofession-orgovernment-led.

The37countriesandareasthatmakeuptheWorldHealthOrganization(WHO)WesternPacificRegion (Annex 2)arediverse,withrespecttoculture,socio-politicalhistories,populationsizeanddemography,geography,economicprosperity,resourcesandhealthstatus.Thisdiversityismirroredinthesignificantvariationinequitableaccesstohealthcare;inthenumber,typeanddistributionofworkforcesthatprovidehealthservices;andinthedevelopmentandimplementationoflegislationthatregulatestheeducationandpracticeofhealth-careworkers(3).Despitethesedifferences,therearealsoopportunitiestodrawontheexperiencesofmanyofthecountriesandareasintheRegiontobetterunderstandhowtoextendtheknowledgeofregulationandregulatoryprocesses,andfurther,whatsupportcanbeputinplaceatthecountrylevel.

ThisreportprovidesanoverviewofthestatusoftheregulationofthehealthworkforceacrosstheRegion. Itrelatesonlytoregulatoryregimes,nottheoverallfunctionalityofeachareaorwhetherintendedoutcomesarebeingachieved.Thesearewiderissues,beyondthescopeofthisinitialreview.

Publishedinformationrelatingtolegislation,governancearrangements,registrationandrenewalprocesses,accreditationofeducationprovidersandprogrammes,andapproachesforsettingandmonitoringadherencetopracticestandardswasidentifiedthroughadeskreview.Thismaterialwasaugmentedwithinformationfromasmallnumberofinterviews.

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Forthedeskreview,anassessmentwasconductedforeachcountryandarea,byprofession,usingasetofkeyquestions(Annex 3).1

Searchesincludedwebsitesandpublicationsfromnationalandinternationalorganizationsandagencies;governmentdepartmentsandministries;country-specificlegislation,acts,decreesandregulations;professionalassociations;research-basedorganizationsanduniversities;andWHOcollaboratingcentres.Acomprehensivelistofreferencematerialhasbeencompiledandisavailableseparately.

Wheresignificantinformationgapsand/orcontradictoryinformationemerged,interviewswithafewkeyinformantswereundertakentoaugmentandvalidatematerialfromthedeskreview.

Thereviewfindingsidentifiedthatregulationofhealthprofessionalsiswellestablishedinsomecountriesandareas,andanevolvingfeatureofhealthsystemdevelopmentinothers.Thisdiversityisevidentinthevarioussystemsforaccreditingeducationprogrammesandmonitoringproviderperformance, intherangeofapproachesforregulatinghealthprofessionalpractice,andininformationgapsonhowregulationisbeingimplemented.Anumberofemergingissues,suchastelemedicine,andincreasedpopulationandpractitionermobility,complicateanalreadycomplex landscape.

1 Thequestionsthatwereusedtoguidethisreviewsought“yes”or“no”answers,whereasthemorecorrectanswersmighthavebeen“partially”,“inprogress”,“underconsultation”or“unclearaboutextentofimplementation”.

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2. TERMINOLOGY

Terminologyornomenclaturecomprisestermsthatareusedtodescribeprocessesandsystems.Acrosscountries,professions,organizationsandagencies,thereisasubtlebutsignificantdifferenceinterminologyappliedtoaspectsofregulationofhealthprofessionaleducationandpractice.Forexample,theterms“licensure”and“registration”,whichareusedinterchangeably,mayhave(oftensubtly)differentmeaningswithintheregulatorysystemofaparticularcountryorbetweenprofessions.Similarly,theterms“accreditation”and“credentialing”mayhavesimilarorsignificantlydifferentmeanings,dependingonthecontextinwhichtheyareused.Otherterms,suchas“discipline”,mayindicatedifferentsanctionsandpenaltiesfordifferentprofessionalgroups and in different jurisdictions.

ItisbeyondthescopeofthisreviewtoconductanextensiveanalysisoftheextentofvariationinregulatorynomenclatureacrosstheRegion.Nonetheless,thisvariabilityisassumedtohaveanimpactonhowdifferentregulatorysystemsandprocessesaredescribedwithincountriesandareas,andalsoontheapparentextentofgapsinpublishedinformation.2ThereviewthushighlightedtheimportanceofasharedunderstandingoftherangeofterminologyappliedtoregulationacrosstheRegion.

2 Thereviewacknowledgesthepotentialforinterpretativeorconfirmationbias.

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3. MATURITY

Thenotionof“maturity”ofregulatorysystemsissubjective;however,forthepurposeofthisreview,itwastakentomeansystemsthatareembedded,i.e.ingrainedinthecontextandcultureofacountry,andwheretheprinciplesofgoodregulation(andbestpractices)areevidentintheprocesses and structures in place (4). Thereviewacknowledgedthattheterm“goodpractice”isalsosubjective,andperceptionsofbestpracticewillvarydependingontheculturalparadigmandsocio-politicalhistoryineachcountry.However,theprinciplesofgoodandeffectiveregulation(i.e.proportionatetotherisksandcostsinvolved;appliedconsistently;targetingtheproblem;andminimizingside-effects,transparency,accountabilityandrelativeagility)shouldstillapply(5).

Withinthisthemeofmaturity,countriesandareasappeartofall intothreebroadcategoriesor“clusters”withregardtodocumentedregulatorysystemsforeducationandpractice.3Theintentionisnottosignaluniformityinregulatorypractice,aswithineachoftheseclusters,thereisalsovariationacrossmostregulatoryactivities.Theclustersaresimplyonewaytoshowgeneralpatternsandtoindicateapossibleapproachforknowledge-sharing.

Cluster oneThefirstclusterfeaturescountriesandareaswithstrong,embeddedregulatorysystems.Thisincludes recent enactment or amendment of legislation and boards or councils responsible for:registration;settingandensuringadherencetostandards,notificationsandcomplaints;anddiscipline.Thesesystemsappeartobeclearly linkedtoeducation,signallingrolesandresponsibilitiesthatlinkaccreditationofprogrammesand/orproviderstopractice.Theregulatorymechanismcoversthelargestrangeofhealthprofessionalgroupings.CountriesandareasinthisclusterincludeAustralia,HongKongSAR(China),NewZealandandSingapore.

Cluster twoThesecondclustergroupscountriesandareasthathavelegislation,acts,decreesorcodesinplacethatdescribearegulatorysystem,primarilyformedicine,dentistry,nursingandmidwiferyandsometimespharmacy,butoftenpatchyinformationaboutimplementationorhowagreedprofessionalstandardsorcompetenciesaredetermined,monitoredandsanctioned.Thesecountriesandareasalsoappeartohaveweakerlinksbetweeneducationstandardsandaccreditation,aswellasthemechanismsthatensureongoingadherencetostandardsofpractice.Thiscluster

3 Thedelineationbetweenclustersispermeable,asmanycountriesandareascouldbeplacedinanotherclusterforsomeoftheirregulatoryactivities.

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ofcountriesandareasalsohasthelargestvariationintheamountofinformationavailableondifferenthealthprofessiongroups.CountriesandareasinthisclusterincludeChina,Fiji,JapanandthePhilippines.

Cluster threeThethirdclusterincludescountriesandareasthatappeartohavelimitedornosystemsinplace.Anactordecreemayexist,butthereisoftenlittleinformationaboutimplementation;thereisalmosttotalrelianceonforeign-trainedhealthworkforces;theyareunderanothercountry’sjurisdiction;and/ortherearelargeinformationgaps.CountriesandareasinthisclusterincludeFrenchPolynesia,theLaoPeople’sDemocraticRepublic,MongoliaandVietNam.

Countriesandareascouldalsobeclusteredaccordingtootherdimensions,suchasthosewithasimilarsocio-politicalhistoryandthereforeasimilarlegislativebase(e.g.formerBritishcoloniesorformerSocialistcountries).Giventhatdifferencesinsocio-politicalhistoryalsodeterminethedesignandpurposeoflegislation,groupingcountriesandareaswithsimilarhistoriesdoesprovideanopportunityforcross-learningandknowledge-sharing.4

Aswiththe“maturity”clustersabove,therearevariationswithincountriesandareasgroupedbyhistory.Somecrossoversbetweenhistoryandmaturitydimensionsareworthexploringfurther.

4 Toillustrate,countriesandareasthatwereformerlyBritishcoloniesincludeAustralia,Fiji,NewZea-landandSingapore.CountrieswithSocialisthistoriesincludeCambodia,China,LaoPeople’sDemo-craticRepublic,MongoliaandVietNam.

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4. COMPONENTS OF HEALTH WORKFORCE REGULATORY SYSTEMS

Inorganizingthematerialcollected,severalcommoncomponentsandgeneralthemesemerged.Thesesixthemes,whicharediscussedinthefollowingsections,areinherentlycomplex.Eachpieceofinformationidentifiedpotentiallylinkstomanyotherissuesthatcouldbeconsideredbutareoutsidethescopeofthisreview.Nonetheless,thethemesdocorrespondtothecriteria(i.e.principles)thatareknowntoimproveeffectiveregulation,andprovideguidanceforfurtheranalysisthatcouldsupportthedevelopmentofhealthpractitionerregulationacrosstheRegion.

4.1. Institutional arrangements

Thissectionreferstothewayhealthpractitionerregulationisorganizedstructurally,nottotheoverarchinggovernanceofcountriesandareas,jurisdictionalrelationships5orthelegislationthatunderpinsthese.Thedifferentconstitutionalarrangements,internallegislationandregulations,andinternationalconventionsandtreatieswillinevitablyintersectwithhealthprofessionaleducationand practice to some degree.6Thisreviewdidnotseektoexaminethesejurisdictionaldifferences;

The six themes are:

1. the institutional arrangements in place;

2. number of health professions whose practice is regulated (and extent of that regulation);

3. degree to which education and accreditation of programmes links to the setting and ensuring adherence to standards of practice;

4. requirements for licensure (e.g. passing a national exam) and evidence of qualifications from an approved course;

5. the processes for credentialing or approving registration of foreign-trained health practitioners; and

6. the extent to which countries rely on support and supply of health practitioners from other countries, and evidence of intergovernmental agreements for this purpose.

5 TheUnitedStatesofAmericahasspecialrelationswithsixjurisdictionsintheRegion:AmericanSamoa,Guam,MarshallIslands,FederatedStatesofMicronesia,CommonwealthoftheNorthernMarianaIslandsandPalau.Someareindependentnations;othersareterritoriesorcommonwealths,witheachcategorydenotingdifferentcitizenshiporstatusforresidents.FrenchPolynesia,NewCaledoniaandWallisandFutunaareunderFrenchjurisdictionandlaw.6 Forexample,lawsrelatingtotheprotectionofpatientsashealthconsumers(e.g.patientbillofrights,includingaccesstoservicesandmedicaltechnologies),monitoringtheperformanceofthehealthsystem,poisons,andaccesstovaccinesandmedicaltechnologies.

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however,theydidhaveanimpactontheamountofpublishedcountry-specificinformationandontheabilitytocross-referencesomeofthatinformation.

