Strengthening health professional regulation in Kenya and Uganda

Regulation can enhance quality and safety in health care, yet the limited research on health care regulation in LMICs suggests it is often ineffective and clinical malpractice, perhaps partly consequently, widespread. We therefore need to better understand how and why health care regulation in LMICs operates and might be improved.

Some research has suggested that developing, 'responsive regulation' (Ayres and Braithwaite, 1992) involving regulator-regulatee dialogue to develop and agree regulatory legitimate regulatory standards, persuade professionals to comply, and detect and sanction noncompliance, may improve regulatory effectiveness in LMICs' health care systems. Using responsive regulation as our 'theory of change', we therefore propose to research health professional regulation for doctors and nurses/midwives in Kenya and Uganda to provide evidence supporting regulators to improve health regulation and, in turn, enhance health systems and the quality and safety of patient care.

As we noted, there is very little research on regulation in LMIC health systems or evidence about its impact on health care practices. We therefore propose mixed methods research, which members of the research team have previously used to research professional regulation, to develop this evidence base. This research would involve: Analysis of documentation and interviews with national regulatory stakeholders in Kenya and Uganda; focus groups with doctors and nurses/midwives in Kenya and Uganda about their experiences/perceptions of regulation; four case studies of health professional regulation at county/district level; and an online survey of Kenyan and Ugandan doctors and nurses/midwives at national level.

Professionals in the Ugandan and Kenyan health systems are regulated by different profession-specific bodies but both countries are establishing single oversight bodies to monitor regulation across all health professions. These major policy changes, coupled with members of the project team's connections to regulators and health policy-makers in both countries, make this research particularly useful and timely. This foundational project aims to provide evidence to help regulators improve regulation and develop research capacity and provide a foundation for a larger research proposal, piloting regulatory improvements and evaluating their impact.

Our international interdisciplinary research team contains experts on regulation, health systems improvement and health policy from Uganda, Kenya and the UK, with experience of conducting research on health systems and regulation, which has had impacted health and regulatory policy. We will collaborate closely with regulatory bodies in Kenya and Uganda throughout the project to ensure that we research issues and questions they believe are important and report findings back to regulatory stakeholders in Kenya and Uganda (at workshops in both countries) and other LMICs (via international regulatory policy and academic conferences, in publications and online) to help them improve health regulation and, in turn, the quality and safety of patient care in Kenya, Uganda and LMICs beyond.

Regulation can enhance quality and safety in health care, yet the limited research on health care regulation in LMICs suggests it is often ineffective and (perhaps partly consequently) poor clinical practice widespread. So, we need to understand how to improve health care regulation in LMICs.

Research has suggested that 'responsive regulation' (Ayres and Braithwaite, 1992), involving regulator-regulatee dialogue to develop/agree regulatory standards, persuade professionals to comply, and detect/sanction noncompliance, may be a more effective form of health care regulation in LMICs. Using responsive regulation as our 'theory of change', we therefore propose to research regulation for doctors and nurses/midwives in Kenya and Uganda to provide evidence supporting improvements to health regulation, health systems and patient care in LMICs.

We will collaborate closely with health regulators and other regulatory stakeholders in Kenya and Uganda (with their representatives on a project advisory board) to ensure we research issues, address questions and provide evidence they find important.

We will conduct a mixed methods research in Kenya and Uganda, analysing documentation, interviewing national regulatory stakeholders, running focus groups with doctors and nurses/midwives about their experiences and perceptions of regulation, conducting case studies of health regulation at county/district level, and running an online survey of Kenyan and Ugandan doctors and nurses/midwives at national level.

We will report findings to regulatory stakeholders at workshops in Kenya and Uganda, to international regulatory stakeholders in policy and academic conferences and publications and online) to help them also better understand how to improve health regulation and patient care. From this foundational project we will aim develop evidence and research capacity as a foundation for a larger research proposal, piloting regulatory improvements and evaluating their impact.

Health care regulation is often ineffective in LMICs, which has implications for the quality and safety of patient care, while there is little evidence about how regulation operates or affects health care. This study will provide evidence of how professional regulation operates and affects two professional groups (doctors and nurses) and their clinical practice in two LMIC health systems (in Uganda and Kenya) and factors that facilitate and inhibit effective health care regulation. This evidence will help regulators improve regulatory effectiveness and, in turn, the quality and safety of patient care. To deliver this impact, this project will specifically target three groups: Kenyan and Ugandan health regulatory stakeholders; international health regulation stakeholders and the academic community involved in health regulation research.

Ugandan and Kenyan health regulatory stakeholders

The project team have existing relations with professional associations, the Ministries of Health and health regulators in Uganda and Kenya (including the Medical Practitioners & Dentists Board (Kenya); Uganda Medical & Dental Practitioners Council; Nursing Council of Kenya; National Nurses Association of Kenya; Uganda Nursing & Midwifery Council; Health Professions Oversight Authority (Kenya)). Representatives of regulatory bodies have agreed to sit on our project advisory board (see letters of support), which will guide and advise the research team to ensure that our research produces evidence that regulators and policy-makers can use to improve regulatory effectiveness. At the end of the project, we will run workshops in Kenya and Uganda, involving key regulatory stakeholders, where we will present our findings about how regulation operates and might be improved, and discuss regulatory stakeholders' involvement in developing in larger research project piloting implementation of regulatory interventions/improvements and evaluating their impact.

International health regulatory stakeholders

Evidence from our research project will be of interest to international health regulatory stakeholders. We will engage the international regulatory communities through presenting findings at regulatory conferences, such as the IAMRA conference, publishing in policy journals, and by making our results online (via WRAP (http://wrap.warwick.ac.uk) with open access. We will publicise these data on our institutional websites in conference presentations and publications.

Academic community

Academics may attend regulatory conferences (such as IAMRA) and access the resources we post online. We will also present our findings at academic conferences and publish our research in relevant policy and academic journals (which international regulatory stakeholders may read too).

Developing the research capacity of members of the research team, strengthening their academic expertise and understanding of health systems research and health professional regulation will benefit the academic community. The research team will be more able to develop the capacity of other academics and advise regulatory stakeholders in Kenya and Uganda. Indeed, a key aim from this foundational project is to develop a research team able to deliver further and larger research projects on regulation in LMIC health systems.

Track record of impact

The project research team have strong connections to the health policy and regulatory community and a track record of conducting research that has impacted on health and regulatory policy (as detailed in our pathway to impact documents) including in LMIC health systems.