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REGULATION AND LICENSING OF HEALTHCARE PROFESSIONALS: A REVIEW

OF INTERNATIONAL TRENDS AND CURRENT APPROACHES

IN PACIFIC ISLAND COUNTRIES

Background paper for the HRH Hub serieson ‘Evidence and Policy Options’ for

healthcare education and training inPacifi c Island countries

Judy McKimm, Philip M. Newton, Ana Da Silva, James Campbell, Rob Condon, Berlin Kafoa, Revite Kirition, Graham Roberts

ACKNOWLEDGEMENTSThe authors of the series of papers on Evidence and Policy Opti ons for healthcare educati on and training in Pacifi c Islands Countries, of which this paper forms a part, acknowledge Emeritus Professor Rob Moulds for his review of the full series. Professor Moulds, a previous Dean of the Fiji School of Medicine, has long experience of health professions educati on in the Pacifi c, and through his involvements in medical educati on in parti cular, has helped to contextualise many of the issues raised in the series.

The authors also wish to acknowledge Ms Mere Ravunibola and Mr Ledua Temani of the College of Medicine, Nursing and Health Sciences, Fiji Nati onal University who assisted with informati on on student enrolments and scholarship off ers.

© Human Resources for Health Knowledge Hub 2013

Suggested citati on:McKimm, J et al. 2013, Regulati on and licensing of healthcare professionals: A review of internati onal trends and current approaches in Pacifi c Island countries, Human Resources for Health Knowledge Hub, Sydney, Australia.

Nati onal Library of Australia Cataloguing-in-Publicati on entry

McKimm, Judy.University of Swansea, United Kingdom andInsti tuto de Cooperación Social Integrare, Barcelona, Spain

Regulati on and licensing of healthcare professionals: A review of internati onal trends and current approaches in Pacifi c Island countries / Judy McKimm ... [et al.]

9780733432927 (pbk.)

Medical personnel — Islands of the Pacifi cMedical personnel — LicencesPublic health personnel — Islands of the Pacifi cPublic health personnel — Licences

Newton, Philip M.University of Swansea, United Kingdom.

Da Silva, Ana.University of Swansea, United Kingdom.

Campbell, James.Insti tuto de Cooperación Social Integrare, Barcelona, Spain.

Condon, Rob.Consultant, WHO South Pacifi c, Suva, Fiji.

Kafoa, Berlin.College of Medicine, Nursing and Health Sciences, Fiji Nati onal University, Fiji.

Kiriti on, Revite.College of Medicine, Nursing and Health Sciences, Fiji Nati onal University, Fiji.

Roberts, Graham.Human Resource for Health Knowledge Hub, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia and Fiji Nati onal University.

353.6

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McKimm, J et al.Regulati on and licensing of healthcare professionals1

CONTENTS

2 Acronyms

3 Summary

4 Introducti on

5 Country fi ndings

11 Cooperati on between countries

12 Funding licensing processes

13 Regulati on and licensing in the Pacifi c

16 Internati onal models of licensing and registrati on

17 Policy implicati ons for the Pacifi c

18 Conclusions

19 References

21 Appendix 1. Fees and payments for licensing of healthcare professionals

26 Appendix 2. Defi niti ons

LIST OF TABLES13 Table 1. Health worker registrati on bodies and requirements in the Pacifi c

LIST OF FIGURES4 Figure 1. Pipeline to generate and recruit the health workforce


AAMC Association of American Medical Colleges

ABMS American Board of Specialties

ACME Accreditation Commission of Midwifery Education

ACGME Accreditation Council for Graduate Medical Education

AHPRA Australian Health Practi ti oner Regulati on Agency

AMA American Medical Association

AMC Australian Medical Council

AMCB American Midwifery Certification Board

ANMAC Australian Nursing and Midwifery Accreditation Council

BoN Boards of Nursing

CACMS Committee of Accreditation of Canadian Medical Schools

CAMC Caribbean Associati on of Medical Councils

CARICOM Caribbean Community

CMA Canadian Medical Association

CMRC Canadian Midwifery Regulators Consortium

CMRE Canadian Midwifery Registration Examination

CMSA Canadian Medical Schools Association

CMP certificate maintenance program

CPD continuing professional development

ECFMG Educati onal Commission for Foreign Medical Graduates

EEA European Economic Area

EU European Union

FSMB Federation of State Medical Boards

GMC General Medical Council

IMED Internati onal Medical School Directory

IMG International Medical Graduate

LCME Liaison Committee on Medical Education

LMCC Licentiate of the Medical Council of Canada

MCCEE Medical Council of Canada Evaluating Examination

MCNZ Medical Council of New Zealand

MCQE Medical Council of Canada Qualifying Examination

MEAC Midwifery Education Accreditation Council

NARM North American Registry of Midwives

NBME National Board of Medical Examiners

NCLEX-PN Licensure Examinati on for Practi cal Nurses

NCLEX-RN Licensure Examinati on for Registered Nurses

NCNZ Nursing Council of New Zealand

NCSBN National Council of State Board of Nurses

NLC Nurse Licensure Compact

NMBA Nursing and Midwifery Board of Australia

NMC Nursing and Midwifery Council

OSCE Objective Structured Clinical Examination

PIC Pacific Island country

RCPS Royal College of Physicians and Surgeons

USMLE United States Medical Licensing Exam

WFME World Federation of Medical Education

WHO World Health Organization

A note about the use of acronyms in this publicati on

Acronyms are used in both the singular and the plural, e.g. NGO (singular) and NGOs (plural).

Acronyms are also used throughout the references and citati ons to shorten some organisati ons with long names.

ACRONYMS


SUMMARY

The process of registrati on and licensing is designed to protect the public from harm perpetrated by incompetent health care workers, parti cularly those in the private sector over whom there is litt le or no administrati ve oversight. This review describes internati onal trends and approaches to regulatory and licensing systems and the integrati on of overseas trained healthcare professionals, including internati onal medical graduates. It is prepared to inform a series of “Evidence and Policy Opti ons” papers currently being developed by the Human Resources for Health Knowledge Hub (HRH Hub) at the University of New South Wales.

The review draws upon examples from countries whose cultural and geographical background may be of relevance and interest to the future development and strengthening of accreditati on and licensing in the Pacifi c Island countries (PICs).

Common trends identi fi ed from the review include:

• Two broad models/types of licensing/registrati on are in common use: 1) based on educati on certi fi cati on by the training insti tuti on and 2) based on nati onal or regional examinati on. Choices between them are largely dependent on a country’s geographical/regional affi liati ons and politi cal and administrati ve structures.

• Most countries have clearly defi ned standards or competencies that professionals wishing to be admitt ed to the register (or part of it) have to achieve.

• Many countries have reciprocal agreements that allow for the free movement of doctors and other health professionals from other countries provided they have graduated from a government registered educati on provider.

• Outside of these reciprocal agreements, overseas-trained healthcare professionals are typically required to take specifi c licensing examinati ons prior to being admitt ed to the register, or to take modifi ed versions of the same existi ng licensing examinati ons as domesti c graduates.

• The licensing of qualifi ed healthcare professionals is usually associated with fees, payable by the individual. Most countries operate a graded system whereby payment is required for each step along the career/registrati on process. Where

licensing exams are required, fees are associated with each sitti ng of these. Where separate fee-paying arrangements exist for overseas-trained graduates, the fees required are generally higher than for locally trained graduates.

• Current practi ces in PICs vary, but most countries have their own registrati on and licensing system for doctors, nurses and midwives coordinated by the relevant councils (typically Medical and Dental Council and Nursing and Midwifery Council).

• Some PICs have additi onal councils for pharmacists, scienti sts and allied health professions but these are in the minority.

The review of trends and approaches towards regulati on and licensing suggests a number of areas with potenti al relevance to PICs:

1. Collaborati on between geographically disparate states/countries to facilitate –

a. common standards, systems and licensing requirements;

b. mobility of healthcare professionals across borders.

