Although licensing and accreditation of health professionals and facilities are established quality control practices in developed countries, many lower-middle income countries struggle to create systems to fulfill this function. Licensing and accrediting programs aim to improve the quality of a wide range of health professions and facilities from midwives and physicians to pharmaceutical vendors and producers. While licensing and accrediting bodies do perform similar functions they have defining characteristics:
- Licensing bodies are legislative governmental bodies which provide healthcare workers such as physicians, nurses and midwives the legal right to work, or in the case of facilities the legal right to operate.
- Accrediting bodies are non-legal bodies which provide certificates to healthcare workers or facilities which meet certain quality standards, or have undergone training and testing by the accrediting body. Providers and facilities which are unaccredited may still have the legal right to provide services, even though these services may be of low quality.
CHMI has been looking at programs profiled on our digital platform to uncover which programs are emerging to ensure quality control through licensing and accreditation. CHMI currently profiles 29 programs offering licensing and accreditation of health professionals and facilities in Lower-Middle Income Countries (LMICs). When analyzed in closer detail this group of programs shows that the majority of programs, 26, are accrediting programs, while only 3 are licensing programs. This is a surprising balance, but it may reflect the capacity of LMIC governments to implement quality control programs through strict licensing. When LMIC governments are unable to enforce licensing to ensure quality control, it may be the case that accrediting bodies are filling this empty space. One example of this is Bidan Delima, a midwife accrediting organization in Indonesia, where no formal midwife licensing program exists. Greater analysis would be needed to be certain if accrediting bodies are filling voids in licensure in LMICs. It should also be noted that some accrediting bodies are government led or implemented projects, though they are not legal bodies which grant legal rights to providers or facilities.
A Brief Landscape:
Licensing and accreditation programs have primarily been profiled in East Africa (14) and Asia (7). The most common health focus areas of programs working in licensing and accreditation are maternal, newborn and child health (10), family planning and reproductive health (11), HIV/AIDS (7), and Primary care (5). The most commonly reported target demographics of programs working in licensing and accreditation included the general population (15), women (11), and children under 5 (6). There were no licensing and accreditation programs which reported working in the fields of malaria, mental health, eye care, dentistry, rehabilitation, or emergency care. This may be due to biases in our database and greater landscaping in these fields for licensing and accrediting bodies may be necessary.
What Types of Licensing and Accreditation Programs Are Documented?
CHMI-profiled programs which offer accreditation and licensing generally fall into three categories:
1) Licensing and accreditation of healthcare workers, such as nurses, midwives and physicians;
2) Licensing and accreditation of pharmaceutical vendors and producers;
3) Accreditation of health facilities.
Thirteen programs in CHMI offer accreditation and licensing to health care workers, five programs license and accredit pharmaceutical vendors and producers, and six accredit health facilities.
Programs which accredit healthcare workers include the Mother Bles Birthing Clinics of the Philippines, which accredits midwives according to national guidelines, and ProFam, Benin which accredits physicians. Physicians who wish to operate under the ProFam, Benin seal must regularly meet quality assurance and performance requirements. Physicians under ProFam must undergo site inspections four times per year, external clinical audits annually, and their participating clinic must undergo client exit interviews once per year. Physicians are given feedback and refresher trainings or on-site coaching to address areas of low performance. High performing practitioners are awarded with medical technical equipment. Physicians who fail to improve performance despite repeated supervisory, on-site coaching visits and refresher trainings are considered for disqualification from the network.
Pharmaceutical vendors and producers:
The five CHMI programs which offer licensing and accreditation to pharmaceutical vendors and producers focus on improving the quality of drugs, or the knowledge of pharmaceutical vendors. The Accredited Drug Dispensing Outlet (ADDO) is one such initiative. ADDO is led by the Tanzanian Food and Drug Authority to train and accredit small, privately operated retail drug outlets in rural and poor areas to sell a set list of essential medicines, including selected prescription drugs. ADDO is one of several accrediting bodies profiled by CHMI which are led by government initiatives, but are not legal bodies. As a result, there are pharmacies which operate legally in Tanzania, which are not accredited by ADDO.