Inrelationtohealthpractitionereducationandpractice,thereisvariationintheextentandcoverageof legislation,howlegislationis interpreted,howregulatorymechanismsandprocessesgiveeffecttolegislation,andaccountabilityarrangementsandgovernance.Inthisreview,governancewastakentomeanthearrangementsinplacethatdictateordenoteaccountabilityamongthelegislator(i.e.governments),theregulatorandthepublic,andhowthesearestructuredandorganized.Therelativematurityofregulatorysystems,andwhetherregulationisgovernment-orprofession-led,appearstoinfluencethetypeofinstitutionalarrangementsinplace,andwhetherotherprofessions(e.g.thelegalprofession)andthegeneralpublicorcommunityareinvolved.

Insomecountriesandareas,regulationofhealthprofessionalsisthedirectresponsibilityoftheministryordepartmentofhealth,suchasCambodia,ChinaandJapan.Othercountrieshavestructuresthatarewithinthegovernmentorministryofhealth,butalsohaveaseparateboardorcouncilforlicensingorregisteringeachprofession.InMalaysia,theProfessionalRegulationCommissionconferslicensingresponsibilitiesonprofession-specificregulatoryboards.Othercountrieshavesystemsthataremoreindependentofgovernment,suchasNewZealandorAustralia,butwhereboardorcouncilmembersareministerialappointments.

Responsibilityforlicensure,settingstandardsanddisciplinemaybeassumedbydifferentagenciesorbodies.Insomecountries,theboardestablishedunderlegislationisresponsibleforallfunctions;inothers,theresponsibilityforregistrationorlicensureanddisciplinemaybeundertheboard,butsettingandassuringstandardsmaybetheresponsibilityofaprofessionalbody(e.g.Fiji).IntheFederatedStatesofMicronesia,governanceandlicensureresponsibilitiessitfirmlywiththe“parent”jurisdiction,butdisciplinarymattersmay(atleastinitially)bewithlocalemployers.Afewrequirethatthedirector-generalorsecretaryofhealthpresidesovertheregulatorybody,includingfordisciplinarymatters,whilesomedelegatethisfunctiontoprofession-specificroles(e.g.achiefnurse).

Informationaboutregistrationrequirementsforforeign-trainedhealthprofessionalsvariesconsiderably,althoughrelianceonhealthprofessionalswhoareforeign-trainediscommontoallcountriesandareasintheRegion,regardlessofthematurityoftheirregulatorysystems.AustraliaandNewZealandimportrelativelyhighnumbersofforeignmedicalgraduatestofillvacanciesinsomemedicalspecialties.Itisbeyondthescopeofthisreviewtoinvestigatethepatterns,issuesandpressuresinrelationtoworkforcemigration,otherthannotingtheirsignificanceformostcountriesandareasintheRegion,andthatingeneral,countriesandareaswithmore“mature”regulatorysystemsarealsolikelytohavemoresophisticatedprocessesforassessingapplicationsforregistrationfromforeign-trainedhealthprofessionals.Theymayalsohaveotherlegislationinplacethatprotectsthepublic(e.g.theCodeofRightsinNewZealand).

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Insummary,governanceandstructuralarrangementsdoappeartobroadlyinfluencethedegreetowhichinitialeducation,qualificationsandlicensuretopracticearelinked,andtheeffectivenessofprocessesthatrelatetoongoingadherencetostandards,managingcomplaintsandimplementingdisciplinarydecisions.

4.2. Regulated professions

ThereiswidevariationinthenumberofhealthprofessionsthatareregulatedintheRegion.LegislationintheCommonwealthoftheNorthernMarianaIslands,forexample,covers28healthprofessions; inAustralia,14; inHongKongSAR(China),13; inNewZealand,16;andinSingapore,8.Othercountriesandareasthathaveregulatorysystemsregulate3–5healthprofessions.CountriesthathavenodocumentedhealthpractitionerregulatorysystemsincludetheLaoPeople’sDemocraticRepublic(althoughlegislationexists),VietNamandsomesmallerPacificislandcountriessuchasTuvalu,althoughtheymayhavearegisterofhealthprofessionals.Fromthedeskreview,itwasoftendifficulttoclarifytheextenttowhichregulationforparticularprofessionscoverededucationaswellaspractice.AsummaryofthenumberofregulatedprofessionsbycountryisincludedinAnnex2.

4.2.1. Medicine, dentistry, nursing and midwifery, and pharmacy

Almostallcountriesthathaveadocumentedregulatorysystemforhealthprofessionalpracticeincludemedicine,dentistry,nursing(andmidwifery),andoftenpharmacyintheirregulatorysystems.Mostcountriesandareas,exceptAustraliaandNewZealand,viewmidwiferyasadvancednursingpractice,andmostregulateitwithinnursinglegislation.

4.2.2. Other professions

Forsomecountriesthatregulateonlymedicine,dentistry,nursingandmidwifery,andpharmacy,thereisalsoinformationonthepresenceofprofessionalassociationsforotheroralliedhealthprofessions(e.g.Fiji)thatmaycarryoutatypeofself-regulatoryroleintermsofdevelopingeducationandstandardsofpractice.Anumberofpublicationsaccessedhighlightedtheimportanceofself-regulationthroughprofessionalbodiesinunderpinningsuccessfulregulation(2).

Informationavailableontheregulationofeducationandpracticeofalliedhealthprofessionalsvaries,asdoesthenumberofalliedhealthprofessionsthatareregulatedinanyonecountry.Australia,HongKongSAR(China)andNewZealandhavelegislationthatregulatesupto10alliedhealthprofessions.SingaporehasaspecificAlliedHealthProfessionsAct(2011)thatregulates

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threealliedhealthprofessions.Japanalsoregulatessomealliedhealthprofessions,suchasphysicalandoccupationaltherapy.

Apartfromthefourcountriesandareasinthefirstcluster,afewinthesecondcluster(e.g.theRepublicofKorea)havealsopassedlegislationtoregulatealliedhealthprofessions.Yettherewasoftenlittleinformationtodemonstratewhetherthatlegislationhasbeenimplemented,orifprocessesareinplacetosetandsanctionstandards.Further,therewerenoobviouslinkstoeducation,orprocessesforcomplaintsanddisciplinarymechanisms.Absenceoftheselinkswasparticularlyevidentwhereeducationandinitialregistrationoccuroutsidethecountry.

Insomecountriesandareas,legislationdidnotappeartohavebeenrolledoutformally.InGuam,agovernmentcodecontainsarticlesspecifictosomealliedhealthprofessions,butaseparateact(fornursingandpharmacy)hasnotbeenpassed.

Othercountriesrecognizeandregulatealliedhealthprofessionsundermedicalormoregenerallegislation. InPapuaNewGuinea,theMedicalRegistrationAct(1980)regulatesprescribedcategoriesofalliedhealthwork,butdoesnotspecifyparticularprofessions.LegislationinSamoaregulates11alliedandtraditionalmedicineprofessionsundertheHealthcareProfessionsStandardsandRegistrationsAct(2007),butthereisnoinformationavailableaboutimplementation.KiribatihastheMedicalServicesAct(1996),butthereviewfoundnoinformationthatdemonstratedimplementationoftheact.

HealthprofessionalsinareasunderthejurisdictionoftheUnitedStatesofAmericaorFranceareassumedtobecoveredbythelawsofthosecountries.Therewaslittleinformationonalliedhealthpractitionerregulationormonitoringofpractice,standardsorrequirementsforprofessionaldevelopmentfortheseareas.

Somecountriesareintheprocessofrecognizingabroaderrangeofhealthprofessionsintheirlegislation,suchasFiji,whichpassedtheAlliedHealthPractitionersDecree(2011),andChina,whichhasregulationinplacethatcoversrehabilitationtherapistsandis intheprocessofconsideringtherecognitionoftheprofessionofphysiotherapy.

4.2.3. Traditional medicine

Informationaccessedsuggestsactionsareunderwaybymanycountriestobetter integratetraditionalandcomplementarymedicine.Regulationisconsideredtobeausefulvehicleforimprovingthetrainingandstandardsoftraditionalmedicinepractitioners;however,notallcountriesandareasregulatetraditionalmedicine,andonecountry,Vanuatu,specificallyexcludestraditionalmedicinefromitshealthpractitionersact.

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Countriesandareasthatdoregulatetraditionalmedicinepracticeinclude:Australia,whichregulatesChinesemedicine(since2000inVictoriaandnationallysince2012);China,whichseparatelyregulatesChinesemedicineandacupuncture;HongKongSAR(China),whichalsoregulatesChinesemedicine;Japan,whichregulatesacupuncture;theRepublicofKorea;andSingapore,throughtheTraditionalandChineseMedicineAct(2011).Malaysia’sTraditionalandComplementaryMedicinesAct(2013)isexpectedtobeimplementedin2015,andwillregulateMalay,ChineseandIndiantraditionalmedicine.

Theexistenceoflegislationmaynotmeanthataseparateregulatorysystemisinplace,however.InthePhilippines,althoughthereistheTraditionalandAlternativeMedicinesAct(1997),medicalprofessionalswhowishtoincorporateChinesemedicineoracupunctureintotheirpracticedoso,andthereisnoseparateregulatoryoversightfortraditionalmedicine.Australianhealthpractitionerregulationallowsforprofessionalregistrationboardstoendorseregisteredpractitionersforthepracticeofacupuncture.Thenationalhealthinsuranceschemealsopaysforacupunctureservicesdeliveredbydoctors,andprivatehealthinsurancecoversarangeofcomplementarytherapieswhetherprovidedthroughregisteredpractitionersornot.

AslightlydifferentapproachhasbeentakenwithregardtotheregulationofAboriginalandTorresStraitIslanderhealthworkersinAustralia.TheapproachregulatespractitionersprovidingprimarycareservicesinAboriginalandTorresStrait Islandercommunities,ratherthanregulatingthepractice of traditional Aboriginal and Torres Strait Islander medicine.

Therewaslittleinformationavailablethatdemonstratedadirectlinkbetweeneducation,standardsandpractice,evenwhereinstitutesfortraditionalmedicineeducationorresearchhavebeenestablished.CambodiahastheNationalCentreofTraditionalMedicinewithintheMinistryofHealth,butpublishedinformationonhowthecentrelinkswithtraditionalmedicineeducationorpracticecouldnotbeidentified.InMongolia,wheremosthospitalshavetraditionalmedicinedepartments,andsixuniversitiesofferbachelor’sandmaster’scoursesintraditionalmedicine,therewasnoinformationontheexistenceofaregulatoryframework,althoughtraditionalmedicineappearstofallundertheNationalLawonDrugs(1998)andStatePolicyonDrugs(2002–2011).

4.2.4. Non-regulated health professions

Notbeingregulatedunderlegislationdoesnotnecessarilyimplyalackofprofessionalstandards,oranincreasedriskofharmtothepublic.Employerscananddoimposeeducationstandardsandtrainingqualificationrequirementsonemployees,andinsomecases,suchasforparamedicsinAustralia,employmentcanactastheregulatorymechanism.Professionalassociationsmaytakeonaself-regulatoryrolebysettingstandards,codesofethicsandrequirementsforcontinuingprofessionaldevelopment.Moreover,ahealthprofessional’spracticemayalsoberegulatedunderemployment,consumerprotectionorpublichealthlaws.