2. Automati c/simplifi ed registrati on and visa requirements for healthcare professionals who currently have a licence to practi se in countries with well-established systems of accreditati on, licensing and registrati on.

3. Establishment of a cultural acclimati on program for internati onal medical graduates (IMGs) including a test of the relevant language of clinical practi ce.

4. Use of limited registrati on/licensing to address “Areas of Need”.

The process of registration and licensing is designed to protect the public from harm perpetrated by incompetent health care workers, parti cularly those in the private sector over whom there is litt le or no administrati ve oversight.


INTRODUCTION

This paper is structured in fi ve parts.

1. An overview of the standard defi niti ons and the contextual challenges in the regulati on and licensing of healthcare professionals.

2. The internati onal evidence, drawn from three conti nents largely focuses on examples from North America (USA + Canada), Australasia (Australia and New Zealand) and Europe (United Kingdom). It considers how governments defi ne, establish, fund, implement and evaluate regulatory and licensing systems for doctors, nurses and midwives with considerati on of how overseas-trained healthcare professionals are licensed.

3. Considerati on of ‘regional’ models (European Union and the Caribbean).

4. The funding of regulati on and licensing.

5. Some of the current practi ces in the Pacifi c Islands.

This leads to a discussion and some initi al conclusions with relevance to the future regulatory and licensing mechanisms in the PIC.

Healthcare challenges Developing a workforce of health professionals that is empowered by knowledge and skills, as well as moti vated and supported by adequate policies, is essenti al both at the nati onal and global level in order to create eff ecti ve, effi cient, safe, sustainable

healthcare systems able to deal with current and future challenges [1, pp.xv].

In order to provide eff ecti ve, safe healthcare, the 1 million new doctors, nurses and midwives who graduate each year need to be regulated; typically through the awarding and extending of a licence to practi se. Parti cularly relevant to PICs, the increased mobility of healthcare professionals who wish to practi se in a country other than the one in which they were trained gives additi onal challenges, as resources and standards vary considerably from country to country.

Meeti ng these challenges is essenti al to guarantee the ongoing quality of the healthcare workforce (fi tness for purpose) as well as the quality and safety of the care they provide (fi tness for practi ce) [2–4]. In line with these demands, some nati onal and regional standardisati on is emerging. For example, the World Federati on of Medical Educati on (WFME), in collaborati on with the World Health Organizati on (WHO) has developed global standards for medical educati on (basic, postgraduate and conti nuing professional development) and for accreditati on of medical schools and internati onal graduates [5,6]. In the European Union, European Parliament Directi ve 2005/36/EC sets common standards for educati on and recogniti on of health professionals across member states [7].

Figure 1 below sets out the processes and responsibiliti es of diff erent organisati ons at various stages of educati on and training of the health workforce in relati on to licensing/registrati on.

Att riti on Migrati onWork in other sectors

Poolof

eligibles

- Primary

- Secondary

- Terti ary

- Professional

- Technical

- Professionals

- Technicians

- Auxiliaries

- Community workers

Accreditati on

Licensing /certi fi caion

Selecti on Graduates RecruitmentHealth

workforce

FIGURE 1. PIPELINE TO GENERATE AND RECRUIT THE HEALTH WORKFORCE

Training insti tuti ons Potenti al workers

Source: WHO (2006). World Health Report [8]


North America: United States and CanadaContext: North America (United States and Canada) has a total of 183 medical and 65 public health schools [8] for a total populati on of approximately 350 million [9]. There are 815,006 doctors and 3,275,499 midwives and nurses [10]. The structures and processes in North America typify licensing and regulati on processes in many developed countries, including those in the European Union, Australia and New Zealand.

Medicine Licensing of doctors in the USA and Canada requires successful completi on of a three-part examinati on that can only be taken by students enrolled in accredited medical programs. However excepti ons may be made for students from unaccredited medical schools in the USA or Canada, who might be eligible for the United States Medical Licensing Exam (USMLE) process if they are sponsored by a licensing authority (state medical board) and meet all the criteria requirements for licensing apart from the examinati on [11].

To be able to practi se medicine in the USA students must pass all three stages of the USMLE. The Federati on of State Medical Boards (FSMB) and the Nati onal Board of Medical Examiners (NBME) sponsor this exam.

USMLE step 1 is usually taken within the fi rst three years of the medical degree and has an emphasis on knowledge of the basic biomedical sciences and the applicati on of this knowledge to explain principles and mechanisms of health, disease and therapy [11].

Step 2 assesses knowledge applicati on to clinical practi ce, clinical sciences, pati ent-centred care and clinical skills. This exam is designed to test that the candidate has the skills necessary to provide safe care to pati ents under supervision [11].

Step 3 tests the ability to apply biomedical and clinical knowledge, use appropriate skills to provide unsupervised care to pati ents, with a special focus on ambulatory setti ngs. The USMLE program recommends the third step to be taken aft er completi on of at least one year of postgraduate medical training, however, requirements and regulati ons related with this step vary between state medical boards [11].

COUNTRY FINDINGS

The USMLE system does not automati cally award licences to practi se. The system only provides the diff erent regional (state) licensing boards with a standard assessment of students’ knowledge and skills at a nati onal and regional level. The USMLE results are reported to those authoriti es and it is their responsibility to defi ne the rules, regulati ons and required scores to pass the USMLE steps in order to obtain a licence in their jurisdicti on. This is equally valid for Canada.

Alternati vely, USA and Canadian medical students who wish to obtain a Licenti ate of the Medical Council of Canada (LMCC) can sit the Medical Council Canada Evaluati ng Examinati on (MCCEE), and the Council’s Qualifying Examinati on (MCQE) part I and part II.

The MCCEE is a generic test of knowledge and basic principles of medicine, similar to USMLE step 1. Part I is a one-day computer-based assessment of graduates for entry into supervised practi ce and postgraduate educati on. Part II is an Objecti ve Structured Clinical Examinati on (OSCE) aimed at medical licensing and ability to practi se independently [12].

Nursing Aft er successful completi on of a state-recognised nursing program graduates are required to pass one of two exams by the Nati onal Council of State Board of Nurses (NCSBN), the Licensure Examinati on for Registered Nurses (NCLEX-RN) or the Licensure Examinati on for Practi cal Nurses (NCLEX-PN).

These nati onal examinati ons ensure that the graduates from nursing schools have the necessary knowledge and skills to enter the nursing profession and are used by the regional BoN to make decisions on licensing of professionals [13]. Although these decisions are currently made on a regional basis, a tendency towards a defi niti on of nati onal standards is emerging regarding a new model to be implemented in accreditati on of undergraduate programs by 2020. (See HRH Hub companion paper on program accreditati on).

In Canada, the process is similar, each province or territory licenses nurses within each individual jurisdicti on [14]. As in the USA the Canada Nurses Associati on (CNA) developed and manages a nati onal exam, Canadian Registered Nurse Examinati on (CRNE), to help the diff erent authoriti es make decisions on licensing [14].


Midwifery and nursing-midwifery As in nursing, graduates must sit an examinati on prior to licensing, administered by the American Midwifery Certi fi cati on Board (AMCB) [15]. The board runs two exams, a nursing-midwifery and a midwifery exam, which provide a certi fi cati on of quality for those entering practi ce, and all approved individuals are automati cally enrolled in a certi fi cate maintenance program (CMP). If the CMP requirements are not completed by the end of the fi ve-year cycle, certi fi cati on lapses, and no new certi fi cate is issued.

As in nursing educati on, although the exam is nati onal, the criteria for licensing decisions are variable according to the state of registrati on [16]. Additi onally for midwives it is possible to register with the North American Registry of Midwives (NARM) [17] .

There are seven midwifery educati on programs available in Canada, each program administers exams recognised by their respecti ve provincial regulatory bodies [18].

Additi onally, the Canadian Midwifery Regulators Consorti um (CMRC), a network of midwifery regulatory authoriti es, works as the advisory body for the local authoriti es, defi ning nati onal standards, models of practi ce, advising government on legal issues, facilitati ng communicati on between diff erent authoriti es and midwife mobility between provinces [19].

