Table 3 Interview extracts illustrating regulatory themes

Weak regulation

Inadequate resources to regulate

“[KMPDC] has been challenged in terms of their scope of work. The Council of less than 20 people with no branches within the country, [KMPDC] are bombed with so much, including training of medical students.” (Kenya Medical Association representative)

“UMDPC is poorly funded, employs a few people, who are usually overwhelmed with work.” (Ugandan Doctor, FGD)

“We had challenges, we were understaffed, didn’t have enough resources.” (Uganda Nursing & Midwifery Council Representative)

“Key challenges? We are a small team; the country is big everybody thinks you are the only people who can provide solutions.” (Health Monitoring Unit representative, Uganda)

Remote regulators

[KMPDC] don’t have any presence in the counties, so there was that gap. They don’t have a presence on the ground. You cannot supervise counties from Nairobi. In five years, not a single person from the board has ever visited. They [regulators] are not in touch with what is happening on the ground.” (Doctor 7, Kenyan county C)

[Regulators] “not really in touch with the nursing fraternity on the ground.” (Nurse 18, Kenyan county V)

“For us, who are upcountry [far from the Ugandan capital city], we haven’t had any direct engagement with [regulators].” (Doctor 4, Ugandan district B)

“I’ve never seen them [UNMC] in more than ten years. Those people are comfortable in those buildings [Kampala offices] but we are here suffering, nurses not complying, professionalism is dying because those guys are not coming out of their offices.” (Nurse 2, Ugandan district B)

Regulators’ more focused on collecting licencing fees than regulating professional practice

“The only time I have interacted with KMPDC was when I was getting the practising license and then when I am getting my annual retention license. You don’t pay, that is the only thing they look at. Coming to the ground to supervise the facilities, in my entire practice, I’ve never seen them.” (Doctor 5, Kenyan country T)

“The only time you interface with the registration body is when they need the [license] fee. If a patient complains of malpractice, nobody is interested. Regulatory bodies are not functional, not looking at professionalism or quality of service but they are more interested in collecting revenue.” (Doctor 3, Ugandan, district)

“As long as the money is going to the Nursing Council of Kenya, your interaction is very nice. But if they don’t need money from you, we don’t see them.” (Kenyan nurse, FGD)

“[Ugandan nurses] don’t have any guidance, we only hear, ‘you have to pay.’” (Nurse 2, Ugandan district B)

Inadequate resources to address health system failures blamed on individual professionals

“The regulator is toothless when it comes to funding classrooms or hospitals. It is a bigger thing than the regulator.” (Kenyan Training provider representative)

“It is difficult to differentiate between a system failure and a professional failure. Doctors and nurses are being accused unfairly by the Kenyan public and sometimes by the Kenyan media because the system is so weak, and it does not support them.” (Kenyan Nursing Council representative)

“The whole system is dysfunctional. The public forgets. The doctor gets all the blame on behalf of the system.” (Kenya Medical Association representative)

“If you want to blame, on face value it looks like the doctor’s or nurse’s medical malpractice or professional negligence but there is always an institutional gap.” (Doctor, Kenyan county)

“If something goes wrong in a hospital, the blame always will be on that nurse but conditions on the ground, that’s what really kills.” (Uganda Nurses & Midwives Council representative)

Weakly enforced regulation

“Basically, they [regulations] don’t exist in practice.” (National stakeholder, Uganda)

“There’s a general perception that measures are not deterrent and punitive enough. But those punitive actions, should really come last after restorative measures. That’s something that the public doesn’t understand.” (Regulatory representative, Uganda)

“No regulatory body, nobody monitors. There is no consequence for doing wrong. So, most of us are driven by the oath and the institution of medical training tends to train you to care, look after patients and do the right thing but even if you don’t do the right thing, the consequences are not there really. If you have a weak regulatory body, you can get away with a lot.” (Uganda doctor 3):

“Regulators are lenient. There are no punitive measures. That encourages impunity. So, they must be able to bite, to deter others from being negligent in future.” (Kenyan training provider representative)

Weak social accountability

“Nobody honestly cares about the common mwanainchi [citizen]. There is no level of accountability.” (Kenyan Medical Association representative)

“Our people are a bit cautious, most of them don’t complain. A complaint usually comes from a backlash from the community.” (Doctor 10, Kenyan county V)

“We need to do a lot of health promotion. They [patients] even fear to ask a doctor whether he [sic] is qualified.” (Ugandan Ministry of Health official)

“Some of the patients are manipulated because they don’t know their rights.” (Doctor 10, Uganda district B)