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Theterm“self-regulation”isuseddifferentlyacrossjurisdictions;however,inthecontextofthisreview,itistakentomeanoversightofprofessionalpracticebyanon-legislatedbody,suchasaprofessionalassociation.Self-regulatorysystemsrelyonestablishedprofessionalassociations,whichcanonly“regulate”associationmembersorthosethatagreetovoluntaryaccreditation,andtheycannotlicenseanindividual(6).

Thereis interestfromsomecountriesandareasintheintroductionofenforceableminimumstandardsofpracticeforhealthprofessionalswhoprovideahealthservicethatisnotregulatedundernationallaw.Australiaisproposingtointroduceanationalcodeofconductforhealth-careworkers,andinNewZealand,thecounsellingprofessionhasadvocatedintroductionofasimilarmechanism,oftenreferredtoas“negativelicensing”.Further,thereareexamplesacrosstheRegionofprofessionalassociationstakingonaself-regulatoryrolefortheirprofessions.AustraliaandNewZealandhaveformalizedalliancesofself-regulatedprofessions.7

Informationabouttheextentofself-regulatoryapproachesacrosstheRegionwaspatchy,andinsomeinstances,itwasdifficulttoseparatethemfromtheadvocacyfunctionsalsocarriedoutbyaprofessionalassociation.Theroleofprofessionalassociationsinpromotingormonitoringstandardsineducation,ethicsandpractice,andinstrengtheningregulation,warrantsfurtheranalysis,andisbeingexploredatthecountrylevel.InthePhilippines,aproposalbythemedicalboardformandatorymembershipofaprofessionalassociationbeforeregistrationcanbegrantediscurrentlybeingconsidered.

4.3. Education and accreditation

AcrosstheRegion,thereiswidevariationinhowstandardsofeducationaremeasured,howaccreditationofeducationprogrammesandprovidersoccurs,anddocumentedevidencelinkingaccreditation of education programmes and registration or licensure requirements.

4.3.1. Education

ThenumberoftrainingschoolsandprofessionalprogrammesvariessignificantlyacrosstheRegion.Ingeneral,developingcountriesinvestfewerresourcesfromsmallereducationbudgets,andtheirpublicuniversitiesdependalmostentirelyonthisbudget.However,thenumberofschoolsandprogrammesisnotalwaysdirectlyrelatedtototalpopulationsizeordemographicpressures(7). Thisreviewdidnotexaminelevelsoffinancialinvestment,norcurriculaandprogrammecontent,

7 Forexample,inAustralia,theNationalAllianceofSelf-RegulatedHealthProfessionsandtheAustralianRegisterofCounsellorsandPsychotherapistsarethenationalself-regulatorybodiesforthoseprofessions.

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butit is importanttonotethesearelikelytobeintegrally linkedtoaccreditationprocesses,educationstandards,registrationrequirementsandongoingmonitoringofpracticeaswellaslabourmarkets.

Thereviewalsodidnotseektoexamineindetailthestructure, lengthandconfigurationofprogrammes,yettheseaspectsdovaryconsiderablyacrossprofessionsandcountries.Inpharmacyeducation,Australia,Malaysia,NewZealandandSingaporerequireaperiodofinternshippriortofulllicensure,whereasJapan,theRepublicofKoreaandVietNamdonot,althoughtheyhavelongerprogrammes.Chinahastheshortestpharmacyprogrammedurationandnointernshiprequirements.Ingeneral,thedurationandconfigurationofmedicalprogrammesappearstobemoreconsistentacrosstheRegion,andinnursing,atrendtowardsdegreeprogrammeswasobserved.

Comparabilityofqualificationsis,however,anissuethatisincreasinglyimpactingmanycountriesandareas,particularlythosethateitherrelyheavilyonaforeign-trainedhealthworkforceortrainextensivelyforforeignmarkets.Moreover,althoughprogrammeaccreditationbyitselfdoesnotguaranteeconsistentorqualitystandardsofeducation,itisusedbyhealth-careprovidersandregulatorstoindicatetherelativetransferabilityorapplicabilityofqualifications.

4.3.2. Programme and provider accreditation and quality assurance Thepurposeofaccreditationistoattesttothequalityofaneducationalprogramme,andforthepublic,prospectivestudents,graduates,employersandprofessionstohaveconfidencethataprogrammewillenablegraduatestoenteraprofessionwiththerequisiteskillsandexpectedcompetencies.Forproviders,suchasuniversitiesandfaculty,accreditationcanserveasaleverforbothfundingandreputation.

Almostallcountriesandareaswithinternaltrainingprogrammeshaveestablishedsystemsforoversightandqualityassuranceofeducationingeneral,butmanydonothavesystemsspecifictoindividualhealthprofessions,whileothershavesystemsthatareonlyjustemerging.Japanhasintroducedatrialprogrammeofaccreditationforbasicmedicaleducation,usingtheglobalstandardsoftheWorldFederationforMedicalEducation,toascertainthequalityofundergraduatemedicaleducation.Further,manyPacificislandcountrieshavefewregulatoryprocedures,criteriaorbenchmarksforreviewingnursingeducation,andfewregulatorybodiesthathavetheskillsortrainingtorevieworauditnursingprogrammes(8).TheextenttowhichtrainingprovidersintheRegionutilizeinternationalbenchmarksandcriteriawasdifficulttoascertaininthetime-frameofthisreview.

Responsibilityforaccreditationofeducationprogrammesandprovidersdiffersbetweencountriesandareas. Inmany,programmesandprovidersareaccreditedbyaministryordepartmentofeducationorsimilar; inothers,suchasMalaysia,this isdonebyaqualificationsagency,

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withinputfromtherelevantprofessionalregulatoryboard.InHongKongSAR(China)andthePhilippines,educationprogrammesareaccreditedbyagenciesotherthanthebodyresponsiblefor registration or licensure.8InAustraliaandNewZealand,acouncilorboardestablishedunderahealthprofessionsregulatoryactisalsoresponsibleforregistrationorlicensureandeducationprogramme accreditation.

Forthosecountrieswithwell-establishedtrainingprogrammesforawiderangeofhealthprofessionals,thereappearstobealinkbetweenprogrammeapprovalandinitialregistrationandlicensing.Insome,suchasthePhilippines,informallinksbetweeneducationandregistrationbodieshaverecentlyemerged.However, inmany,atthepost-registrationlevel,systemsforregistrationandregulationarelessconsistentthanthoseof initial licensing,particularlyfornursingandmidwifery,alliedhealthprofessionsandspecialists (8–10).

Indicationsarethatexternalaccreditationofprogrammes(i.e.thosecarriedoutbyabodyexternaltotheeducationinstitute) is increasing. InthePhilippinesthis increaseismotivatedbytheprerequisitethatonlyforeign-trainedhealthprofessionalswhohavegraduatedfromexternallyaccreditedschoolscanapplytopractiseintheUnitedStatesofAmerica.Accordingly,thereappearstobeincreasedinterestinexternalaccreditationbodiesprovidingservicestoothercountries.Organizations,suchastheSouthPacificBoardforEducationalAssessment,areincreasingtheirroleacrossthePacific;CanadaoffersaccreditationservicestoafewcountriesacrosstheRegion;andAustraliaandNewZealandhaveanumberofcouncilsthataccreditcoursesandprovidersacrossbothcountriesinmedicineandpharmacy.

Materialgatheredfrominterviewssuggeststhattherearedifferentperspectivesonwhetheraccreditationandregulationofeducationcoursesandprovidersandthatofregistrationforpracticearepartofonecontinuumorareapproachedasseparateendeavours.Inpart,thisappearstobeinfluencedbysocio-politicalhistoriesandbroaderjurisdictionalparadigms.

4.3.3. Credentialing

Inadditiontoaccreditationofprogrammesandproviders,andregulationofpractice,somecountriesandprofessionshavemechanismsorframeworkstocredentialpractitioners.Theterm“credentialing”isuseddifferentlyacrossprofessions,countriesandregulatoryauthorities.Itisappliedtovalidationandrevalidationofqualificationsorcredentialsaswellastoauthorizingaparticularindividualtoworkinaspecific(usuallyadvanced)scopeofpractice,ofteninaprescribedservicesetting.Credentialingmayalsorefertodemonstrationofskillsandrecognitionofadditionaltrainingthatenablesindividualhealthpractitionerstoprovideadvancedorspecializedcarefor

8 InthePhilippines,theCommissiononHigherEducationsetsminimumeducationstandardsandaccreditsprogrammesandproviders,andtheProfessionalRegulationCommissionisresponsibleforthelicensureexam,registration,licensingand“oathtaking”.

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certainhealthconditions,incertainspecifiedenvironments.Theprocessesareusuallydefinedinanorganizationalpolicy,andthereforepertainonlytothatorganization.

Thewidevarianceinterminologyandconventionaroundcredentialingmeansthatonlyasuperficiallookwaspossibleinthetime-frameofthisreview.Thatsaid,itmaybeanimportantleveroutsideofregulationtoensurethatpracticeisbenchmarkedagainstasetofagreedstandardsandassistinthedevelopmentofprocessesforperformanceimprovement.Someexamplesareoutlinedheretoillustratetheuseofcredentialing.

InAustralia,credentialingreferstotheinitialauthenticationofqualificationsandverificationofdocumentationagainstsetcriteriathatallowsaprofessionaltobeemployedinpractice.Re-credentialingformallyreconfirmsqualificationsandcurrencyofpracticewithrespecttoprofessionalregistrationorprofessionalassociationmembership,disciplinaryactions,criminalhistoryreportsandperformancereviewprocesses.Theseprocessesareundertakenbythenationalregulatoryagencyatthetimeoftheannualrenewalofpracticecertificates(ifinaregulatedhealthprofession),orbythestategovernmentifitisaself-regulatedornon-regulatedprofession.

Inothercountries, implementationofformalizedsystemsforrevalidationofqualificationsislimitedoremerging.Japanintroducedane-learningsystemforpharmacistsin2012thatsupportslifelonglearningandrequirementsforrevalidationofqualifications(7).However,thereviewwasnotabletoidentifyinformationthatdescribeshowthisisbeingimplemented,especiallygiventhatlicensureisgrantedforlife.

Credentialinginbothdefinitionsappearstobemoregeneralizedindevelopedcountrieswithembeddedregulatorysystems,andusuallyexists inadditiontothescopesofpracticeandcompetenciesthatmustbedemonstratedforregistrationandlicensure.

4.4. Licensing or registration requirements

4.4.1. Pre-licensing

Forthosecountrieswithestablishedregulatorysystems,thereisvariationinpre-licensingorpre-registrationrequirements.Thisisparticularlysoinrelationtonursingandmidwifery,wherebymostcountriesstipulateeitheradiplomaordegreequalificationtoregisterasanurseoramidwife;however,someacceptseverallevelsoftrainingtobeeligibleforregistration.InChina,90%ofnurseshaveassociatedegree-levelqualifications,equivalenttosecondaryeducation(thatofages15–16years),andthereiswidevariationininformationrelatingtoboththestandardsandqualityoftrainingandintherequirementsforlicensure.