Case Study: Nurse Licensure Compact (NLC)Historically, the 50 states comprising the United States of America have had strong separate politi cal and cultural identi ti es. This has meant that the accreditati on and licensing of healthcare professionals has included signifi cant state-specifi c elements, limiti ng their mobility between states.

A recent innovati on which could provide useful guidance for PICs has been the development, in the USA, of the Nurse Licensure Compact (NLC), a process which allows for ‘mutual recogniti on’ of nursing licences between member states. 24 states are currently part of the program and nurses who obtain a licence to practi se in a member state are automati cally able to practi se in other member states, providing they are a resident of the state in which they obtained the licence.

BOX 1. NURSE LICENSURE COMPACT

Source: NCSBN Website [internet] 2012 [cited 2012 May]. Available from: htt ps://www.ncsbn.org/nlc.htm

Also it is the responsibility of the CMRC to develop and administer a Canadian Midwifery Registrati on Examinati on (CMRE), which is the nati onal examinati on for entry to practi se, recognised in some of the provinces.

Overseas-trained doctorsOverseas-trained doctors or internati onal medical graduates (IMGs) comprise ~25% of the physician workforce in the USA [20]. Graduates from universiti es other than those in the USA or Canada can apply for licensing in either of these countries. Two credenti aling pathways exist:

1. Graduates may apply for certi fi cati on by the Educati onal Commission for Foreign Medical Graduates (ECFMG), which will confi rm their identi ty, personal details and enrolment in/graduati on from a medical school listed in the Internati onal Medical School Directory (IMED). Candidates must pass the USMLE Steps 1 and 2, aft er which a certi fi cate is issued to allow the candidate to apply for postgraduate training in the USA (which includes the USMLE Step 3) [20].

2. Graduates may have their credenti als approved by the Medical Council of Canada, successfully complete the MCCEE and MCQE part I and then register for postgraduate medical training.


BOX 2. EDUCATIONAL COMMISSION FOR FOREIGN MEDICAL GRADUATES (ECFMG) ACCULTURATION PROGRAM

Case Study: Educational Commission for Foreign Medical Graduates (ECFMG) Acculturation Program

Accreditati on, licensing and registrati on are only one part of the transiti on process for overseas doctors. There are oft en enormous cultural diff erences to adjust to and these may have a signifi cant impact on the practi ce of overseas doctors – obvious examples include cultural diff erences in atti tudes towards gender, sexual orientati on, mental health, contracepti on and end-of-life arrangements.

Cultural diff erences may impact the life of doctors outside of their practi ce and so provide an additi onal barrier to their successful assimilati on into the workforce. In the USA, the body responsible for the management of internati onal medical graduates (the ECFMG) also runs an acculturati on program, providing resources to facilitate cultural acclimati on and thereby address these issues.

Overseas-trained nurses and midwives In the USA, eligibility for the Nati onal Council of State Board of Nurses exams and subsequent registrati on is defi ned state by state by the BoN. Both overseas-trained nurses and midwives are advised to contact the BoN, provide proof of credenti als and seek advice. If they are considered eligible then they take the NCLEX-RN/PN to become registered or practi cal nurses. Overseas-trained midwives can then apply for retraining in an American College of Nurse-Midwives accredited program [16].

In Canada, a program has been created to help internati onal midwives register for practi ce in the country. The Multi -jurisdicti onal Midwifery Bridging Project (MMBP) is a nine-month program based on the Internati onal Midwifery Pre-registrati on Program (IMPP) provided by Ryerson University’s (Toronto) G. Raymond Chan School of Conti nuing Educati on [19].

United Kingdom Context: The United Kingdom (UK) has 45 medical schools [22], 166,006 qualifi ed doctors and 631,201 nurses and midwives (in 2010) for a total populati on of 62,262,000 [23].

Medicine The General Medical Council (GMC) is responsible for the accreditati on of undergraduate and postgraduate

medical programs, licensing of newly qualifi ed medical students and revalidati on of medical professionals. Registrati on is a two-part process. Graduates are granted ‘provisional registrati on’ on successful completi on of a GMC accredited medical program. They then undertake one year (the F1 year) of postgraduate training/work, which, if completed successfully, leads to full registrati on.

The GMC is both the licensing/registrati on body and the accreditati on body of medical schools in the UK. As it serves both roles, consistency between standards for medical school educati on/outcomes and nati onal requirements for entering the professions can more easily be achieved.

Therefore, contrary to the system in the USA and Canada, no nati onal exam upon graduati on is required before graduates from UK medicals schools apply for provisional registrati on with a licence to practi se [24].

This provisional licence has no ti me period, although a 2012 GMC consultati on has suggested that a three-year ti me limit be imposed for Foundati on trainees, and a ‘stop the clock’ mechanism for trainees with domesti c or health issues. However, the licence does limit the type of acti viti es and employment that the holder can apply for (only locum posts, approved by the medical school as part of the foundati on training program) and a fee is required to hold the provisional licence aft er two years.

Source: [21]


Aft er the fi rst year of postgraduate medical educati on, medical trainees must complete a certi fi cate of experience to submit to the medical school or deanery, along with a form that certi fi es their competency as F1s. Medical school or deaneries make this informati on available to the GMC; to be added to the candidate’s online applicati on. The candidate must also answer a set of questi ons regarding their own conduct and health records (‘fi tness to practi se’).

Once those are completed, applicati on for full registrati on is complete, and those holding full registrati on are considered to have the necessary knowledge and skills to practi se medicine in the UK [24].

In 2012, the GMC introduced a new revalidati on process under which all currently registered doctors must regularly demonstrate their fi tness to practi se and that they are up-to-date in all areas in which they work (clinical practi ce, educati on, leadership/management and research). The revalidati on process is closely ti ed to annual formal appraisal processes which are carried out by the employing organisati ons.

Nursing and midwiferyAll students graduati ng from a UK Nursing and Midwifery accredited program can register with the NMC by submitti ng an applicati on form. Comprehensive standards are defi ned by the NMC for all scopes of practi ce and stages of educati on and training which have to be met. The NMC will then carry out a credenti aling check of the informati on provided and if all is in order will issue the registrati on [25].

Nurses and midwives are required to maintain registrati on by engagement in the ‘Prep’ process which requires 450 hours of registered practi ce and 35 hours of learning acti vity (conti nuing professional development) in the previous three years. The practi ce standard can be met through administrati ve, supervisory, teaching, research and managerial roles as well as providing direct pati ent care [25].

Overseas-trained doctors Overseas-trained doctors have to register with the GMC. Evidence of qualifi cati ons has to be provided. Based on European Union Directi ve 2005/36/EC

almost all European qualifi cati ons will be eligible for an equivalent certi fi cati on in the UK [24].

For non-European Union doctors there are three possible routes into licensing for practi sing in the UK: (1) the Professional and Linguisti c Assessments Board (PLAB) test, (2) acceptable postgraduate qualifi cati ons from a UK medical Royal (Specialty) College or (3) 12-months work in an approved practi ce which agrees to sponsor the candidate through the process of licensing. In the latt er case the candidates can only practi se in that specifi c setti ng and not anywhere else unti l they are given a full registrati on with licence to practi se in the UK [24].

Overseas-trained nurses and midwivesFor all EU/EEA-qualifi ed nurses and midwives, automati c registrati on is possible only if the candidate holds a qualifi cati on listed under the same category from their training country.

For all other candidates, including from non-EU/EEA countries, a registrati on pack must be fi lled in and returned for assessment by the NMC.

Australia and New Zealand Context: Australia has 19 medical schools registered in the IMED database [22], 62,800 qualifi ed doctors and 201,300 nurses and midwives (in 2009) [26] for a total populati on of 22,893,487 [27]. As in the UK, Australia has two main types of undergraduate medical programs - entry level for people who have just completed secondary educati on or graduate entry programs. New Zealand has 2 medical schools registered in the IMED database [22], 11,412 qualifi ed doctors (in 2010) and 44,491 nurses and midwives (in 2007) for a total populati on of 4,433,890 [28].

