Development of NHPC Accreditation and Licensing System Status 09 08 03

DEVELOPMENT OF THE ACCREDITATION AND LICENSING SYSTEM IN THE HEALTH SECTOR OF SOMALILAND”

EVOLVING WORKING PAPER

STATUS AS OF 03 AUGUST 2009

AND TASKS FOR THE FURTHER DEVELOPMENT

NATIONAL HEALTH PROFESSIONS COUNCIL (RE-)ESTABLISHMENT WORKING GROUP

SAHRA ADAN GULAIDABDUKARIM YUSUF MUSEABDULLAHI ABDURAHMAN OMARISMAIL ADAM ABULLAHIAHMED IBRAHIM BEDEAHMED SULEIMAN OMER


TABLE OF CONTENT

Table of Content.........................................................................................1Abbreviations..............................................................................................8Definitions...................................................................................................81 Purpose of this Document...................................................................102 Background.........................................................................................113 Purpose of the Accreditation and Licensing System..........................124 Methodology used in designing the Accreditation, Licensing and Register System........................................................................................13

4.1 Adherence to the Principles of NHPC........................................134.2 Design in Consensus with Partners and Stakeholders...............134.3 Utilisation of Experiences through Literature Review and Site Visits 144.4 In Respect and Support of the Relationships between NHPC and MoHL 144.5 Mandate of SMA and SLNMA....................................................15

5 Implementation Phases and modules – NHPC Concept Paper April 0916

5.1 Still Outstanding Preparatory Steps Other than the Accreditation system during 2009.........................................................165.2 Modules and Phases...................................................................16

5.2.1 Modules...................................................................................175.2.2 Phases......................................................................................17

6 Standards of Target Groups...............................................................196.1 Individual Health Professionals.................................................19

6.1.1 Nurses and Auxiliary Nurses...................................................196.1.2 Midwifes and Auxiliary Midwifes............................................196.1.3 Physicians ( General Practitioner, Specialists (Surgeon, Ophthalmologist, Internal Medicine, Others)....................................196.1.4 Pharmacists and Laboratory Technicians...............................206.1.5 Other Health Cadres working in Somaliland..........................206.1.6 Cadres using Traditional Healing Procedures........................20

6.2 Health Service Delivery Facilities..............................................216.2.1 Primary level -Public and Private: Health Posts, Health Centres, Mother and Child Health Centres (MCHs), Clinics etc.......216.2.2 Secondary level, public and private........................................216.2.3 Tertiary level, public and private............................................21

6.3 Basic and Continuous Medical/Health Education and Trainings21

STATUS AS OF 03 AUGUST 2009 AND TASKS FOR THE FURTHER DEVELOPMENT 1


6.3.1 Nursing and Midwifery Schools and Their Continuous Education............................................................................................216.3.2 Other Institutions/Schools; Public and Private.......................216.3.3 Tutors......................................................................................216.3.4 Curriculum for Basic Education in Health..............................216.3.5 Curriculum for Continuous Education in Health....................216.3.6 Examination Process...............................................................21

6.4 “Traditional Health System” in Somaliland...............................227 In Preparation of the Accreditation....................................................23

7.1 Listing of Individuals and Services Currently Providing Health Care Services / Training............................................................................

....................................................................................................237.1.1 Health Professionals................................................................237.1.2 Basic and Continuous Medical/Health Education and Trainings

237.1.3 Health Service Providers.........................................................23

7.2 Assessment Validation Criteria Based on the Standards...........247.2.1 Health Professionals................................................................247.2.2 Basic and Continuous Medical/Health Education and Trainings

247.2.3 Health Service Providers.........................................................25

7.3 Assessment Tools.......................................................................257.4 Selection Modalities of the Accreditation Committee Members

258 Licensing and Re-licensing System and Procedure...........................26

8.1 Purpose and Objectives of Licensing.........................................268.2 Accreditation and Licensing Relation........................................278.3 Types of License.........................................................................27

8.3.1 Level and Grading of Licensing...............................................278.3.2 Individual Licensure................................................................278.3.3 Institutional Licensure............................................................278.3.4 Suitability................................................................................27