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Pre-licensingrequirementsformedicinearegenerallymoreconsistentacrosstheRegion.Mostlegislationandassociatedregulatorydocumentsstipulatethatqualificationsmustbefromapprovedcoursesandfromanapproveduniversity,andidentifytheperiodofinternshiprequiredbeforefulllicensureisgranted.Periodsofinternshipmay,however,varybetween1and2years.

Wheretrainingoccursoutsideacountry,mostcountriesoutlineanapproachwherebyqualificationsmustbefromaprogrammeofstudyapprovedbytherelevantcouncilorboard(wherethesebodiesexist),theregister,oraministryordepartment.

4.4.2. National exams

Thereisvariationinwhetheranationalexamisusedtoqualifygraduatesforregistrationorlicensure,whetherthisexamislinkedtoacurriculum,andwhatinvolvementprofessionalassociationshaveinsettingthecontentorstandardsfortheexam.InJapan,allregulatedhealthprofessionalsarerequiredtopassthenationalexamsetbytheMinistryofHealth,LabourandWelfare.Theredoesnotappeartobeadirectlinktoeducationnortoparticipationfromvariousacademicinstitutions;educationproviders;professionalassociations;ortheMinistryofEducation,Culture,Sports,ScienceandTechnology.Cambodiaintroducedanationalexamfordentists,nursesandpharmacistsin2012,andonein2014,formedicine.Documentsaccessedsuggestthatthereisanintentiontostrengthenthelinksbetweentherequirementsfortheexamandthecurriculumthere.

HongKongSAR(China)requirespassinganationalexamformostprofessionsthatareregulated,withtheexceptionofmedicalgraduatesoftheUniversityofHongKongandtheChineseUniversityofHongKong.Physiotherapygraduatesofuniversitiesotherthanthetwoabovemayberequiredtotakethephysiotherapyboardexam(M.Skinner,WorldFederationofPhysicalTherapy,personalcommunication,June2014).

InNewZealand,thereisvariationamongprofessionsastowhetherpassinganationalexitexam9isrequired,andifindividualsarerequiredtodemonstratethattheypossessanumberofcompetenciesprescribedbytheregulatoryboardorcouncil.Nursesandmidwivesarerequiredtopassthestatefinalsandnationalexam,respectively.DoctorsanddentiststrainedinNewZealandorincountriesthattherespectiveboardsorcouncilsrecognizeas“equivalent”arenotrequiredtotakethenationalexam.Thosetrainedincountriesnotincludedinthislistarerequiredtotaketheexam.Australiadoesnothaveanationalexitexamforgraduatingnursesandmidwives,buttheNursingandMidwiferyBoardhasanumberofregistrationstandardsthatmustbemettogain and maintain registration.

Othercountriesstipulateanexamrequirementformostprofessionsthatareregulated,suchasinMalaysia,MongoliaandthePhilippines,butthestandardsmaynotbeconsistentacrossproviders.

9 Anexitexamisatestorexamthatstudentsmustpasstograduateorreceivetheirqualification.

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4.4.3. Registration

Theterms“registration”and“licensure”areoftenusedinterchangeably inrelationtohealthpractitionerregulation,buttheycanimplydifferentstatusandpermissions.Registrationinthecontextofthisreviewistheprocessofenrollingonaregisterofhealthprofessionalsandenteringdetailssuchasname,occupationandqualifications.Itmaynotindicatefulllicensure,asmanyprofessionsrequireatwo-stepprocesstogainfullregistrationandlicencetopractiseindependently.Thisisanimportantpoint,asthepurposeofgoodregulationistomanagehowpractitionersgetontheregister,howongoingcompetentpracticeisassuredtostayontheregister,andhowtocensureorremovepractitionersfromtheregisterwhenseriousprofessionalorconductissuesarise.Theprinciplesof“right-touch”regulationcanapply i.e.usingtheminimumregulatoryforcetoachievethedesiredresult(Annex 6).Ultimately,thepublicshouldhaveconfidencethatregisteredhealthprofessionalsaresafeandtheirpracticerelevant.

RegistrationrequirementsvaryconsiderablybetweenprofessionsandacrosscountriesintheRegion,andincludevariouscategoriesfromstudenttospecialist,thedurationmayalsovary.Mostcountriesrequiredoctorstoundergoaperiodofinternshipandprovisionalregistrationpriortofullregistrationbeinggranted,andsomerequiresecondaryregistrationforspecialists.Informationonthelatterwaspatchyhowever,andwhereitdidexist,indicatesarangeofdifferentapproaches.

Countriesandareasinthefirstclusterhaveprescriptiverequirementstoregisterasadoctorandtoobtainspecialistregistration.Theyalsohavestronglinksbetweentheregulatorybodyandprofessionalassociationsinrelationtoregistrationprocesses,aswellasmandatorycontinuingprofessionaldevelopment.Processesforcountriesandareasinthesecondclusterwerelesseasytoidentify,particularlywithregardtospecialists. InJapan,whereregistrationisfor life,professionalspecialistassociationshavehistoricallyauthorizedandcredentialedspecialistpractice,yetanecdotallythisroleisincreasinglybeingundertakenbytheMinistryofHealth,LabourandWelfare.Discussionsabouttheremodellingofthespecialtycertificationsystemhavecommenced,withtheintentionofintroducinganewcertificationandqualityassurancesystemin2017.Officialrecognitionofgeneralpractitionersandfamilyphysicianswillalsocommencein2017.

PapuaNewGuineaandSolomonIslandsrequirenursestoundergoaprovisionallyregisteredorprobationaryperiodbeforebeingfullyregistered,whereasothercountrieshavenospecifiedregistrationrequirementsotherthanobtainingarelevantqualification.Afewcountriesrequirenursestohaveaperiodofpracticalexperiencepriortoobtainingregistration,andmanystipulate(ofteninlegislation)thatnursesmustalsobea“fitandproperperson”or“ofgoodcharacter”.InsomesmallercountriessuchasTokelau,withnointernalnursingtraining,thechiefnursemayassessreadinessfor(lifetime)registrationinthatcountry,butthenursemustalsocomplywithanyrequirementsforrenewalofannualpracticecertificatesinthecountryoffirstregistration.

VietNamandtheLaoPeople’sDemocraticRepublichavenoregistrationrequirementsforanyhealthprofessionals,butrelyingonlyonpublishedinformationmeansthestatusofproposed

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orrecentlyamendedregulationsorlegislationmaybedifficulttoidentify.10Legislationmayalsostipulatecriteriaforgrantingprovisionalandtemporaryregistration,includingtime-framesandsupervisoryrequirements.Provisionalregistrationismostcommonlyappliedtoprofessionsthathaveaperiodof internship,butmayalsoapplytonursinginsomecountries.TemporaryregistrationappearstobeavailableformostprofessionsinmostcountriesandareasintheRegion,andlegislationusuallyspecifiestheexemptions,situationsandtime-framesforwhichitmaybegranted.Thesemostoftenrelatetoemergenciesandreliefmissions.Becauseofthesignificantvariabilityinprerequisitesandcriteriaacrossprofessionsandcountriesinrelationtotemporaryorprovisionalregistration,thisreportsimplynotesitratherthanattemptingtocompareandcontrast.

4.4.4. Renewal

Thereisvariabilityamongcountriesandareasandacrossprofessionsregardingrequirementsforrenewalofregistrationor licensuretomaintainpracticecertificates.Whereinformationisavailable,mostcountriesrequirerenewalofregistrationonanannualbasis,suchasAustraliaandNewZealand,whereassomerequirebiannualrenewal,suchastheCommonwealthoftheNorthernMarianaIslands.HongKongSAR(China)requiresanannualrenewalfordoctorsanddentistsandmostotherregulatedhealthprofessions,butthree-yearlyrenewalfornursesandmidwives.Stillothershavealongerperiodofrenewal,asinMongolia,whichiseveryfiveyearsforallregulatedhealthprofessions.

Othercountriesissuelifelonglicencesforsomeprofessions,suchasfornursesinSolomonIslands,andallregulatedhealthprofessionalsinJapan.Acoupleofcountriescurrentlyhavenolicensingrequirements,suchastheLaoPeople’sDemocraticRepublicandVietNam,andthereforenorenewalrequirement.

Manycountriesandareasthatrequireperiodicrenewalofapracticecertificateorlicencehaveregulationsthatalsodescribethecontinuingcompetencythatmustbedemonstrated,and/orthecontinuingprofessionaldevelopmentthatmustbeundertakentomaintainregistration.Anumberofcountrieshaverenewalrequirementsthatrelatemoretodeclarationsoffraudorcriminalconvictionsthantodemonstratingprofessionalclinicalcompetenceandadheringtopracticestandardsprescribedbytheprofession.

Informationabouttherequirementforcontinuingprofessionaldevelopmentwaspatchyacrossprofessionsandcountriesintermsofwhetheritismandatoryorvoluntary.Insomecountries,evenwhereacontinuingprofessionaldevelopmentrequirementisstipulatedinlegislation,suchasSingapore,itwasdifficulttoascertainhowitismonitoredbytheregulatorybody,andiftherearepenaltiesfornotcompletingtherequirements.Inmanycountries,therelevantprofessional

10ThePhysicianActof2012wasdraftedtoreplacetheMedicalCareActof1959buthasnotyetpasseddespiteanumberofattemptstoprogressitthroughthelegislative timetable.

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associationdeterminesandsupportsongoingcontinuingprofessionaldevelopmentrequirements,but,ingeneral,theredidnotappeartobeaclearlinkbetweenmandatorycontinuingprofessionaldevelopmentandrenewalofregistration,andwhetherrecent legislation,eitherprimaryoramended,madeadifferencetore-registrationprocessesoverall.

Beyondthisreview,theimpactofvariationsintherequirementsforcontinuingprofessionaldevelopmentonothercomponentsofregulationwarrantsfurther investigation. Informationfrominterviewssuggeststhatcontinuingprofessionaldevelopmentobligationsareexpectedtobecompliedwithratherthanenforced,andinmostcountries,theyarenotfolloweduproutinely.Introducingaconsistentsystemfromundergraduateeducationthroughcontinuingprofessionaldevelopment,withoversightfromanationalbodysuchastheGeneralMedicalCouncilintheUnitedKingdom,isviewedbysomeasanimportantstepfromaqualityassuranceperspective(M.Skinner,WorldFederationofPhysicalTherapy,personalcommunication,June2014).

4.5. Notifications, complaints and disciplinary processes

Whilemanycountriesspecifynotificationand/orcomplaintproceduresintheirlegislation,asidefromcountriesinthefirstcluster,publishedinformationonhowtheseproceduresareimplementedissporadic,includingaboutthetypeofpenaltyapplied.11Insomecountries,suchasMalaysia,disciplinarymattersappeartopertainmoretofraudthanprofessionalmisconduct.

Manycountrieshavelegislationthatestablishesadisciplinarycouncilorprofessionalconductcommittee,although,insomecases,itwasdifficulttoidentifythedisciplinaryprocessesinplace.Thisinformationgapwascommonforcountrieswithsignificantrelianceonforeign-trainedandforeign-registeredhealthprofessionals.Whereinformationdidexist, it indicatedthatmattersofdisciplineweremanagedinthefirstinstancebyanemployer,andescalatedtotheexternalprofessionalorregistrationbodyifserious.