Medicine The Australian Medical Board (AMB) awards fi ve types of registrati on: (1) General, (2) Specialist, (3) Provisional, (4) Limited, and (5) Non-Practi sing:

1. General registrati on certi fi es that individuals have the necessary knowledge and skills to practi se autonomously in Australia. It requires the completi on of both undergraduate and postgraduate training.

2. Specialist registrati on is awarded to those who have been assessed by an Australian Medical


Council (AMC) accredited specialist college. Limited registrati on can be awarded to those who qualify from a medical school outside Australia or New Zealand.

3. Provisional registrati on is awarded to a graduate of an approved undergraduate medical degree in Australia or New Zealand. This licence, similar to that given to UK graduates by the GMC, allows graduates to proceed with postgraduate medical training, working only in approved training positi ons (intern). This licence is also given to internati onal medical graduates holding AMC certi fi cati on, allowing them to work for a period of 12 months in a supervised training positi on unti l they qualify for full registrati on.

4. Limited registrati on is the type usually awarded to internati onal medical graduates and is broken down further into four sub-types dependent on purpose: Postgraduate training or supervised practi ce; Area of Need; Public interest, and; Teaching or research. The ‘Area of Need’ category, as the name suggests, allows for individuals to practi se in Areas of Need if they have the necessary experti se in that parti cular area but not in all areas required for general or specialist registrati on. This licensing category is parti cularly used to fi ll workforce gaps in rural or remote areas and is associated with requirements for supervision and development.

5. Non Practi sing registrati on is for those who are not currently practi sing in Australia but might want to keep their registrati on.

It also off ers a ‘student registrati on’ which is automati c if the students are enrolled in an AMC approved program.

The Medical Council of New Zealand (MCNZ) is responsible for granti ng licences to practi se in New Zealand. Its functi ons and responsibiliti es and types of registrati on awarded are similar to those of the AMC [29].

Nursing and midwifery In Australia, the Nursing and Midwifery Board of Australia (NMBA) is responsible for licensing nurses and midwives who wish to practi se in those countries, for developing standards for the profession, assessing overseas professionals and accrediti ng courses.

The NMBA works at the nati onal level, defi ning policies and standards, while state and territory boards make decisions about the registrati on of nurses and midwives in their specifi c regions. The NMBA grants four types of registrati on – general; limited; non-practi sing, and; student registrati on [30].

The Nursing Council of New Zealand (NCNZ) has similar responsibiliti es to the NMBA [31]. Registering as a nurse in New Zealand involves a lett er of support from the head of school of nursing at the insti tuti on at which an applicant studied, two references and a declarati on of communicati on skills and moti vati on [31].

Overseas-trained doctors The AMC is responsible for assessing the knowledge, skills and quality of previous training of doctors trained in other countries who wish to practi se in Australia.

This process can follow three alternati ve routes to certi fi cati on depending on where the undergraduate medical training took place, whether or not the insti tuti on of training has similar standards (AMC-approved) and the level of training (graduate, specialist) of the candidate.

• Competent authority pathway, for those who qualifi ed from a university listed in the IMED or an AMC-approved authority (example: UK universiti es recognised by the GMC). Candidates must have been approved and provide evidence of qualifi cati ons. Successful applicants are then required to work under supervision in an AMC accredited training placement (provider) while undertaking a workplace-based assessment. Aft er this period, and following a recommendati on from the supervisor, an AMC certi fi cate can be awarded to the candidate allowing for registrati on with the Australian Medical Board.

• Standard pathway is for non-specialist internati onal medical graduates who do not qualify for the competency authority pathway. It requires the candidate to be assessed by a multi ple choice questi on (MCQ) examinati on and a clinical examinati on or a workplace-based assessment (CAT and AMC clinical examinati on) with one of the AMC accredited authoriti es.


• Specialist pathway: Specialists from other countries can apply for certi fi cati on choosing one of three opti ons:

1) Specialist recogniti on, consisti ng of a verifi cati on/assessment of previous qualifi cati ons.

2) ‘Areas of Need’, this pathway allows specialists not holding a formal certi fi cati on in the specialty being assessed to be off ered a job as a specialist in an Area of Need.

3) Specialist-in-training applicati on: For medical specialists who have been awarded a medical qualifi cati on by a university listed in the IMED and intend to take further training in Australia, and have already secured a relevant training positi on approved by the Medical Board of Australia.

In New Zealand there are several opti ons for registering for overseas-trained doctors depending on how long they wish to practi se in the country. For those wishing to develop a long-term career in the country and wishing to have a specialist registrati on a vocati onal pathway is available with four licensing opti ons.

Alternati vely those who wish to enter general practi ce also have four available opti ons. For short-term practi ce in the country there are special purpose pathways, encompassing seven possible types of licence according to the purpose of the visit [29].

Overseas-trained nurses and midwivesRegistrati on with the NMBA can be achieved by internati onally qualifi ed nurses and midwives on the bases of fi ve criteria: (1) Proof of identi fy, (2) English language profi ciency (3) meeti ng current Australian nursing and midwifery educati on standards, (4) evidence of having practi sed as a nurse and/or midwife within a period of ti me close to the applicati on, and (5) demonstrati on that there are no health or conduct (‘fi tness to practi se’) issues which may aff ect their ability to practi se nursing and/or midwifery in Australia [31].


COOPERATION BETWEEN COUNTRIES

Some models of cooperati on between countries exist to develop and standardise regulati on and licensing. Two examples are provided below.

Europe: Automatic mutual recognition The European Economic Area (EEA) was established on 1 January 1994 following an agreement between the member states. In 1999, 29 European countries signed ‘the Bologna declarati on’ to create and adopt a system leading to more comparable degrees within these countries.

Since then eff orts have been made to change existi ng models to fi t the new standards and models defi ned by the Bologna declarati on, so that the mobility of qualifi ed professionals in Europe could be made easier for practi ti oners and regulators [32].

Having comparable degrees with automati c recogniti on of qualifi cati ons between countries, thus removing the need for further costly assessment procedures has clear fi nancial benefi ts.

The European Parliament and Council of the European Union subsequently approved Directi ve 2005/36/EC(7) to allow recogniti on of professionals across borders in the EU/EEA zone and enabled the setti ng of standards for basic and advanced training of doctors, nurses and midwives across European countries, providing a list of accredited insti tuti ons and programs.

Licensing conti nues to be under the remit of professional bodies within countries/member states, however this directi ve provides a legal framework for the recogniti on of EU/EEA zone doctors, nurses and midwives within Europe. It should be noted, however, that concern for ensuring competency in the language of clinical practi ce is currently entering regulati on.

Caribbean: Medical EducationThe Caribbean region comprises a group of island nati ons, each with disti nct cultural and politi cal identi ti es. There are two major types of medical school in the Caribbean – ‘regional’ and ‘off shore’.

Regional schools train graduates for the country in which they are located (and for the wider Caribbean). Off shore schools are eff ecti vely satellite campuses for foreign universiti es, usually from the USA. These will not be considered further.

Registrati on to practi se medicine in the Caribbean Community (CARICOM) has, historically, varied from country to country, with most countries having their own medical board. Graduates from accredited schools in the UK, USA and Canada were able to register for a licence, while some Caribbean countries had their own licensing exams.

The Caribbean Associati on of Medical Councils (CAMC) was formed in 2003 to bring some consistency to the registrati on process and facilitate movement of doctors across, and into, the region.1 CAMC examinati ons were introduced to “assess for registrati on purposes, the general body of medical knowledge and clinical skills of trained doctors whose basic medical qualifi cati ons are not recognised by the regional medical councils, i.e. doctors trained in medical schools that have not been formally reviewed and accredited by the CAMC”.

