The regulation-practice gap, regulatory relationships, and quality improvement in resource-constrained health systems: Findings from a study of professional regulation for doctors and nurses in Uganda

Regulation is a core mechanism for maintaining the availability and quality of the health workforce, underpinning a WHO building block for health system improvement, but often fails in resource-constrained health systems in the Global South. This paper examines views and experiences of professional regulation for doctors and nurses/midwives in Uganda, regulatory problems and opportunities for improvement. We conducted focus groups, 60 interviews with Ugandan national regulatory stakeholders, doctors, and nurses/midwives, and a national survey completed by 2213 Ugandan doctors and nurses/midwives. With limited resources, staff, and significant responsibilities, Ugandan health regulators were perceived as focusing on collecting fees, registering, and licensing health practitioners, rather than ensuring high-quality professional practice. While Ugandan doctors, nurses and midwives support regulation in principle, they reported limited engagement with distant regulators, who rarely noticed or addressed malpractice. However, we found one positive case where nurses described good personal relationships with a local regulator, who supported, mentored and explained to nurses what regulation and compliance meant in practice, and here nurses viewed regulation as working well. Thus, we explain how regulatory relationships can bridge the geographical gap between regulators and health professionals and the interpretive gap between written standards and practice. Improving relationships between regulators and regulated health workers holds potential to address the regulation-practice gap, which is generally undermining regulation and professionals’ practice in resource-constrained countries in the Global South. However, regulatory relationships must be supported by adequate resources and transparent mechanisms to prevent local-level regulatory capture, politics, and corruption. • Ugandan doctors and nurses/midwives perceived health professional regulators as poorly resourced, focused on registering, licencing and collecting licence fees, rather than regulating and ensuring high standards of practice. • Ugandan doctors and nurses/midwives reported little engagement with healthcare regulators, who were therefore perceived as unaware of malpractice or challenges facing practitioners on the ‘frontline’ of health care practice. • However, in one Ugandan district we researched nurses viewed regulation more positively. Here a senior nurse ran a local nursing/midwifery regulation office and had developed constructive relationships and two-way dialogue between the regulators and regulated health practitioners. We explain this positive outlier case using theory about ‘relational regulation’, which we suggest can improve regulation and compliance by developing legitimacy and understanding, including health practitioners’ understanding of regulation and regulators’ understanding of regulated frontline practice.