Afewcountriesinthesecondclusterhavelocal,regional,provincialandnationalprocessesdescribedinlegislation,althoughthelevelatwhichdisciplinarymattersaredealtwithmaydifferacrossprofessions.Forexample,Cambodia’sMedicalCouncilRoyalDecree(2000)statesthatdisciplinarymattersrelatingtodoctorsaredealtwithbyanationaldisciplinarycouncil.TheCambodiaDentalCouncilRoyalDecree(2005)statesthatdisciplineistheresponsibilityofaregionaldisciplinarycouncil.TheCambodiaCouncilofNursesRoyalDecree(2007)requiresdisciplinarymatterstobedealtwithbyanationaldisciplinarycommittee,butmidwiferyistheresponsibilityofaregionaldisciplinarycommittee.Inlegislationforpharmacists,thePharmacistCouncilofCambodiaRoyalDecree(2010)establishedtheBoardoftheRegionalPharmacists’

11 ThePhysicianActof2012wasdraftedtoreplacetheMedicalCareActof1959buthasnotyetpasseddespiteanumberofattemptstoprogressitthroughthelegislative timetable.

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Counciltodealwithdisciplinaryissues.RegionalcomplaintsprocessesarealsopresentinJapan,whereundertherevisionoftheMedicalServiceLaw(2006),localgovernmentsestablishedtheCentreforSupportingSafetyinMedicalTreatment,offeringcomplaintresolutionforpatientsandrelatives.However,theMinistryofHealth,LabourandWelfarealsohastheauthoritytosuspendorrevokelicences,andare-educationprogrammefordoctorswhoreceivean“administrativepenalty”toresumetheirpractice,wasintroducedin2005(N.Ban,O.Fukushima,JapanSocietyforMedicalEducation,personalcommunication,September2014).

Insomecountries,disciplinarymattersaretheresponsibilityofgovernmentagenciesthatalsohaveother,broaderresponsibilities.InMongolia,disciplinarymattersrelatingtomedicalpracticemaybedealtwithbytheDepartmentofHealthEthicsCommittee,StateProfessionalInspectionAgencyorNationalPoliceAgency(11).AmendmentstotheHealthLawofMongolia(1998)arecurrentlybeingconsidered,andthesemayassistwithclarifyingdisciplinaryprocesses.

Countriesandareasinthefirstclusterappeartohavethemosttransparentprocessesinrelationtonotifications,complaintsanddiscipline.Othershaveclearprocessesdescribedinlegislation,butinformationfrominterviewssuggeststhatimplementationisnotalwaysalignedwithlegislativeintent,andthatthewayinwhichcomplaintsanddisciplinarymattersaredealtwithisstronglyinfluencedbysocio-politicalhistories.Revisionofcurrentlegislationrelatingtocomplaintprocessesisoccurringinsomecountries,suchasJapan,whereresponsibilityforinvestigationofmedicalaccidentsandcomplicationsismovingfromthepolicetonew,purpose-specificagenciesorcentres(N.Ban,O.Fukushima,JapanSocietyforMedicalEducation,personalcommunication,September2014).

FurtheranalysisofsystemsandprocessesformanagingcomplaintsanddisciplineacrosstheRegion,andtheirlinkstogovernance,education,accreditation,continuingprofessionaldevelopmentand licensure is needed.

4.6. Reciprocal agreements

4.6.1. Recognition of qualifications and prior learning

Theincreasingmobilityofhealthpractitionersthroughouttheireducation,trainingandpracticeblurstheregulatorypictureinanalreadydiverseRegion.Ahealthprofessionalmayreceivetraininginonecountry,completeaninternshipinanotherandbeemployedinseveralothers.Further,recognitionofpriorlearninganddeterminingequivalenceinregardtoqualificationsisincreasinglycomplex,giventhevariabilityineducationalqualityandstandards,andintherequirementsfor

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andinstitutionaloversightofcontinuingprofessionaldevelopment.Somecountrieslistequivalentorrecognizedqualificationsandproviderswithintheirlegislation,suchasMalaysia,whilelegislationinotherssimplynotesthatboardsorcouncilsareabletodetermineequivalenceonacase-by-casebasis.Japanacceptsapplicantsfor licensurefromforeignmedicalgraduatesthathavecompletedsixyearsofmedicaleducationinaschoollistedintheWorldDirectoryofMedicalSchools.WhilethismeansthatlicensureisrelativelyopeninJapantoforeign-trainedmedicalprofessionals,applicantsstillmusttakethenationalexam,whichisinJapanese,thusreducingthepotentialpoolofcandidates.

Theprocessesusedtoassessthequalificationsandregistrationstatusofpractitionersalsovary.OnestudyonnursinginPacificislandcountriesnotedatendencytorelyonmaterialpresented,whichmayincludeacurriculumvitae,references,copyofqualifications,andsometimesamedicalcertificate.Fewcountriesusecompetenciestoassesssuitabilityforforeign-trainednursestogain registration (8).Othercountriesinthefirstclusterhaveprescriptiverequirements,includinglevelsandperiodsofsupervision,forrecognizingandregisteringforeign-trainedprofessionals.

SeveralagenciesprovideservicesandsupporttocountriesacrosstheRegion, intermsofeducatingandtraininghealthprofessionals,accreditingeducationproviders,andsupplyinghealthprofessionals,throughaidorotherin-countrysupport.Thisreviewsoughtonlytoidentifyinformationasitrelatestoregulationofhealthpractitionereducationandpractice,yetitwasoftendifficulttoseparatearrangementsandprocessesgiventhenumberofpotentialagenciesinvolvedandtherangeandinherentcomplexityofissuesbeingsupportedacrosstheRegion.

Acrossallofthecountriesandareas,includingthosewithwell-establishedregulatorysystems,thereviewcouldnotidentifyasubstantialamountofpublishedinformationonthenumber,nature,tenureandimpactofreciprocalagreementsfortheprovisionoftraining,credentialing,supervisionandsupplyofworkforcepersonnel.WhilesomewebsitesreferredtoreciprocalagreementsformedicaltrainingandsupplyofpersonnelwithcountriessuchasCuba,itwasdifficulttoascertainwhatthearrangementsfor internships,qualityassurance, impactonsupervisioncapacityorassuranceofongoingcompetencemaybe.

Similarly, inCookIslands,whichhaslegislationtoregulatehealthprofessionalsbutreliesonanothercountrytoprovidemedicaltrainingandinternships,thereislittleinformationonhowtheconnectiontoeducationqualityandtheperformanceofeducationprovidersismade.Itisalsounclearhowongoingcompetenceisassessedorwhoisresponsibleforsanctionswherestandardsarenotmetorforenforcinganydisciplinarymeasures.Anecdotalevidencesuggeststhatlocalarrangementsviaanemployerwouldmanagesomedisciplinarymatters,referringontothebodythatinitiallyregisteredapractitionerformoreseriousmatters,butthereviewwasunabletoobtainpublishedinformationsubstantiatingthisassumption.

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4.6.2. Mutual recognition agreements

Thenumber,purposeandsuccessofmemorandaofunderstanding,mutualrecognitionagreementsorbilateralagreementsbetweencountriesthatexistforthepurposeoftrainingandsupplyintopracticevariesconsiderably.Manycountrieshavenohealthprofessionaltraining,relyingentirelyonforeign-trainedpersonnel,suchasMacaoSAR(China),whichreliesonChinaorHongKongSAR(China);Palau,whichreliesonFiji,NewZealandandtheUnitedStatesofAmerica;andmanysmallerPacificislandcountriesthatrelyonAustralia,Fiji,NewZealandandPapuaNewGuinea.ReciprocalandmutualrecognitionagreementstofacilitatetrainingandworkforcesupplyacrosstheRegionareconsequentlydiverse,andmayincludenumerousinterconnectedarrangementsamonggovernments,states,trainingproviders,internationalagenciesandindividualcountries.

Ahealthprofessionallicencemayenablehimorhertopractiseacross,forexample,Americanstateandterritoryboundaries,suchasfornursesinAmericanSamoa,12orconversely,registrationenablespracticeonly intheprovinceinwhichapractitioneris initiallyregistered,suchasinCambodia.Evenwherebilateralagreementsareinplace,suchasbetweenAustraliaandNewZealand,thereisvariabilitybetweenprofessionsonwhethercoursesandqualificationswillberecognizedfromeachcountry.

AsidefromagreementsinplaceforAmericanstatesandterritoriesandAssociationofSoutheastAsianNations(ASEAN)memberstates,materialonotheragreementsisscatteredacrossagency,departmentandinstitutionalpublicationsanddifficulttoidentify.

AbriefoutlineofASEANmutualrecognitionagreementsforthesevencountriesintheRegionwhichareASEANmembersillustratestheintentandpotentialbreadthofmutualrecognitionagreementsintheRegion.13UnderASEANagreements,14thegovernmentsofBruneiDarussalam,Cambodia,theLaoPeople’sDemocraticRepublic,Malaysia,thePhilippines,SingaporeandVietNampermitthemobilityofmedical,nursinganddentalpractitionerswithinASEAN.Specifically,thesemutualrecognitionagreementsexisttoexchangeinformationandenhancecooperationinrespectofmutualrecognitionofhealthpractitioners;promoteadoptionofbestpracticesonstandardsandqualifications;andprovideopportunitiesforcapacity-buildingandtrainingofmedical,nursinganddentalpractitioners.

Accordingtothemutualrecognitionagreements,eachhostcountry,subjecttoitsowndomesticregulations,isresponsibleforevaluatingthequalifications,trainingandexperiencesofforeignmedical,nursinganddentalpractitioners,andcanimposeanyotherrequirementorassessment

12 Themutualrecognitionmodelofnurselicensureallowsanursetohaveonelicence(inhisorherhomestateofresidency)andtopractise(bothphysicallyandelectronically)inotherstatesorterritoriesthatparticipateinthismodelofnursingregulation.Undermutualrecognition,anursemaypractiseacrossstatelinesunlessotherwiserestricted.Practiceissubjecttoeachstate’slawsandrules.13ThereviewdidnotassesstheimplementationstatusorsuccessofthisagreementonstrengtheningpractitionerregulationforanyoftheASEANmembercountries.14TheASEANFrameworkAgreementonServicesandtheASEANVision2020aimforastable,prosperousandhighlycompetitiveASEANeconomicregionthatresultsinthefreeflowofgoods,servicesandinvestment;equitableeconomicdevelopmentandreducedpovertyandsocioeconomicdisparities;andenhancedpolitical,economicandsocialstability.

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forregistrationwhereapplicable.Onceregistered,practiceisassessed,monitoredanddisciplinedaccordingtotheprofessionalandethicalcodesofconductandstandardsofpracticeofthehostcountry.

ASEANhasestablishedjointcoordinatingcommitteesonmedical,nursinganddentalpractitionerstofacilitatetheimplementationofmutualrecognitionagreements,andtoencouragestandardizationandadoptionofmechanismsandproceduresintheimplementationofthemutualrecognitionagreements.Thejointcommitteesalsoencouragetheexchangeofinformationregardinglawsanddevelopmentsinthepracticeofmedicine,nursinganddentistrywithintheRegionwithaviewtoharmonizationinaccordancewithregionaland/orinternationalstandards.ASEANintegrationin2015is likelytoputpressureongovernmentstostreamlineandacceleratethesemutualrecognitionarrangementsaswell.