The examinati ons are conducted bi-annually in April and November by the Medical Council of Jamaica and administered by the Faculty of Medical Sciences at the University of the West Indies (UWI). There is a current proposal by CAMC that all graduates (i.e. including those from accredited medical schools) should pass the exam before being licensed to practi se.

CAMC has noted a number of issues with both implementi ng and administering the examinati ons and registrati on of foreign-trained doctors across CARICOM that are of relevance to PICs and the Pacifi c region. Issues include establishing the associati on as a legally consti tuted body, clearly defi ning the roles of CAMC and the separate Nati onal Medical Councils and clarifying the sovereignty of the latt er, establishing an intergovernmental agreement to legalise CAMC’s licensing role, allocati ng suffi cient resources to the program and issues relati ng to the establishment of the secretariat.

For the accreditati on of educati onal programs, the Caribbean Accreditati on Authority for Educati on in Medicine and other Health Professions performs a similar role to that performed by the CAMC with licensing and registrati on, bringing consistency and unity to accreditati on.2

1 Further informati on available at: htt p://www.camcweb.org/2 Further informati on available at: htt p://www.caam-hp.org/

about.html


FUNDING LICENSING PROCESSES

The regulati on and licensing processes described above require a substanti al amount of investment in ti me and resources. The fi nancial costs are largely dependent on the number of candidates, insti tuti on or individuals that apply for regulati on and licensing, but also on the process and organisati on. Therefore making an informed decision on licensing systems requires an understanding of the costs associated with diff erent modaliti es.

An analysis of the Annual Reports (where available) of the licensing bodies described above was carried out in order to understand the fees charged for these processes and to determine whether or not they have direct governmental funding.

The licensing of qualifi ed healthcare professionals is usually associated with fees, payable by the individual. Most countries operate a graded system whereby payment is required for each step along the career/registrati on process. Where licensing exams are required, fees are associated with each sitti ng of these.

Where separate fee-paying arrangements exist for overseas-trained graduates, the fees required are generally higher than for locally trained graduates. See Appendix 1 (page 21) for full details and country-by country breakdown.


REGULATION AND LICENSING IN THE PACIFIC

Current practi ces in PICs are variable, but most countries have their own registrati on and licensing system for doctors, nurses and midwives coordinated by the relevant councils (typically Medical and Dental Council and Nursing and Midwifery Council). Some PICs have additi onal councils for pharmacists, scienti sts and allied health professions but these are in the minority.

Table 1 (below) lists the registrati on bodes in each PIC, the workers covered, the frequency and requirements of re-registrati on.

Many PICs have been working in relati ve isolati on (although oft en donor-funded) to develop and establish more robust regulati on and licensing systems. For those countries with established training programs for health professionals, there is a clear link between program approval/accreditati on

and initi al registrati on and licensing. Regional and in-country systems for accrediti ng programs and approving terti ary qualifi cati ons are beginning to be agreed, which will provide benchmarks for performance standards on graduati on. For example, recent developments by the South Pacifi c Board of Educati onal Assessment (SPBEA) in preparing a regional qualifi cati ons framework off ers the potenti al for standardisati on across the region.

The majority of PICs tend to formally recognise initi al qualifi cati ons from medical schools listed on IMED and training/qualifi cati ons from Medical Royal Colleges and nursing schools from Australasia, the UK/Ireland, US and Canada. Systems for registrati on and regulati on at post-registrati on level are less consistent than those of initi al licensing, parti cularly for nursing/midwifery, allied health professions and advanced practi ti oners.

TABLE 1. HEALTH WORKER REGISTRATION BODIES AND REQUIREMENTS IN THE PACIFIC

Country Registration Bodies

Health Workers Covered

Frequency of Registration / Licensing

Requirements of Registration

Cook Islands

Medical and Dental Council

Medical andDental Practi ti oners

Conditi onal registrati on for 2 years and then full registrati on

Conditi onal registrati on - Holds a qualifi cati on from Australia, Fiji, New Zealand, the Republic of Ireland or the United Kingdom, or a country with an equivalent standard.Full Registrati on - Conditi onally registered or practi sed as a medical or dental practi ti oner for not less than 2 years.

Nursing Council Registered Nurses, Community Nurses,Nurse Aides,Midwives,Nurse trainee

Annual Holds a nursing qualifi cati on from a recognised training insti tuti on.

Fiji Medical and Dental Council

Medical, dental practi ti oners; dental therapist; all medical and dental students

Annual Holds a medical or dental qualifi cati on from a recognised training insti tuti on.Conditi onal registrati on on graduati on leading to full aft er internship. Annual licensing includes a CPD requirement.

Nursing Council Nurses, midwives,nurse specialists,nurse practi ti oners and nursing students

Annual Holds a nursing qualifi cati on from a recognised training insti tuti on.

Medical and Dental Council

Medical assistants (no longer in producti on)

Annual Holds an accepted Certi fi cate from Fiji School of Medicine. Although registered by the MDC there is no specifi c menti on of the MA cadre MDC decree of 2010.

Pharmacy and Poisons Board

Pharmacists Annual Passed the fi nal examinati on of an Insti tuti on of an approved Commonwealth country. May be asked to sit an additi onal examinati on for the Board.






Fiji (cont.) Fiji Radiati on Health Board

Medical imaging technologists

Full registrati on - ongoing; Provisional registrati on - 3 months; Temporary registrati on - 24 months

Holds a recognised certi fi cate in medical imaging science from an approved training insti tuti on, passed any examinati on or training if required has proven ability to use relevant equipment. Licence issued by the Fiji Society for Medical Imaging Technologists Council.

Kiribati Kiribati Medical Council

Medical offi cers Not specifi ed Successfully completi on of a university course in medical and surgical study at a university or insti tuti on approved by the Medical Council and has completed one year’s training as an intern or resident at a hospital

Kiribati Nursing Council

Nurses and midwives Not specifi ed Holds a recognised qualifi cati on by an approved insti tuti on, is a registered nurse or midwife in another country with an equal or higher training standard, has an approved special qualifi cati on.


Pharmacists Not specifi ed Passed the fi nal examinati on of an insti tuti on of Great Britain or Northern Ireland, or another approved state.

Marshall Islands

Board of Health Professions

All health workers Biennial Registrati on for nurses: Complete a nursing course from CMI or approved insti tuti on, pass a skills checklist, pass a Board-set examinati on, reference lett er from a nursing school instructor. No available informati on for medical practi ti oners or other.

Federated States of Micronesia

MoH Committ ee headed by Secretary Health

All health workers Ongoing Approval of qualifi cati on and experience endorsed by the Secretary of Health.

Nauru Health Practi ti oners Registrati on Board

Medical practi ti oners, denti sts and nurses

Ongoing Holds approved qualifi cati on or experience, will practi ce in Nauru to the benefi t of the Nauru community.

Niue There is no specifi c legislati on for registrati on of health workers and no registrati on councils.

Palau Board of Health Professions

Doctors, allied health and environmental health workers

Annual

Papua New Guinea

Medical Board Medical practi ti oners, dental practi ti oners and allied health staff

2 years provisional, then full registrati on. Annual licensing

Provisional registrati on - Completed a medical/dental degree from UPNG or recognised university.Full registrati on - held provisional registrati on for 2 years, practi sed full ti me at a hospital or health facility, completed medical/dental degree at a recognised overseas university.

Nursing Council Registered nurses, enrolled nurses and nurse aides

Annual Provisional registrati on - Completed a training program from UPNG or a recognised university.Full registrati on - completed a Council approved program, held provisional registrati on and proved qualifi cati ons to practi ce.

Samoa Medical Council Medical practi ti oners Annual Hold a qualifi cati on from a recognised insti tuti on, good character, has practi cal experience as required by the Council.

Nursing and Midwifery Council

Registered nurses, enrolled nurses, specialist nurses and midwives

Annual Hold a qualifi cati on from a recognised insti tuti on, good character, has practi cal experience as required by the Council.

