National health workforce accreditation and regulation in Palestine: a qualitative assessment

Abstract

Background: The Health Workforce Accreditation and Regulation (HWAR) is a set of policies and processes designed to improve the quality of health services and the performance of health professionals. Various efforts were implemented, mainly by WHO, to advance and strengthen practices and activities of HWAR. In Palestine, HWAR seems to be lagging and to require strengthening at both national policy and institutional levels, based on local evidence. HWAR is rarely investigated in Palestine and possibly also in the Eastern Mediterranean. We aimed to assess the current status of HWAR in Palestine, to identify the challenges, and to propose useful policy and technical actions for the effectiveness of HWAR. Methods: We did a qualitative assessment with a purposive sampling strategy to identify key informants from health authorities and institutions in government institutions (Palestinian Ministry of Health and National Legislative Council), academia (universities), and private and non-governmental organisations. Ethical and administration approvals were obtained from the Helsinki Committee at the Palestinian Health Research Council. The study was implemented from mid-October to mid-November, 2019. 22 in-depth interviews were done with key personnel from leadership and policy levels, including health policy makers, experts, and academics (six female, 16 male). Open questions in the interviews covered HWAR domains: conceptual, governance and policy, technical practices, resource and capacity, and gaps and solutions. Triangulated qualitative methods (thematic and ground theory) were used for data analysis and management. Findings: We found a lack of understanding of HWAR, and perceptions of HWAR were inconsistent. Despite the existence of a strong legal framework for HWAR and an abundance of untapped skillful health workers, graduates, and students in Palestine and abroad, the majority of participants had a negative view of HWAR, perceiving it as fragmented, poorly regulated, and poorly coordinated. The governing system for HWAR was described as having no specific body or no clear mechanisms of operation. Interviewees reported that some existing accreditation and regulatory standards are well applied but that most need to be updated, reviewed, and enforced at a larger scale. They also reported that HWAR regulatory, executive, and education stakeholders have no consensus on HWAR governance, which is driven by individual initiatives and capacity rather than a systematic evidence-based approach. Overall, the participants described HWAR practices and resources as of low quality. Benefits of a well-established HWAR system and mechanism were suggested, such as an increase in the quality of services, patient safety, trust, and satisfaction with the performance of health system, and a reduction in resource waste. Factors affecting HWAR and the challenges for its implementation were identified—eg, political instability, deficit of education and training, shortage of resources and capacities, and lack of governance and oversight. Actionable solutions at the level of the health system, institutions, and individuals were proposed, establishing a unified and effective HWAR governance structure, policy and regulations, and guidelines and standards for practices. Interpretation: Interviewees emphasised the importance of HWAR as a key pillar of health system governance for improving health care and achieving universal health coverage. HWAR national policy and guidelines need substantial reform to tackle poor implementation, communication, standardisation, monitoring, and evaluation. Stakeholders, ministries, syndicates, and academic institutions should work together through an integrated national accreditation and regulation system. Interviewees suggested that system reform must be driven by a common vision, well-established guidelines, and an accreditation and regulation policy for better awareness, best practices, and effective mechanisms.