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5. FINANCING

Regulatorysystems,schemesandprocessesrequireasignificantamountoffinancialinvestmentintimeandresources,atvariouslevelsandbyarangeofcontributors.AlthoughlegislationinmostcountriesandareasintheRegiondescribesthemechanismforfundingregistrationprocesses,regulatorysystemsspanafarbroaderarrayoffunctions.Costscanoccuracrossseveralareasoftheregulatoryprocess, includingaccreditationofeducationandtrainingprogrammesandproviders;pre-licensingapplicationandexaminationprocesses;registrationandlicensing;renewalofregistrationandissuingofpracticecertificates;assuringcompetencethroughimposingandmonitoringrequirementsforcontinuingprofessionaldevelopment;andnotifications,complaintsanddisciplinaryprocesses.Whobearsthosecostsandhowmuchfundingisrequiredateachlevelaregenerallydeterminedbythenumberofapplicantsandcandidates,thetypeofinstitutionalarrangementsthatareinplace,aswellasthepurposeofregulationitself.

Theexactamountsandsourcesoffundingacrossanentireregulatorysystemaredifficulttoascertainformostcountriesandareasbecauseofthemultidimensionalnatureofregulation,andbecauseresponsibilityforvariousfunctionscansitacrossarangeofagencies.AllcountriesandareasintheRegionthathaveasystemforregulatinghealthprofessionaleducationandpracticeimposeregistrationandlicensingfeestofinanceregulatoryprocesses,somealsoreceivealevelofstatefunding,andadegreeofprivateinvestmentornongovernmentalassistanceexistsinmanysystems.15Alongwithregulationandlegalrequirements,manycountriesofferincentivestoguideandchangethebehaviourofprivateentities,includinghealth-careconsumers,providersandinsurancecompanies,andtheseactivitiescouldbroadlybeconsideredpartoftheregulatorysystem(2).

CognizantofthecomplexityanddifferencesinregulatoryapproachesacrosstheRegion,onlyabriefoverviewofthefinancingofregulatorysystems,usingthesixthematicareasdiscussedabove,isprovidedhere.

Attheeducationandtraininglevel,theaccreditationofprogrammesandproviders,whichaimstoimprovequalitybycombiningpredefinedstandardsandfinancialincentives,maybefundedthroughamixofinstitution,stateandprivatefunding,andinvolveagencieswithinoroutsidecountriesandareas.ImplementingtheWHOguidelinesontransformingandscaling-uphealthprofessionals education and training implies a concomitant investment in time and resources relatingtoaccreditationprocessestoensurethequantity,qualityandrelevanceofhealth

15 Forexample,assistanceprovidedbytheWorldBank,WHOandotherinternationalorganizations.

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professionals (12).Thisisparticularlyrelevantwiththerapidgrowthofprivate,for-profitinstitutionsoperatinginthehealtheducationarena.

Thesecondareaofcost isregistrationprocesses, includingpre-registrationapplicationsandexaminations,re-licensingandrenewalofpracticecertificates.Registrationtypically incursafee,payablebytheapplicanttoaregulatoryagencyorboard,foreachstepinthecareerandregistrationprocess.InthePhilippines,examinationfeesarepaidtotheCommissionforHigherEducation,whereasregistrationfeesarepaidtotheProfessionalRegulationCommission.InHongKongSAR(China),differentfeesarerequiredforthelicensingexam,generalregistration,specialistregistrationandpracticecertificates,andarepaidtotherelevanthealthprofessionalregulatoryboard.Cambodiahasfivelevelsofregistration,annualregistrationfees,andforsomeregistrants,amonthlyfee.Countriesandareasthatrequireforeign-trainedhealthprofessionalstopasstherelevantlanguageproficiencyteststobeeligibleforregistrationchargeindividualapplicantsanexaminationfee.Somecountriesandareassupportapplicantstoprepareforthisexam,suchasinNewZealandwhereapartiallygovernment-fundedschemehasoperatedforthelastseveralyears,aimedatreducingthenumberofre-examinations.

Insomesystems,althoughregistrationandpracticecertificatefeesarepaidbyindividualhealthprofessionals,employeesmaybereimbursedforthosefeesbytheiremployers.ThisisthecaseinNewZealand,meaningthatsomeofthecostsofrunningtheregulatorysystemareindirectlymetbytheGovernmentforpublicsectoremployees,orbytheprivatesectorifprivatelyemployed.Australianlegislation,ontheotherhand,doesnotpermitpaymentofregistrationfeesbyemployers,onthepremisethatachievingthestandardsrequiredtobeeligibleforregistration,andmaintainingongoingcompetenceandfitnesstopractise,areindividualresponsibilities.

AcrosstheRegion,notifications,complaintsanddisciplinaryprocessesmaybeadministeredatnationalorlocallevels,andreceivefundingfromarangeofsources.InNewZealand,althoughtheHealthPractitionersCompetenceAssuranceAct(2003)requireseachregistrationauthoritytoappointanexecutiveofficertothenationalHealthPractitionersDisciplinaryTribunal, thetribunalisadministeredbytheMinistryofHealth.Feesfortribunalmembers,includingforthechairanddeputychair,arealsometbytheMinistryofHealth.InAustralia,disciplinarymattersmaybereferredtostate-baseddisciplinarytribunals,andadministrativecostsmetatastatelevel.Bothcountrieshavearangeofotherentitieswhoserolesmayintersectwiththedisciplineofhealthprofessionalsatsomepoint.

InCambodia,disciplinarymattersmaybedealtwithateithernationalorprovincialleveldependingontheprofessionandseriousnessofcomplaints.InJapan,whereresponsibilityformanagingcomplaintssitswithlocalgovernmentattheprefecturelevel,administrativecostsareincurred

16 Thetribunalhearsanddeterminesdisciplinaryproceedingsbroughtagainstregisteredhealthpractitioners.17 OtherlegislationestablishesentitiessuchastheHealthandDisabilityCommissionerinNewZealand,andHealthOmbudsmeninNewZealandandAustraliawhoalsohearcomplaintsanddisciplinarymatters,andincurcostsrelatedtoregulation.

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atthislevel.Countriesandareasthathaverecentlyreviewedorauditedtheirregulatorysystemsappeartobemovingtowardsmoreconnectedprocesses,evenifprofessionsareeachregulatedbyseparateboards.Interestisemergingfromsomecountries,suchasAustralia,intheconceptofmulti-professionapproaches,andinNewZealand, inasharedsecretariatacrossseveralprofessions.

Itwouldbeusefultoexplorethecostsandfinancingofthespecifictasksandresponsibilitiesthatfallwithineachofthecoreelementsofregulationdescribedabove(e.g.thetimeandfinancialresourcesrequiredtosetandassurepracticestandards,towhomthisresponsibilityfalls,andifotheragenciescontribute).Similarly,fornotifications,exploringthecomplaintsanddisciplinaryprocesses,whatotheragenciesorcommissionsmaybeinvolved,andwherethecostsfall(administrativeandparticipatory)acrossthesystemwouldbeuseful.

Whateverinstitutionalarrangementsareinplace,regulatorysystemsneedclearoperationalrulestoensureefficientuseoffunds,transparentfinancialreportingmechanisms,agreaterdegreeofpublicaccountabilityembeddedintheirlegislationorregulations,andimplementationoffinancialauditandpublicexpenditurereviews(13).Theprinciplesofgoodregulationandaresponsiveregulatoryframework18thatreducestheadministrativeandfinancialburdenonhealthprofessionalsandgoverningentitiesareimportantconsiderationsinstrengtheningregulationintheRegion.

18 TheresponsiveregulatoryframeworkdevelopedbyAyresandBraithwaitein1995viewsregulationasaseriesofregulatoryactionsortoolsofvaryingdegreesofinterventionandcost,arrangedintheshapeofapyramid.Atthebaseofthepyramidaretheleastinterventionalandcostlyactivities,suchasself-regulationandpersuasion,whileprogressivelymoreintensiveandcostlyinterventionsoccupysuccessivelevelsofthepyramid.Attheapexarethesanctionsandruinouspowersavailabletogovernment.Thisapproachproposesthatregulationshouldfocusonlow-costandlow-interventionactivitiesatthebaseofthepyramid,andonlyprogressivelyescalateiftheseactivitiesfailtohavethedesiredeffect.SeeAyres,I.andBraithwaite,J.Responsive regulation: transcending the regulation debate.Oxford,OxfordUniversityPress,1992.

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6. EMERGING ISSUES

6.1. Global mobility

ThehealthworkforceisincreasinglymobileacrosstheRegionandaroundtheglobe.Rapideconomicgrowth,decliningfertility,changingdemographyanddemanddrivenbydistributionandshortageissuesarejustsomeofthefactorsinfluencingthistrend.Thisreviewdidnotseektoexaminemobilityindetail;however,itisevidentfromtheliteraturethatmobilityisimpactingregulatorysystems,acrossallcoreelementsofstatutoryregulation.Ensuringthatqualityandstandardsineducation,standardsforregistrationandongoingcompetencyandfitnesstopractisemeettherequirementsofdestinationcountriesiscomplexandchallenging,particularlywithmultipleentrypointsanddestinationsforanincreasingnumberofhealthprofessionals.

6.2. Telemedicine

Astelemedicinebecomesmorewidelyused,theissueofassuringcompetenceandadherencetostandardsbecomescomplex.RegulatoryauthoritiesinAustraliaandNewZealandareexploringtheimplicationsforindividualhealthprofessionalsoftelehealthservicesprovidedfromanothercountry(C.Reid,NursingCouncilofNewZealand,personalcommunication,July2014). FijiNationalUniversityhasamemorandumofunderstandingwithaprivatehealth-careproviderinIndiaforcooperationintraining,capacity-buildingandorganizingtelemedicine,alongwithamobilehealthprogramme.

Althoughtheobligationsforassuringcompetencemaybecapturedinservice-levelagreementsbetweencountries,thisremainsagreyareaandparticularlydifficultwiththeincreaseinthenumberofprivatehealth-careproviders,externalaccreditationbodiesandcountriesprovidingtraining.

6.3. Private providers

Thereisanincreasingnumberofprivateeducationproviders,aswellasdemandfromtheprivatesectorforhealthpractitioners.InMalaysia,thereisincreasingdemandforpharmaciststopractiseinboththepublicandprivatesectors,andthis,inturn,isdrivingpositivechangeinpharmacyeducationandinthestatusofpharmacistsinboththepublicandprivatesectors.However,there

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isalsoincreasingdifficultyin:findingclinicalplacementsforstudentsfrombothprivateandpublicinstitutions;shortagesofteachingacademicsandincreasedforeignrecruitmenttomeetthisshortage;andensuringquality(7).