Allied Health Professional Council

All allied health staff Annual Holds a practi sing certi fi cate, holds minimum competencies set by the council. Required to maintain and upgrade competence by parti cipati ng in ongoing professional educati on.






Solomon Islands

Medical and Dental Board

Medical and dental practi ti oners

Holds recognised qualifi cati ons, good character, fi t and proper person to practi se.

Nursing Council Registered nurses, midwives andauxiliary nurses

12 month probati on, then full registrati on for life

2 step process: Part A - Complete Diploma in Nursing from SICHE, 12 month probati on program. Part B - Full registrati on upon completi on of probati on program.


Pharmacists Passed fi nal examinati on of the Pharmaceuti cal Society of Great Britain or Northern Ireland or another qualifi cati on approved by the Board, above the age of 21 years.

Tokelau No councils exist There is no specifi c legislati on for registrati on of health workers

Tonga Medical and Dental Practi ce Board

Medical and Dental Practi ti oners,Health Offi cers,Dental therapists

Annual Holds an approved qualifi cati on.

Nurses Board Registered nurses, midwives,nurse practi ti oners


Pharmacy Board Pharmacists,Pharmacy Assistants


Tuvalu Medical and Dental Register

Medical and Dental Practi ti oners,Nurses,Midwives

Doctor: Conditi onal registrati on – holder of an approved qualifi cati on; Full registrati on – conditi onally registered and more than 1 year of practi cal experience in an approved insti tuti on or hospital; or eligible for conditi onal registrati on and has experience outside Tuvalu for 1 year in an insti tuti on or hospital of equal standard; or eligible for conditi onal registrati on and practi sed medicine and surgery for 5 years conti nuously from date of receiving his/her qualifi cati on.Dentists: Approved qualifi cati on.Nurses and midwives: Approved training and examinati on and has good character or has approved special qualifi cati ons

Register of Pharmacists

Pharmacists Pass the fi nal examinati on of the Pharmaceuti cal Society of Great Britain or Northern Ireland or another approved body, over 21 years of age.

Vanuatu Health Practi ti oners Board

Denti sts,Pharmacists, Physiotherapists Radiographers, Osteopaths,Laboratory Technicians

Holds a qualifi cati on by an approved insti tuti on and enti tled to practi se in the country that the qualifi cati on was gained.

Nursing Council Registered Nurses, Midwives,Nurse Practi ti oners

Annual General Nurse: Approved qualifi cati ons and met requirements determined by the Council, fi t and proper person.Midwife: Approved additi onal qualifi cati ons.

Source: Compiled from Human Resources for Health Knowledge Hub Country profi les [Kafoa 2011]


INTERNATIONAL MODELS OF LICENSING AND REGISTRATION

Models of licensing and registrationFinal decision on the licensing of healthcare professionals is the responsibility of the professional bodies, although in some cases, for example in the United States, independent agencies can be responsible for developing and dealing with the logisti cs of nati onal examinati ons. Two models of licensing can be identi fi ed from the review:

• Based on educati on certi fi cati on: Countries in which the certi fi cati on of completi on of an accredited program is suffi cient to register with the professional body. Example: UK and other European countries, Australia and New Zealand.

• Based on nati onal examinati ons: Professional bodies, or independent agencies, run nati onal examinati ons and licensing can only take place aft er successful completi on of those examinati ons.Example: Canada, USA.

In the case of the UK, registrati on with the professional body follows graduati on from an accredited medical, nursing or midwifery program, either with or without extra training requirements.

Graduates can then enter practi ce and, depending on profession and speciality area, can conti nue training into postgraduate educati on and (for doctors) ulti mately register in a medical specialty. Nurses can also work towards extended scope of practi ce or a speciality area.

In the USA and Canada a three-part examinati on is required in order to obtain a license to practi ce medicine independently and register for further postgraduate medical educati on. Only students from accredited programs are eligible to take this examinati on.

In additi on to licensing requirements, two general systems for licensing and registrati on exist that depend largely on geography. In some countries, registrati on is with a central regulatory body, usually government appointed. Examples from medicine include the UK (General Medical Council), Ireland, India, Pakistan, South Africa and Egypt and the Pacifi c countries.

In other countries, registrati on is with a regional (provincial or state) regulatory body, with varying input from a nati onal organisati on. Examples from medicine include the USA and Canada, both of which have nati onal licensing exams that must be passed in order to obtain a (regional) license to practi ce. This is also the case in Germany, Spain, Poland, Italy and Greece.

All developed countries considered in this report have requirements for qualifi ed practi ti oners to maintain their licence to practi ce clinically, typically requiring a minimum amount of ti me of clinical practi ce each year, plus evidence of conti nuing appropriate professional development. This is usually submitt ed via a portf olio comprising evidence, rather than a practi cal or writt en examinati on.

Requirements vary for registering undergraduate students. In the UK, students do not register with a professional body unti l they graduate and are about to obtain either a provisional or full license (varies with the profession). In the USA, undergraduate medical students are required to register in order to sit the nati onal licensing exams. In Australia all students of healthcare professions register with the Australian Health Practi ti oner Regulati on Agency (AHPRA) ‘to protect public safety’ [33].

Regulating the regulatorA relati vely recent development in many countries is a ‘regulator for the regulator’. These are generally government-appointed independent bodies with varying powers and responsibiliti es.

In Australia the AHPRA oversees the registrati on and accreditati on of all health practi ti oner programs, including nursing, midwifery and medicine implementi ng the ‘Nati onal Registrati on and Accreditati on Scheme’ of 2010.3 Supporti ng the APHRA, each discipline then has its own ‘board’, responsible for registrati on and decisions about accreditati on.

A similar model operates in the United Kingdom, where the government-appointed Council for Healthcare Regulatory Excellence (CHRE), established in 2003, regulates the professional ‘Councils’ for each profession (e.g. the General Medical and Dental Councils and the Nursing and Midwifery Council).4

The potenti al for registrati on authoriti es to have a negati ve eff ect on the workforce should be noted. Where an authority has a legal monopoly on entry into the profession the potenti al exists for the authority to regulate the supply of professionals, create scarcity and increase average income of those registered.

3 Further informati on available at: htt p://www.ahpra.gov.au/4 Further informati on available at: htt p://www.chre.org.uk/


The review suggests a number of areas with potenti al relevance to PICs and to Pacifi c regional organisati ons:

Registration and licensing for all health professionals working in PICs1. Commonly agreed registrati on and licensing

requirements and processes in the Pacifi c could result from multi -country collaborati on to guarantee the quality of health workers and to facilitate regional professional mobility, while also retaining the sovereignty of nati onal councils or registrati on bodies.

2. Defi ning common competencies for each profession, contextualized specifi cally for PICs’ needs, would enable benchmarking of health professionals wishing to obtain licensing or registrati on in the region.

3. Mapping the competencies of the Pacifi c Island graduates att ained through the diversity of medical educati on programs now available will assist in identi fying areas for supplementary training or orientati on to contextualize their educati on to the Pacifi c region’s health needs.

4. The internati onal experience of countries with regional affi liati ons suggests the potenti al for regional examinati on(s) and/or an internship based on agreed, common competency standards to provide assessment of all graduates before entering practi ce or a common internship assessment, and to identi fy areas for supplementary training.

Overseas trained health professionals5. Internati onal comparison provides examples for

enabling automati c/simplifi ed registrati on and visa requirements for healthcare professionals who currently have a licence to practi se in countries with well-established educati on and regulatory systems.

6. Licensing and registrati on of overseas trained health professionals from countries without well-established systems of program accreditati on, licensing and registrati on may include requirements to work within a defi ned/limited scope-of-practi ce, or a specifi c length of service, and/or require training to address areas

of need/defi ciencies. Similar considerati ons apply to medical graduates who have completed undergraduate training overseas but have not completed formal registrati on requirements before returning to the Pacifi c.

7. Good practi ce for the registrati on for overseas trained healthcare professionals entails establishing a health systems orientati on program including a cultural assimilati on component, and which includes a test of competency in the relevant language.

