Design, delivery and effectiveness of health practitioner regulation systems: an integrative review

(2023) 21:72 Leslie et al. Human Resources for Health https://doi.org/10.1186/s12960-023-00848-y Human Resources for Health Open Access RESEARCH Design, delivery and effectiveness of health practitioner regulation systems: an integrative review Kathleen Leslie1,10* , Ivy Lynn Bourgeault2,10, Anne‑Louise Carlton3, Madhan Balasubramanian4,5, Raha Mirshahi2,10, Stephanie D. Short6, Jenny Carè7, Giorgio Cometto8 and Vivian Lin9 Abstract Background Health practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions. Methods We conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework. Findings This large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures–processes–outcomes conceptual framework. Governance reforms in HPR are shifting towards multiprofession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strate‑ gies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evalu‑ ation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accredita‑ tion of health practitioner education programs, mandatory reporting obligations, remediation programs, and statu‑ tory registration of traditional and complementary medicine practitioners. Conclusion We identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals. *Correspondence: Kathleen Leslie Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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Human Resources for Health (2023) 21:72 Page 2 of 31 Keywords Health practitioner regulation, Health systems, Health workforce, Systematic reviews, Integrative review Introduction Health systems face considerable challenges in recruiting, training, distributing and retaining a sufficiently skilled and competent health workforce. These challenges are compounded by factors such as the increasing volume and privatization of health practitioner education, accelerating international mobility, a rise in cross-border service delivery; more team-based service delivery models, and the growing significance of frequently unregulated occupations like community health workers and traditional and complementary medicine (T&CM) practitioners [1].1 In response to the complex demands on health systems involving health workforces, some governments have reformed health practitioner regulation (HPR) systems to better serve the public interest [2–7]. HPR systems are increasingly acknowledged for their role in enhancing the availability, accessibility, quality, and sustainability of the health workforce, which is essential to make progress toward Universal Health Coverage and the Sustainable Development Goals [1]. Strengthening HPR systems can help to assure competence of the health workforce and the safety of services they provide, and foster the flexibility and innovation needed to meet population health needs. HPR can maximize the potential of the existing health workforce and assist in aligning health workforce investments with health system needs [8, 9]. There are significant gaps in our knowledge about leading HPR policy and practice, such as which regulatory models, institutional governance and combination of regulatory functions work best in different contexts. This review aimed to synthesize the evidence base around HPR design and delivery to help governments, regulators, and policymakers achieve health system and workforce goals. Defining health practitioner regulation Based on the International Standard Classification of Occupations [10], we defined health practitioners to include health professionals, associate health professionals, and personal care workers in health services. We excluded categories of health workers not directly engaged with patient care or diagnostics, such as health care management and support staff. Practitioners from all areas of practice (acute, home, community, or public 1 T&CM was the term commonly used in the literature we reviewed. T&CM is part of a broader category of traditional, complementary and integrative medicine, the term used by the WHO. health) wer (...truncated)