Deconcentration to improve regulation in low- and middle-income country health systems: Findings from research on regulation for doctors, nurses and midwives in Kenya and Uganda

Abstract Background: Regulating health professionals in Low- and Middle-Income Countries (LMICs) is a key challenge. While holding potential to improve professional practice and patient care, regulation is often weakly implemented and enforced across LMIC health systems, allowing poor practices to continue. Therefore, there is need to understand how regulation can be improved across resource constrained LMIC health systems. Methods: We conducted mixed-methods research on health professional regulation in Uganda and Kenya (2019-2021), using qualitative interviews with national regulatory stakeholders, sub-national regulatory actors, ‘frontline’ doctors and nurses/midwives, and a bi-national survey. Results: Due to resource constraints, Kenyan and Ugandan regulators were generally perceived to be ‘remote’ and ‘out of touch’ with ‘frontline’ professionals. Weak regulation was blamed for failing to address widespread malpractice and inadequate standards of health professional training. However, doctors and nurses/midwives were positive about online licencing and regulation where they had relationships with accessible regulators. Conclusion: We propose an ambidextrous approach to regulatory improvement in resource constrained LMIC health systems; simultaneously deconcentrating regulatory monitoring and support to local level, to address frontline problems, while funding this using efficiency savings from developing and streamlining online regulatory administration.