Health workforce planning8. A review of existi ng formal and informal

arrangements between the PICs in health workforce producti on, planning and deployment would identi fy areas for improved governance and stewardship in future licensing and registrati on mechanisms.

9. Leadership is needed to adopt a regional overarching framework that links commonly agreed sets of standards for accrediti ng health professionals’ educati on programs with processes for licensing and with regulati on mechanisms.

10. PICs may wish to commit to sustained politi cal and fi nancial support to establish regionally agreed standards in order to guarantee health professionals’ competence to practi ce in the region, and to att ract independent investment from development partners.

POLICY IMPLICATIONS FOR THE PACIFIC


The objecti ve of establishing a Pacifi c health workforce, rather than many nati onal workforces, will require agreement by sovereign states on common standards, common internati onal accreditati on standards, complementary licensing arrangements and comparable terms and conditi ons of employment.

It can reasonably be expected that when Pacifi c doctors and other health professions trained internati onally return home, they will also look for opportuniti es for intra-regional professional mobility, as have their predecessors at Fiji Nati onal University and the University of Papua New Guinea, thereby assisti ng to fi ll professional skills gaps in the region.

Achieving such common approaches to allow intraregional health worker mobility would require commitment and cooperati on of nati onal medical, nursing, midwifery and health professional councils where they exist, and public sector employers.

This was discussed at the Pacifi c Island Countries Health Ministers’ meeti ng in 2011, which recommended that a “regional framework for regional professional competencies, accreditation & standards for various health workforce cadres” be developed [WHO 2011].

The current large scale-up of the medical workforce consequent to Cuban scholarship off erings will begin to place strain on health ministries’ budgets, commencing in 2014, as they absorb new medical graduates into nati onal health systems.

The need for establishing transparent and robust processes for assimilati ng many internati onal medical school graduates provides a signifi cant driver and opportunity to develop and establish standards and processes for initi al licensing, intern training and competency assessment for defi ned scopes of practi ce.

This forthcoming imperati ve could be the catalyst for developing the regional framework that the PIC health ministers recommended in 2011.

CONCLUSIONS


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30. AHPRA. Registrati on and Endorsement [Internet]. NMBA Website. [cited 2012 May 6]. Available from: htt p://www.nursingmidwiferyboard.gov.au/Registrati on-and-Endorsement.aspx

31. NMBA. Framework for the assessment of internati onally qualifi ed nurses and midwives for registrati on [Internet]. 2011. Available from: www.anmc.org.au/internati onal_projects

32. CRE. The Bologna Declarati on on the European space for higher educati on: an explanati on. 1999 p. 8.

33. AHPRA. Student Registrati on [Internet]. AHPRA Website. 2012 [cited 2012 Jul 24]. Available from: htt p://www.ahpra.gov.au/Registrati on/Student-Registrati ons.aspx


APP

END

ICES

APP

END

IX 1

. FEE

S A

ND

PAY

MEN

TS F

OR

LICE

NSI

NG

OF

HEA

LTH

CA

RE P

ROFE

SSIO

NA

LS

All

fees

are

giv

en in

loca

l cur

renc

y

Requ

irem

ents

and

fees

Coun

trie

sH

ealt

h Pr

ofes

sion

Lice

nsin

g bo

dy

Hom

eIn

tern

ati o

nal G

radu

ates

Sour

ceRe

quir

emen

tsFe

esRe

quir

emen

tsFe

esG

over

nmen

t fu

ndin

g di

rect

onl

y

US

Med

icin

eSt

ate

Med

ical

Bo

ards

USM

LE s

tep

I, st

ep II

(C

linic

al K

now

ledg

e ex

am +

Clin

ical

Ski

lls

exam

) and

ste

p III

exa

ms

plus

a re

gist

rati o

n fe

e de

pend

ent o

n th

e re

gion

al M

edic

al b

oard

(R

EF)

USM

LE S

tep

1: $

535,

St

ep 2

CK:

$53

5*St

ep 1

and

2CK

El

igib

ility

Per

iod

Exte

nsio

n: $

65St

ep 2

CS:

$1,

140

Step

3 is

$74

5 w

ith

the

exce

pti o

n of

Iow

a $7

95;

Sout

h D

akot

a $8

95;

Verm

ont $

780

USM

LE S

teps

1, S

tep

2 Cl

inic

al K

now

ledg

e an

d Cl

inic

al S

kills

;EC

FMG

regi

strati o

n;

post

-gra

duat

e tr

aini

ng in

th

e U

S, U

SMLE

ste

p 3

and

regi

strati o

n w

ith S

tate

M

edic

al B

oard

App

licati

on

for

ECFM

G

Certi

fi cati o

n $5

0U

SMLE

Ste

p 1

$790

USM

LE S

tep

2 CK

$79

0St

ep 2

CS

$1,3

75 A

dditi

onal

fe

es a

pply

for

any

resc

hedu

ling,

rech

ecki

ng

and

issu

ing

of tr

ansc

ript

sA

pplic

ati o

n In

form

ati o

n Ex

chan

ge V

isito

r Sp

onso

rshi

p Pr

ogra

m (E

VSP)

$2

75Ve

rifi c

ati o

n to

Sta

te M

edic

al

Lice

nsin

g A

utho

rity

$35

No

ww

w.u

smle

.org

/

Nur

sing

Stat

e Bo

ard

of N

urse

s

App

licati

on

for

licen

sure

to

the

BoN

in w

hich

will

pr

acti s

e;N

ati o

nal c

erti fi

cati

on

e xam

inati

on

NCL

EX

Regi

strati o

n Fe

e $2

00Li

cens

ure

Fee

depe

nden

t on

the

stat

e bo

ard

of

licen

sing

Prev

ious

reco

rds

verifi c

ati o

n,

exam

and

regi

stry

with

BoN

Fees

as

for

‘Hom

e’

appl

ican

ts p

lus

Add

iti on

al

Inte

rnati

ona

l Sch

edul

ing

Fee

(+va

lue

adde

d ta

x w

here

ap

plic

able

) $15

0

No

htt p

s://

ww

w.

ncsb

n.or

g/nc

lex.

htm

Mid

wife

ry

Am

eric

an

Mid

wife

Ce

rti fi

cati o

n Bo

ard

Gra

duati

on

from

ACM

E ce

rti fi

ed p

rogr

am;

Nati

ona

l Exa

min

ati o

n (s

ame

as fo

r nu

rsin

g);

Regi

strati o

n

Nati

ona

l certi fi

cati

on

exam

inati

on

is

$500

.00,

re-e

xam

inati

on

fee

is $

500.

0 in

clud

es

an e

xam

inati

on

proc

essi

ng fe

e of

$1

21. P

lus

a $6

5/ye

ar

for

the

CMP

Prev

ious

reco

rds

verifi c

ati o

n;

exam

and

re-t

rain

in a

n AC

NM

acc

redi

ted

prog

ram

an

d re

gist

ry w

ith A

MCB

Sam

e as

Hom

e pl

us a

ve

rifi c

ati o

n of

Certi fi

cati

on

$50.

00A C

NM

, 201

1


Cana

da

Med

icin

e

Roya

l Col

lege

of

Phy

sici

ans

and

Surg

eons

Ca

nada

(R

CPSC

)

MCC

EE a

nd M

CQE

part

I or

USM

LE a

s in

US

Firs

t-ti m

e ap

plic

ant:

C$

1,61

5Re

peat

app

lican

t:

C$1,

365

Qua

lifyi

ng

Exam

inati

on

Part

I:

C$90

0Q

ualif

ying

Ex

amin

ati o

n Pa

rt II

: C$

2,15

0A

dditi

onal

fees

fo

r re

sche

dulin

g,

rech

ecki

ng a

nd

issu

ing

tran

scri

pts

MCC

EE C

$64

MCC

QE

Part

I C$

64

Requ

irem

ents

will

dep

end

on

the

chos

en ro

ute.