Informationsuggeststhattherapidincreaseinthenumberofprivateeducationprovidersiscreatingchallengesinmonitoringpoorlyperformingeducationproviders,andinrestrictingthenumberofnewschoolsopening.Forexample,inthePhilippines,despiteasignificantincreaseinthenumberofnursingschools(from40in1980to470in2010),lessthanhalfofthestudentspassthelicensureexam.19Whilesimilarissuesarereportedinregardtothenumberandqualityofprivatemedicalschools,20initiativessuchastheintroductionofanoutcome-basededucationframeworkfrom2015areexpectedtoimprovestandards(14).

Somecountriesrequireprivatehealth-careserviceproviderstoberegistered.InKiribati,theMedicalCouncilalsolicensesprivatehospitals,butitisunclearhowthisislinkedtoarequirementforpractitionerstoalsoberegistered.Therewasinsufficientinformationtoenableclarification,andfurtheranalysisintheseareasofregulationmayberequired.

6.4. Interprofessional practice

Thetrendinmanycountriestowardsstrengthenedprimaryhealth-careservices,andforprimaryandsecondarycaresettingsandservicestobecomemoreintegrated,meansthataregulatorymodelthattakesintoaccountinterprofessionalcollaborativepracticeislikelytobemosteffective.AustraliaandNewZealandareinvestigatingwhethercurrentregulationissufficientlyflexibletoaccommodatechangesinthewaypractitionerswillwork,includingacrossmultiplesettings,particularlyinresponsetochangingpopulationhealthdemandsandongoingresourcechallenges.InthePhilippines,whereregulationofeducationandpracticehasbeenundertakenbyseparatecommissions,healthpanelsfromboththeCommissiononHigherEducationandtheProfessionalRegulationCommissionnowmeetregularly,albeitinformally.Panelmembersarestronglysupportiveofthisdevelopmentanditspotentialtofostermoreinterprofessionalpractice. TheemergenceofinterprofessionalpracticeandintegratedclinicsislessevidentinothercountriessuchasJapan,wherepatientsdonotneedareferraltoseeaspecialist,andcanchooseeitheraclinicorahospitalastheirfirstpointofcontactwiththehealth-caresystem.TheJapanesehealthsystemoverallisphysiciandominated,withnursingplayingamuchsmallerroleinpatientcare.

19 A Lancet commissionhighlightedacallfrom20professionalandacademicleadersformajorreforminthetrainingofdoctorsandotherhealth-careprofessionalsforthe21stcentury.Changesareneededbecauseoffragmented,outdatedandstaticcurriculathatproduceill-equippedgraduates.Thecommissionarguedformajorreformacrosstheentiremedicaleducationsystemtoproducecompetency-ledcurriculaforthefuture.20Ofthe38medicalschools,only6aregovernment-ownedandfunded,andtheremaining32areprivatelyrun.

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Exacerbatedbyincreasedhealth-caredemandsfromarapidlyageingpopulation,theresultantshortagesinthenumberofdoctorsisparticularlyevidentinsomeareasofmedicalspecialtyandinrurallocations.Informationfrominterviewssuggeststhatregulationcouldplayastrongerroleininfluencingthenumber,typeanddeploymentofhealthprofessionalstomeetsomeoftheaforementionedchallenges.

FormanycountriesintheRegion,however,severeworkforceshortagesandensuringaccess,coverageandqualityaremorepressingissues.Manyhealthprofessionalsinthesecountriesarealreadyworkingacrossadiverserangeofresponsibilitiesbynecessity,arangethatwouldcrossprofessionalboundariesinothercountries.

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7. CONCLUSION

Thisreviewsoughtto identifypublishedinformationonthesystemsandprocessesfortheregulationofhealthprofessionaleducationandpracticeintheWesternPacificRegion.Itdidnotseektoascertaintherelativeefficiencyoreffectivenessofregulatorysystemsonhowwelltheyachieveoutcomesorimprovehealth-carecoverage.However,apartfromthecountriesthatfallintothefirstcluster,andafewinthesecond,therewasapaucityofinformationon,orevidenceof,implementationofregulatoryprocesses.

Thereportprovidesanoverview,summarizingfindingstodate,butinformationgapsremain.Eachpieceof informationidentifiedpotentiallyyieldsafurthercascadeofquestions.Furtherconsiderationisneededtodeterminewhetherexploringanswerstomanyofthesequestionssitswithinthisproject,orcomprisesseparateworkstreams.21

Regulationexists inglobal,economicandsocio-politicalcontexts.Regulatorysystemsandprocessesareimpactedbynumerousfactors,includingmobility,governmentpolicies,internationalprogrammes,incentives,privateinvestmentandbroaderpoliticalagendas.ReviewedmaterialindicatesthatthesystemsandprocessesthatregulatehealthprofessionalsintheRegionarereflectiveofsocio-politicalandculturalhistoriesineachcountry.Acrossparadigmsofindividualismandprofessionalself-determinationtocollectivismandtightgovernmentcontrolarephilosophicalandpracticaldifferencesthatdeterminewhereregulationisfocused,andhowitisimplemented.Thisreviewdidnotseektoexploretherelativemeritsofthedifferentapproaches;rather,itsoughttodescribesystemsandprocessesandtoarticulatethesimilaritiesanddifferences,notinglinksandidentifyingemergingthemes.

Socio-politicalandculturalhistoriesalsoinfluencenomenclature,i.e.thetermsusedandappliedtodescribesystemsandsetsofactivities.ThisreviewhighlightstheimportanceofclarifyingandgeneratingasharedunderstandingoftherangeofterminologyappliedtoregulationacrosstheRegion.Thefindingsreinforcethepremisethatregulatoryprocessesandsystemsmustbeconsideredincontext,cognizantofcountrycharacteristics,andthatcountriesaresupportedtodesign,implementandenforceregulationaccordingtotheirpolitical,economicandculturalmilieu (2).

21 Limitationsofthedeskreviewmethodareacknowledged.Writtendocumentsdonotnecessarilyprovidecomprehensiveorcorrectanswersandaresimplyoneformofevidence,andshouldbeusedcarefullyandwithothertypesofdata.

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Healthprofessionaleducation,trainingandpracticearenotnecessarily linearinnature,andtheremaybemultipleparties,agenciesandcountriesinvolvedinthetraining,registrationanddeploymentofanyonepractitioner.Furtheranalysisissuggestedtohelpidentifytheimpactsofout-of-countrytrainingandaccreditationoninternplaces,teachingandsupervisorycapacity,andtheissuingandrenewalofregistrationorlicensurecertificates.

Emergingissues,suchastheincreaseduseofexternaleducationaccreditationagenciesandadvancesintelemedicine,createfurtherchallengesforregulators.Anunderstandingofthismultidimensionalpictureandits influenceonregulatoryapproaches, includinginrelationtomemorandaofunderstanding,mutualrecognitionagreementsandbilateralagreements,becomes important.

Thisreviewhighlightsthatthereisunlikelytobeasinglestrategyformovingclosertobestpracticeregulation.Insomecountries,itmaybeacaseofmaintainingthemomentumofreformsorimprovingregulatoryagencyperformanceorprocesseswithinexistinglegalframeworks.Inothers,anewimpetusmayberequiredthatfocusesonknowledge-sharing,andmovingtowardsbetterregulatoryprocessesandalegalframework.Regardlessoftheprocessesthatareinplace,andtheirlevelofdevelopment,regulationismorelikelytobesuccessfulifitisbasedonasetofprinciplesthatensureitistherightvehicletogiveeffecttopolicy,andtheriskthatisbeingmanaged(Annex 5).Goodregulationalsoneedspoliticalcommitment,reasonableinstitutionalcapacity,systematic interactionwithrepresentativesoftheprivatesector,professionalrepresentativebodiesperformingself-regulationandclarityoflong-termpurpose(1).

Despitegapsandlimitations,theinformationgatheredinthisreviewdoesprovidearegionaloverviewofthecurrentstatusofhealthpractitionerregulation.Thisreportalsoestablishesabaselineagainstwhichprogressinstrengtheningcapacitiesandprocessesforhealthpractitionerregulationcanbemeasured.Thethemesthatemergedcouldformthebuildingblocksforknowledge-sharingandaframeworkthatwillsupportbestpractice,effectiveand“right-touch”approachestoregulationatacountrylevel (Annex 6).

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Inbuildingthisframework,thefollowingquestionsmaybeusefulinguidingdiscussionontheoptionsandnextstepsforstrengtheningregulationintheRegion.

1. Whatshouldbethebasicobjectiveforworkforceregulation(e.g.protectingpublichealthandsafety,ensuringprofessionalaccountabilityorrecognizingprofessionalstanding)?

2. Isthereaminimumsetofregulatoryrequirementsneededtomakeadifference?3. Arethereexamplesofgoodpracticesacrossregulatorycomponents?4. Whataretheoptimalinstitutionalarrangements?5. Shouldpeopleotherthanthoseintheprofession, includingconsumers,beinvolvedin

governance?6. Howshouldregulatorsbemadeaccountable,andtowhom?7. Howshouldthelegislativeframeworkbesetout(e.g.profession-specificoroverall)?8. Whatoptionscanbeimplementedfornon-regulatedprofessions?9. Whataretheoptionsforstrengtheningtherelationshipbetweeneducationandregulation?10. Whataretheimpactsofincreasedmobilityonregulation?11. Whatmutualrecognitionagreementsexist;atwhatlevel;andwhataretheirimplicationsfor

education,practiceandregulation?12. Whatresourcesareneeded,bothtimeandfinancial,tosupporteffectiveandefficient

regulation?

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1. Regulatory policy and the road to sustainable growth. Paris: Organisation for Economic Co-operation and Development; 2010.

2. Harding A, Preker A, editors. Private participation in health services. Washington (DC): World Bank; 2003.

3. Western Pacific country health information profiles: 2011 revision. Manila, Regional Office for the Western Pacific: World Health Organization; 2011.

4. The best practice regulation model: principles and assessments. Wellington: New Zealand Treasury; 2012.

5. Council for Healthcare Regulatory Excellence. Right-touch regulation. London: Professional Standards Authority; 2010 (http://www.professionalstandards.org.uk, accessed 5 August 2015).

6. Randall G. Understanding professional self-regulation. Toronto: Ontario Association of Veterinary Technicians; 2000 (http://www.oavt.org/self_regulation/docs/about_selfreg_randall.pdf, accessed 5 August 2015).

7. 2013 FIPEd global education report. The Hague: International Pharmaceutical Federation (FIP); 2013.

8. McManus M, Usher K. Overview of regulation of nurses in the Pacific region. Melbourne: South Pacific Nurses Forum; 2012 (www.spnf.org.au/reports, accessed 6 August 2015).

9. Health Practitioner Regulation National Law (2010) Australia.

10. Health Practitioners Competency Assurance Act (2003) New Zealand.

11. Kwon S, Richardson E, editors. Mongolia health system review – World Health Organization. Health Syst Transit. 2013;3(2).

12. Transforming and scaling up health professionals’ education and training: World Health Organization guidelines 2013. Geneva: World Health Organization; 2013.

REFERENCES

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13. Leadership and governance: Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies. Geneva: World health Organization; 2010.

14. Roxas, A. Rationalizing medical education in the Philippines. Manila: Health Human Resource Development Bureau, Department of Health, http://hhrdb.doh.gov.ph/hrhnetworkphils/hrhn-dl file/5th%20Forum/1%20Panel%20A%20-%20Rationalizing%20of%20Medical%20Education%20 in%20the%20Philippines.pdf.

