Policy and Regulatory Environment

Understanding the relevant aspects of policy can promote advocacy efforts and increase coordination across the many levels of governance involved in the pre-service education system. This section also addresses how to involve stakeholders, policy and the regulatory environment issues. The State of the World’s Midwifery Report includes recommendations about strengthening the policy and regulatory environment to maximize the impact of midwifery services.

Involve stakeholders strategically. The stakeholder analysis tools described in the Advocacy section provide guidance for determining the best involvement for various stakeholders. Working groups are often formed during the key stakeholder meeting. Working groups may include: a national group of key officials who will help shape interventions and make necessary policy changes, a technical advisory group that contributes to decisions related to educational interventions, and institutional or clinical practice site-level working groups. The Sample Terms of Reference document establishes terms of reference for the different groups involved in implementing educational standards and curricular revisions.

Review levels of governance. Levels of governance, the regulatory framework that supports pre-service education system, are supported by the related ministries and professional councils and often outlined by national laws. The regulatory framework includes selection criteria, accreditation or other regulation, and licensing and graduation requirements. The technical brief on Licensure, Certification and Accreditation provides a concise summary of these important issues. For regulation issues, refer to the International Confederation of Midwives (ICM) Standards for Midwifery Regulation.

Address scope of practice issues based on task analysis findings or national priorities. Countries that want to change or share tasks between cadres of health care workers must ensure that national policies and professional scopes of practice are revised to reflect new competencies expected of that cadre. Coordinate with stakeholders and the national working groups to revise the job description to match the new scope of practice (Smith and Hyre 2009). This step may be done during meetings or in collaboration with the coordinating body over the course of the program. The WHO Task Shifting brief provides guidance on this process.

Review existing accreditation or other quality assurance mechanisms. Accreditation of private and public sector schools is essential for quality assurance and regulation (Crisp, Gawanas and Sharp 2008; Frenk and Chen, et al. 2010; WHO 2009). Accreditation or national regulatory bodies will help improve and maintain quality (Fullerton and Leshabari 2010). Work with national partners to provide certification or accreditation in these key educational areas: (a) effective recruitment, management and deployment of students; (b) management of resources; (c) faculty teaching and clinical excellence; (d) administrative process; and (e) development and maintenance of an evidence-based curriculum. Jhpiego uses the Standards-Based Management and Recognition (SBM-R) approach to implement educational quality assurance or accreditation. SBM-R uses agreed-upon standards to assess performance, identify gaps, and select appropriate interventions. This process is outlined in the Standards-Based Management and Recognition Implementation Guide.

Review the licensure/re-licensure process to ensure standards exist to license health care workers. The licensure process, which should facilitate life-long learning, is a regulatory responsibility of the professional council, which is charged by the government to ensure competency to protect the public. Initial licensing should occur when pre-service education is completed and must be logically linked to the required entry-level job competencies. Both licensure examinations and institutional examinations must be based on the identified core competencies. Assist ministries of health, education councils, or professional councils to revise the licensure and graduation exams to ensure priority health areas are adequately assessed before deployment. Work with the national and technical working groups to ensure that core competencies are assessed in licensure, certification, and graduation exams. This may be done as part of a workshop or over the course of program implementation.

Link continuing education to re-licensure or certification and continued professional development. Pre-service education starts a career of life-long learning, supported by continued professional development. After graduation, provide continuing education to maintain skills, and link it to re-licensure (Dal Poz, et al. 2009). Professional associations can play a strong role in developing and implementing continuing education or professional development systems. Councils ensure continued competency by requiring organized systems of continuing education and professional development.

Ensure deployment strategies to support priorities. Deployment should seek to successfully match health workers’ skill sets with communities ready to receive them (Dal Poz, et al. 2009; Smith and Hyre 2009). A robust deployment strategy can address underserved areas and reduce attrition (WHO 2007). Key to deployment is effective recruitment; for example, recruiting community members for community-based positions or selecting students from areas of priority need with hopes they will be more willing to be posted there than other students (Smith and Hyre 2009, WHO 2006). Thailand has successfully used rural recruitment strategies and bonding to increase access in rural areas (WHO 2010). Deployment issues are not always addressed, but are important if the country is attempting to meet the needs of a specific geographic population. The Bridges to Employment document outlines strategies for retaining graduates until they can be successfully deployed.

Lessons Learned: Policy and regulatory environment

 These tasks are often high-level efforts that require time, persistence, advocacy, and commitment. Many of these tasks are accomplished through the power and collaboration of the related national working groups over the life of the program. Support and investment in these working groups not only builds national capacity, but ensures the program is relevant and sustainable.

 Do sufficient research to understand what other recent assessment information might be available either from the government or other NGOs.

 In Kenya, the addition of several questions on reproductive health to the licensure exam helped ensure long-term commitment to the topic during the curriculum.

 A working understanding of the existing regulatory frameworks, processes, and regulatory bodies is essential.