Dep

ende

nt o

n th

e RC

PSC

chos

en p

athw

ay to

lice

nsin

g an

d pr

ovin

ce o

f reg

istr

ati o

n.

htt p

://w

ww

.roy

alco

llege

.ca

/pub

lic/c

rede

nti a

ls/

accr

edita

ti on

No

htt p

://w

ww

.ro

yalc

olle

ge.c

a/pu

blic

Nur

sing

Cana

da

Nur

ses

Ass

ociati o

n (C

AN

)

Cana

dian

Reg

iste

red

Nur

se E

xam

inati

on,

CRN

E

Fees

for

exam

s w

ill

be d

efi n

ed b

y th

e re

gion

al p

rovi

nces

Polic

ies

on fo

reig

n nu

rses

dep

end

on th

e re

gulati o

ns a

pplie

d by

indi

vidu

al p

rovi

nces

an

exam

is g

ener

ally

requ

ired

exce

pt

in Q

uebe

c

htt p

://w

ww

.cno

.or

g/en

Mid

wife

ry

Cana

dian

A

ssoc

iati o

n of

Mid

wiv

es

(CA

M)

Exam

s ad

min

iste

red

by th

e ed

ucati

ona

l pr

ogra

ms

and

reco

gnis

ed

by re

gion

al p

rovi

nces

, an

d Ca

nadi

an M

idw

ifery

Re

gist

rati o

n Ex

amin

ati o

n (C

MRE

) whi

ch is

the

nati o

nal e

xam

inati

on

for

entr

y to

pra

cti s

e ad

min

iste

red

by th

e CM

RC in

som

e pr

ovin

ces

NA

Exam

s, if

requ

ired,

are

ad

min

iste

red

by re

gion

al

prov

ince

s. In

tern

ati o

nal

Mid

wife

ry P

re-r

egis

trati

on

Prog

ram

(IM

PP)

NA

ww

w.c

anad

ian

mid

wiv

es.o

rg/


UK

Med

icin

e

Gen

eral

M

edic

al

Coun

cil

(GM

C)

Gra

duati

on

from

an

GM

C-U

K ac

cred

ited

prog

ram

,Ce

rti fi

cate

of C

ompl

eti o

n of

(pos

tgra

duat

e)Tr

aini

ng (C

CT)

Prov

isio

nal

regi

strati o

n £9

5;

Full

regi

strati o

n fo

r do

ctor

s w

ho h

old,

or

hav

e pr

evio

usly

he

ld, p

rovi

sion

al

regi

strati o

n or

for

thos

e w

ho s

ubm

it th

eir

appl

icati

on

with

in tw

o ye

ars

of

pass

ing

a pr

imar

y m

edic

al q

ualifi

cati

on

£195

;Fu

ll re

gist

rati o

n fo

r do

ctor

s no

t cov

ered

by

the

scen

ario

s ab

ove

£390

;Te

mpo

rary

Ful

l re

gist

rati o

n fo

r vi

siti n

g ov

erse

as

doct

or £

390

Ann

ual r

eten

ti on

fee

(pay

able

by

all

regi

ster

ed d

octo

rs)

£390

;A

nnua

l ret

enti o

n fe

e w

ithou

t lic

ence

to

practi s

e - £

140

Verifi c

ati o

n of

cre

denti

als

Ce

rti fi

cate

of C

ompl

eti o

n of

(p

ostg

radu

ate)

Tra

inin

g (C

CT)

whe

n ap

plic

able

, and

, in

the

case

of n

on-E

U/E

EA d

octo

rs,

the

PLA

B ex

am

Certi

fi ca

te o

f Elig

ibili

ty fo

r Sp

ecia

list o

r G

P Re

gist

rati o

n (C

ESR)

£1,

500;

Certi

fi ca

te o

f Com

pleti

on

of

Trai

ning

(CCT

) £39

0;PL

AB

Exam

fees

: Par

t 1 o

f th

e PL

AB

test

£14

5;Pa

rt 2

of t

he P

LAB

test

£43

0;Re

ques

t for

cle

rica

l che

ck

of re

sults

for

the

PLA

B te

st

£40;

App

licati

on

for

sub-

spec

ialty

re

cogn

iti on

or

Certi

fi ca

te

of G

P ac

quire

d ri

ghts

£27

5.

Ann

ual r

eten

ti on

fee

for

regi

strati o

n w

ith a

lice

nce

to

practi s

e £3

90an

d w

ithou

t lic

ence

to

practi s

e £1

40 A

dditi

onal

ly th

ere

are

appe

al a

nd re

view

s.

ww

w.g

mc-

uk.

org

Nur

sing

&

Mid

wife

ry

Nur

sing

and

M

idw

ifery

Co

unci

l (N

MC)

Gra

duat

e fr

om a

UK

prog

ram

Ann

ual r

egis

trati

on

fee

£76;

Subs

eque

nt e

ntri

es

of re

gist

ered

qu

alifi

cati o

ns £

23;

Fee

for

reco

rdin

g a

qual

ifi cati o

n £2

5

Verifi c

ati o

n of

cre

denti

als

an

d po

ssib

le e

ducati o

nal

prog

ram

s (c

ase-

by-c

ase)

.

Euro

pe e

valu

ati o

n fe

e £1

10;

Out

side

Eur

ope

eval

uati o

n fe

e £1

40;

Ann

ual r

egis

trati

on

fee:

£76

htt p

://w

ww

.nm

c-uk

.org

/Re

gist

rati o

n/Pl

anni

ng-t

o-w

ork-

outs

ide-

the-

UK/


Aus

tral

ia

Med

icin

eA

ustr

alia

n M

edic

al

Boar

d (A

MB)

Gra

duati

ng

from

a A

MC

appr

oved

pro

gram

Com

pete

nt A

utho

rity

Pa

thw

ay $

600

plus

AM

C Ce

rti fi

cate

$2

75;

Spec

ialis

t rec

ogniti o

n or

Are

a of

Nee

d sp

ecia

list $

285;

Stan

dard

and

Sp

ecia

list

(rec

ogniti o

n) $

285

Requ

ired

docu

men

ts a

nd

appr

oval

s de

pend

on

the

rout

e to

certi fi

cati

on

chos

en,

som

e m

ay re

quire

exa

ms

Stan

dard

Pat

hway

$23

0 A

MC

Certi

fi ca

te $

275

Spec

ialis

t rec

ogniti o

n or

A

rea

of N

eed

spec

ialis

t $28

5St

anda

rd a

nd S

peci

alis

t (r

ecog

niti o

n) $

285

Prim

ary

Sour

ce V

erifi

cati o

n Sp

ecia

list-

in-T

rain

ing

$230

Co

mpe

tent

Aut

hori

ty

Path

way

$60

0pl

us A

MC

Certi

fi ca

te $

275

Exam

inati

on

fees

: CAT

MCQ

ex

amin

ati o

n au

thor

isati

on

$2,1

00;

Clin

ical

Exa

min

ati o

n (p

er

att e

mpt

) $2,

850

No

htt p

://w

ww

.am

c.or

g.au

/in

dex.

php/

ass/

fees

#pat

hway

-fe

es

Nur

sing

&

Mid

wife

ry

Nur

sing

&

Mid

wife

ry

Boar

d of

A

ustr

alia

(N

MBA

)

Gra

duat

e fr

om A

ustr

alia

n or

New

Zea

land

re

cogn

ised

pro

gram

and

co

mpl

eti o

n of

an

AM

C re

cogn

ised

pos

tgra

duat

e pr

ogra

m o

f tra

inin

g.

App

licati

on

for

gene

ral r

egis

trati

on

$160

;Fe

e fo

r an

nual

re

new

al o

f gen

eral

re

gist

rati o

n $1

60

Eval

uati o

n ba

sed

on 5

cr

iteri

a: P

roof

iden

ti fy;

En

glis

h la

regulation and licensing of healthcare ......regulati on and licensing of healthcare professionals...

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