Clumsy Solutions For Complexities Within Professional Healthcare Regulation: Navigating Plurality Of Policy Instruments For Expanded Entry & Practice Rights Of Healthcare Professionals.

Given the historically acute shortages in human health resources and the onset of health crises, such as the recent Covid-19 pandemic, global health bodies advocate for expanding entry and practice rights within the health professions. While regulation, a key macro influence within the health professions, has great normative appeal, policy scholars know little about how regulation operationalises in reality. Moreover, establishing relevant links between the regulatory tools and approaches within health policy is fairly new scholarship and remains an underdeveloped area of study. Further, a need is felt to break up the jurisdictional and professional silos present within the professional healthcare regulation literature and transcend the zero-sum notions of policy instruments (good versus evil, market versus state, carrot versus stick). By exploring and interrogating the role of regulation in both organising and expanding entry and practice rights, this thesis focuses on the content, choice, and effects of policy instrument mixes within the health professions. This research is one of the first to systematically study policy instruments’ implementation in professional healthcare regulation using a theoretical framework that blends different strands of literature. Useful lessons are proposed for both governments and health professions so they do not have to start from scratch when developing and implementing regulations to determine entry and practice rights and their expansion within the health professions. Designed as qualitative case studies involving four regions of England, Scotland, Ontario, and Nova Scotia, the thesis relies on a detailed literature review, a historical process tracing exercise, and 45 semi-structured interviews conducted across the four cases. These approaches focus on understanding the ease and challenges with which role expansion occurs within the health professions. The thesis synthesizes findings in a comparative fashion to show how professional healthcare regulation highlights regulatory pluralism. Further, the current landscape represents a case for smart regulation and enforced self-regulation, especially as the relationship between the state and health professions has continued to metamorphosise over the last two decades. By applying a cultural theory framework, the thesis further shows the hybrid nature of policy instruments being embraced by regions, reinvention of hierarchy as a form of control, and the desire to achieve uniformity in regulation as evidenced by the cycling or rotating nature of policy instruments within the health professions. The role of risk as a neutral criteria and other variable criteria, including dominance of a profession, lobbying by professional groups, and economic conditions in a region, are further explored to understand the factors influencing the choice of policy instruments within the health professions. Finally, by capturing stakeholders’ perceptions, the thesis examines which instrument mix and regulatory approach is associated with the values of effectiveness, efficiency, and equity for both the health professions and the government. The thesis concludes that while regulation has a strong link with the overall organising and management of entry and practice rights within the health professions, its link with the expansion of rights remains rather bleak. By studying the reforms that the Covid-19 pandemic triggered, the thesis further identifies positive avenues for role expansion within the health professions. However, given that several of these reforms were necessitated by a crisis and are now being rolled back, the thesis concludes that Covid-19 has not emerged as a critical juncture in the regulatory reforms within the health professions. Going forward, the thesis advocates for more policy impetus towards developing and strengthening the existing regulatory approaches and instruments in order to redirect the focus on role expansion within the health professions.

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