Although ADDO is not a legal body, it demonstrates that accrediting bodies are able to significantly improve the quality of pharmaceutical vendors. While baseline data showed 39% of shopkeepers recommended incorrect medicines, only 14% of shopkeepers who participated in ADDO did. Based on the success of ADDO, MSH, the implementing organization, replicated the program in Liberia under the name Accredited Medicines Stores (AMS). As of March 2013 the AMS had 120 proprietors and 358 accredited dispensers in Liberia.
In Nigeria, the National Agency for Food and Drug Administration (NAFDAC) is one of three programs profiled by CHMI which conduct stricter quality control through licensing. NAFDAC regularly inspects pharmaceutical manufacturing facilities to ensure they comply with established quality standards based on good manufacturing practices issued by the WHO, and provide licensing for pharmaceutical production in Nigeria. Overseas manufacturing facilities intending to export to Nigeria must also comply with inspection standards to be granted authorization for marketing and export to Nigeria.
Six CHMI-profiled programs license and accredit healthcare facilities, to ensure that they meet standards for patient safety and quality of care. Some of these programs, such as the National Hospital Accreditation Program in Zambia, measure the quality of hospitals based on standardized quality indicators. Other programs, such as the Safecare Foundation, which operates in six countries across Africa, are designed to assist facilities in step-wise quality improvement. Safecare’s five step program awards “Certificates of Improvement” to facilities as they meet benchmarks for improved quality. Facilities which have earned the Safecare Foundations Level 5 Certificate of Improvement become eligible for more formal accreditation programs through JCI or COHSASA. Safecare’s system promotes manageable improvements so as not to discourage and demotivate African facilities with unreachable international norms.
Providing structure for quality assurance:
Several organizations are improving the quality of healthcare services through the power of social franchising and health care networking. Such tools can be particularly powerful in countries lacking the ability to implement and enforce quality standards of care through licensing.
Ten of the accreditation programs profiled by CHMI operate under a franchise model. Under a health franchise model providers are organized under a common brand. This is usually regulated for quality control by either a governing body or a body of peers interested in maintaining the brands name for commercial purposes. In either case, regulation of quality comes from within the organization, and is for the purpose of the organizations’ own best interest. Not all franchises operate an accreditation program. Many franchises, particularly those which sell health commodities through community salespersons, do not require that the salespersons be accredited. Franchises which are more clinically oriented, however, do tend to operate accreditation programs to ensure that the knowledge and skills of the providers operating under the brand name is of high quality. Accreditation programs under franchising models provide members the opportunity for training and skills development leading to certification. Providers certified under the franchises training program are then able to market their services under the brand name, signifying to patients the quality of their establishment.
An example of this quality assurance structure is the Bidan Delima program in Indonesia, which trains midwives on best practices in midwifery services, reproductive health and family planning. Midwives who pass the training and exam, become certified Bidan Delima midwives, and are able to perform their services under the franchise’s brand name, which is widely trusted across Indonesia. Currently Bidan Delima is operating in 21 of 33 provinces in Indonesia, with over 9,000 midwives.
Three other CHMI profiled programs operate under the health services network model. Providers under a health network are more loosely organized compared to franchises. Members retain their separate identities and do not provide health services under a common brand; however, membership in a health network can still be marketed by health providers as a sign of their services quality. Like franchises, these health services networks ensure a high quality membership by requiring network accreditation first. Shasthya Sena, a CHMI program in Bangladesh, is one program operating under the health network model. The program reports that it has trained and accredited 135 informal providers. Network members are expected to adhere to quality standards in safety, appropriateness of treatment, and avoidance of unnecessary costs to patients. The network is governed by members of government, civil society, and formal private practice.
Developments of Licensing and Accreditation
As CHMI continues to learn about new licensing and accrediting programs we will continue to share innovations in the field, promising practices, and the evidence behind them. Please also contact me if you know of other programs working to improve quality of health services through licensing and accreditation.
Photo: Mwanahawa shows off the certificate of accreditation from ADDO in Tanzania.