Inadequate regulation of health professional education & training

Inadequate regulation of medical & nursing education

“We are producing professional health workers who are half-baked. None has any experience, training hands-on that you need to see a patient. Stop opening schools every county, training masses, producing lower quality professionals. So, it’s a matter of regulation. Medical training will one day just dilute, anybody will be a doctor.” (Doctor 12, Kenyan county V)

“Private medical schools, it’s a mess. The quality of our doctors is down, they’re not properly trained. I don’t see any regulatory mechanism for who gets into medical school, who qualifies, there’s no unified standards. Everybody qualifies doctors in any way they like.” (Ugandan doctor 3)

“These [regulatory] bodies are not visible anywhere, they should be visiting [medical] schools mostly to engage with the finalists, so that when you qualify, you know to come to this body, and this will be required of you.” (Doctor 7, Ugandan district A)

“As professional councils, the manpower we have is limited to assessing whether training providers have standards. We’re unable to get into whether teachers can teach competently.” (Regulator, Uganda)

“Trainees are half-baked because of these mushrooming institutions. If you get money, you can start a nursing school. This thing is affecting nurses. Everywhere there is a problem. The training period is limited, and their practical period is too short. They don’t care. A patient is not a big deal to them because they are after money.” (Nurse 2, Ugandan district B)

“Training needs to be improved aggressively monitored. Not to just leave it to the institution” (Doctor 25, Uganda district A)

Overenrolling students

“If you look at education, the ratio of a tutor [to students] is 1:60 in government [training institutions], in private [training institutions] it is 1:200 but 1:10 in a class, that’s the recommendation of WHO. We shall produce fake substandard people.” (Uganda Nurses & Midwives Union representative)

“[X] university; they are admitting 400 medical students to train in a place where they are only allowed to admit a maximum of 150. So, this is likely to compromise the quality of training. And I was telling them I am worried that even the products [health professionals] you are going to give us is not going to meet the standard that we have.” (Kenyan regulator 3)

“Someone just opens the school with the aim of getting money with 1,000 students. Where do you get the patients from to practice on? You can expect fake nurses.” (Nurse 9, Ugandan district B)

Inadequate internships & mentoring

“The regulator has failed in ensuring proper training and mentorship of the younger doctors. Many internship centres don’t have equipment, enough lecturers. Doctors who graduate from these universities don’t have all the required skills and knowledge.” (Medical organisation representative, Kenya)

Streamlining online regulatory administration

Developing online (re)licencing

“We don’t have to travel, it’s very easy. Once I’ve done my CPD, I renew my license, click, and pay with M-Pesa and you print your certificate. Before we used to travel to Nairobi. That would take a week. Now it’s a few minutes.” (Doctor 7, Kenyan county T)

“The Nursing Council of Kenya are doing well, even the registration or renewal of licenses is online.” (Nurse, Kenyan county)

“We register online. Tt doesn’t even take 10 min. Before, we used to involve in transport.” (Doctor, 10 Ugandan district B)

“I am going to renew [my nursing license online]. It has been fast; registration it is fast now.” (Nurse 7, Ugandan district A)

Streamlining regulatory administration

“Time and effort are focused on registration, licensing and collecting fees, which is a huge job that someone else could do, so regulators are free to regulate the profession. Currently enforcement is geared towards people who have not paid licences, instead of practice, ethics, and conduct.” (Ministry of Health official, Uganda)

Improving regulation through deconcentration

Relational & local regulation more effective

“It used to be difficult. Once registration was brought to this hospital, there is now no problem. When there are problems they [regional office] forward them to the Council, then they come, see problems, and get solutions.” (Nurse, Ugandan district A)

“[The Uganda Health Monitoring Unit] are doing a good job, at least they come… monitor… you feel like they have guided… Sometimes, instead of guiding or finding out, they are rude and want to arrest you, but at least we have interfaced with them. Other regulators, no.” (Nurse 10, Ugandan district B)

“The Nursing Council seems to be more vibrant than the Medical Council. The perception is that nurses would be more regulated. I think it’s just the system setup; the person doing the day-to-day running of the hospital is the nurse. Nurses seem to have a direction.” (Kenyan medical FGD)

Calls for regulatory decentralisation to local level

“Decentralise to the Counties and strengthen and empower those at the County level to oversee regulation. In every county have a regulator and officers in touch with what is happening to the professionals down here.” (Doctor 10, Kenyan county V)

“The council needs also to decentralise the operations, to have these regional offices. It should be easier for us to go to these regional offices to assess our issues.” (Doctor 7, Ugandan district B)

“We embrace the need for us to expand this office outside Kampala.” (Uganda medical regulatory representative)