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Country LegislationKiribati Act on Public Health Nurses, Midwives and Nurses 1948, amended 2009

Pharmacists Act 1950Medical and Dental Practitioners Act 1981Medical Services Act 1996Medical Services Act 1996. Enrolled Nurses, Nurses and Midwives Ordinance 1968 rev 1977Medical Services Act 1996; Para Medical

Lao People’s Democratic Republic

Law on Health Care No.139/PM. 2005Medical Act 1971, amended 2012Dental Act 1971 and amendmentsNursing Act 1950; amended 1985Midwifery Act 1966Registrations of Pharmacists Act 1951Optical Act 1991 and amendmentsTraditional and Complementary Medicine Act 2013

Marshall Islands Marshall Islands Revised Code, Title 19, Regulation of Professions and Occupations 2004Nursing Practice Act 2005

Mongolia Health Law 1998Law on Drugs 1998State Policy on Drugs 2002–2011

Nauru Health Practitioners’ Act 1999 (Commenced 2003)Nauru Practitioners Board Act 1999

New Zealand Health Practitioners Competence Assurance Act 2003Health and Disability Commissioner Act 1994

Commonwealth of the Northern Mariana Islands

Health Care Professions Licensing Act 2005

Niue Niue Act 1966 (NZ); Article 21 – Niue ConstitutionPalau Palau Health Professionals Licensing Act 2000 (Palau National Code, Title 34)Papua New Guinea Medical Registration Act 1980

Medical Act 1980, Part 3 Nurses By-Law, Health Practitioners Bill 1984

ANNEX 1: Legislation, acts and decrees consulted for this review, by country and area

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Country LegislationPhilippines Medical Act 1959

Republic Act No. 6111, Medical Care Plan, and Medical Care Commission 1969Philippine Nursing Act 2001Higher Education Act 1994 Republic Act No. 8981 – The Professional Regulation Commission Modernization Act 2000Republic Act No. 7722, Presidential Decree no. 223. 1973Republic Act No. 4419, The Philippine Dental Act 1965Republic Act No. 5680, Physical and Occupational Therapy LawTraditional and Alternative Medicines Act 1997

Samoa Healthcare Professions, Registration and Standards Act 2007Medical Practitioners Act 2007Dental Practitioners Act 2007Nursing and Midwifery Act 2007Pharmacy Act 2007

Singapore Medical Registration Act 1997Dental Registration Act 1999, revised 2009Nurses and Midwives Act 2006Pharmacists Registration Act 2007Optometrists and Opticians Act 2007Allied Health Professions Act 2011Traditional Chinese Medicine Practitioners Act 2000

Solomon Islands Medical and Dental Practitioners Act 1996Nursing Council Amendment Act 1997Pharmacy Practitioners Act 1997Pharmacy and Poisons Act 1988

Tonga Health Practitioners Registration Act 2001Health Services Act 1991Health Practitioners Review Act 2001Medical and Dental Practice Act 2001Nurses Act 2001 and Amendment Act 2004Pharmacy Act 2001

Tuvalu Nurses Act 1975Vanuatu Health Practitioners Act 2006

Nurses Act 2000Control of Pharmacists Act 1953; scheduled amendment bill 2014

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CountryNumber of regulated

professions

Australia 14Brunei Darussalam 4Cambodia 4China 5Cook Islands 4Fiji 6Japan 13Kiribati 13Lao People’s Democratic Republic

0

Malaysia 8Marshall IslandsMicronesia, Federated States of

2

Mongolia 3Nauru 3New Zealand 16NiuePalau 3Papua New Guinea 3Philippines 13Republic of Korea 21Samoa 3Singapore 8Solomon Islands 3Tonga 4TuvaluVanuatu 8Viet Nam 0

ANNEX 2: Countries and areas of the Western Pacific Region and number of regulated professions

AreasNumber of regulated

professions

American Samoa (USA) 3French Polynesia (France) 4Guam (USA) 4Hong Kong SAR (China) 13Macao SAR (China) 6New Caledonia (France)Northern Mariana Islands, Commonwealth of the (USA)

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Pitcairn Islands (United Kingdom)Tokelau (New Zealand)Wallis and Fortuna (France)

USA = United States of America.

Notes: 1. A blank space indicates no information or very small number of or no resident health professionals.2. The exact number of regulated professions per country may differ from the numbers presented in this table due to differences in terminology and titles across countries and areas.

Source: Western Pacific country health information profiles: 2011 revision. Manila, Regional Office for the Western Pacific, World Health Organization, 2011.

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ANNEX 3: Questions to guide the desk review and list of professions reviewed

• Is there a regulatory mechanism in place?• Is it underpinned by legislation, and what is the name of the act, decree, code, etc.?• Are there categories of registration? How many registrants are in each?• What are the registration requirements (e.g. licence, registration, secondary licence/registration)?• What are the pre-licensing requirements (i.e. primary qualification and duration, assessment, supervision, and

duration of pre-licence period)?• Is there a body responsible for licensure?• Is a register maintained? Is it public? Does it cover complaints or disciplinary history?• What are the APC and other requirements (i.e. re-entry, grandparenting, exclusions, private practice)?• Are there links to education?• Is there an education accreditation mechanism? What is the body responsible for programme or provider

performance and sanctions?• How are practice standards set and sanctioned? What is the body responsible? Describe the process.• How is adherence to practice standards ensured? What is the body responsible? Describe the process.• Is there a complaints or disciplinary mechanism(s)? What is the body responsible? Describe the process.• Notes, issues and gaps

Medicine Optometry OsteopathyDentistry Psychology ChiropracticNursing Physio/physical therapy Chinese medicineMidwifery Occupational therapy Aboriginal/traditional medicinePharmacy Podiatry/orthotists AcupunctureMedical radiation practice Psychotherapy TechniciansOther Other Other

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ANNEX 4: The best practice regulation model: principles and assessments(Source: The best practice regulation model: principles and assessments. Wellington: New Zealand Treasury; 2012)

• Proportionality. The burden of rules and their enforcement should be proportionate to the benefits that are expected to result. Another way to describe this principle is to place the emphasis on a risk-based, cost–benefit regulatory framework and risk-based decision-making by regulators. This includes that a regime is effective and that any change has benefits that outweigh the costs of disruption.

• Certainty. The regulatory system should be predictable to provide certainty to regulated entities and be consistent with other policies. There can be a tension between certainty and flexibility. A principles- or performance-based regime that provides for safe harbours, such as deemed-to-comply standards, tries to resolve this tension, but ensuring both attributes are optimally reflected is a challenge.

• Flexibility. Regulated entities should have the scope to adopt least-cost and innovative approaches to meeting legal obligations. A regulatory regime is flexible if the underlying regulatory approach is principles- or performance-based; policies and procedures are in place to ensure that it is administered flexibly; and nonregulatory measures, including self-regulation, are used wherever possible.

• Flexibility and durability can be two sides of the same coin. A regime that is flexible is more likely to be durable, as long as the conditions are in place for the regime to learn. Indicators of durability are that feedback systems are in place to assess how the law is working in practice, decisions are reassessed at regular intervals and when new information comes up, and the regulatory regime is up-to-date with technological change. These two principles have been grouped for carrying out assessments.

• Durability. Closely associated with flexibility, the regulatory system has the capacity to evolve to respond to new information and changing circumstances.

• Transparency and accountability. This is reflected in the principle that rules development and enforcement should be transparent. In essence, regulators must be able to justify decisions and be subject to public scrutiny. This principle also includes nondiscrimination, provision for appeals and a sound legal basis for decisions.

• Capable regulators. The regulator has the people and systems necessary to operate an efficient, effective regulatory regime. A key indicator is that capability assessments occur at regular intervals and are subject to independent input or review.

• Growth-supporting. Economic objectives are given an appropriate weight relative to other specified objectives. These other objectives could be related to health, safety or environmental protection, or consumer and investor protection. Economic objectives include impacts on competition, innovation, exports, compliance costs and trade and investment openness. A regime embodies this attribute if the identification and justification of trade-offs between economic and other objectives are explicit parts of decision-making.

The growth-supporting principle is associated with a particular outcome, and hence, to some extent, differs from the previous six, as they can be seen as intermediate objectives. It does not assume that growth should be given prominence over other outcomes, but reflects that growth as an objective is not always identified or given due weight. It seeks to ensure that trade-offs between economic and other objectives are explicitly considered along with any other objectives emphasized in a regime.

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ANNEX 5: Council of Australian Governments principles of best practice regulation (Source: Best practice regulation: a guide for ministerial councils and national standard setting bodies. Canberra, Council of Australian Governments, 2007)

The Council of Australian Governments has agreed that all governments will ensure that regulatory processes in their jurisdiction are consistent with the following principles:

1. Establishing a case for action before addressing a problem.

2. A range of feasible policy options must be considered, including self-regulatory, co-regulatory and non-regulatory approaches, and their benefits and costs assessed.

3. Adopting the option that generates the greatest net benefit for the community.

4. In accordance with the Competition Principles Agreement, legislation should not restrict competition unless it can be demonstrated that:a. the objectives of the regulation can only be achieved by restricting competition, andb. the benefits of the restrictions to the community as a whole outweigh the costs.

5. Providing effective guidance to relevant regulators and regulated parties in order to ensure that the policy intent and expected compliance requirements of the regulation are clear.

6. Ensuring that regulation remains relevant and effective over time.

7. Consulting effectively with affected key stakeholders at all stages of the regulatory cycle.

8. Government action should be effective and proportional to the issue being addressed.

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ANNEX 6: Right-touch regulation, Council for Healthcare Regulatory Excellence (Source: Right-touch regulation. London: Professional Standards Authority; 2010, http://www.professionalstandards.org.uk)

Right-touch regulation describes the approach we adopt in the work we do. It is the approach that we encourage the health professional regulators to work towards. It frames the contributions we make to wider debates about the quality and safety of healthcare.

Right-touch regulation means always asking what risk we are trying to regulate, being proportionate and targeted in regulating that risk or finding ways other than regulation to promote good practice and high-quality healthcare. It is the minimum regulatory force required to achieve the desired result.

The concept has developed through our oversight role of the health professional regulators. It builds upon the principles of good regulation, identified by the Better Regulation Executive: proportionate, consistent, targeted, transparent, accountable. To these we added a sixth principle of agility. Agility in regulation means looking forward to anticipate change rather than looking back to prevent the last crisis from happening again.

In practice, we have identified the following eight elements that sit at the heart of right-touch regulation:

• Identify the problem before the solution• Quantify the risks• Get as close to the problem as possible• Focus on the outcome• Use regulation only when necessary• Keep it simple• Check for unintended consequences• Review and respond to change

In our view, the benefit of this approach is ensuring that regulation has its most efficient impact on the problem being tackled. It also enables all parts of the system to play their full part in providing a more appropriate response to a problem. In healthcare, this includes the contribution of employers, educators, professionals and patients. The consequences of this approach may be less regulation or may be more regulation, but will certainly mean better regulation. 1.

This publication is available on the Internet at: www.wpro.who.int/hrh/documents/publications