8.4 Time Periods and Conditional Licence.......................................288.4.1 Unconditional Licence.............................................................288.4.2 Temporary / Conditional Licence............................................288.4.3 Rejected Licence.....................................................................28

8.5 Relicensing.................................................................................288.5.1 Procedural Steps.....................................................................28

9 Register system..................................................................................30



9.1.1 Definition.................................................................................309.1.2 Conditions to get registered....................................................309.1.3 Maintenance of register..........................................................309.1.4 Paper based and IT Data base.................................................30

10 Accreditation Process.........................................................................3110.1 Self Assessment..........................................................................3110.2 External Assessment..................................................................3110.3 Decision......................................................................................3110.4 Licensing....................................................................................3210.5 Registration................................................................................32

11 Appeal for disputed Assessments.......................................................3311.1 Procedure...................................................................................3311.2 Appeal Committee......................................................................3311.3 Counselling.................................................................................34

12 Accreditation, Licensing and Registration Tools...............................3413 Accompanying Mechanisms...............................................................35

13.1 Capacity Building of NHPC Accreditation Unit.........................3513.2 Site Visits of NHPC staff and Committee Members...................3513.3 Establishment of Fee Collection System....................................35

14 Annex:.................................................................................................3614.1 Standards (ST) Health Professionals Forms ST 1x..................36

14.1.1 Nurses (N) – Form ST 1.1./N/09........................................3614.1.2 Auxiliary Nurses(AN) - Form ST 1.2./AN/09......................3614.1.3 Midwifes (M) - Form ST 1.3./M/09....................................3614.1.4 Auxiliary Midwifes (AM) - Form ST 1.4./AM/09...................3614.1.5 General Practitioner (GP)- Form ST 1.5./GP/09.................3614.1.6 Internal Medicine (IM) - Form ST 1.6./IM/09......................3614.1.7 Ophthalmologist (OP) - Form ST 1.7./OP/09......................3614.1.8 Surgeon (SU) - Form ST 1.8./SU/09..................................3614.1.9 To be completed (others - Form AC/ST/PH/XX/09...............3714.1.10 Pharmacists (PH) - Form ST 1.9./PH/09.........................3714.1.11 Laboratory technicians (LT) - Form ST 1.10./LT/09........3714.1.12 Laboratory technicians/Microscopists (MI) - Form ST 1.11./LT/MI/09....................................................................................3714.1.13 Other cadres working in Somaliland - Form AC/ST/XX/09 3714.1.14 To be completed (others - Form AC/ST/PH/XX/09.............37

14.2 Standards (ST) Health Service Delivery Facilities (HF) Forms ST 2x 38

14.2.1 Health post - Form ST 2.1./HP/09.....................................38



14.2.2 Health Centre - Form ST 2.2./HC/09.................................3814.2.3 Mother and child health centres (MCHs) – Form ST 2.3./MCH/09.......................................................................................3814.2.4 Clinics - Form ST 2.4./CL/09............................................3814.2.5 Secondary level, public and private - Form ST 2.5./SL/09...3814.2.6 Tertiary level, public and private - Form ST 2.6./TL/09.......38

14.3 Standards (ST) • Basic and Continuous Medical/Health Education and Trainings (HT) Forms ST 3x..........................................39

14.3.1 Nursing Schools; Public and Private - Form ST 3.1/NS/09...3914.3.2 Midwifery Schools ; Public and Private Form ST 3.1/MS/09. 3914.3.3 Medical Schools ; Public and Private Form ST 3.1/MDS/09. 3914.3.4 Other Institutions/schools; public and private - Form ST 3.1/IN/09.............................................................................................3914.3.5 Tutors - Form ST 3.2./TU/09............................................3914.3.6 Curriculum for Basic Nursing Education - Form ST 3.3/BNE/09.........................................................................................3914.3.7 Curriculum for Basic Midwifery Education - Form ST 3.3/BME/09.........................................................................................3914.3.8 Curriculum for Continuous Medical/Health Education – Form ST 3.4./CE/09............................................................................3914.3.9 Examination Process - Form ST 3.5/EM/09.........................3914.3.10 “Traditional Health System” in Somaliland - Forum ST 3.10./TM/09........................................................................................40

14.4 Accreditation Procedure (AP) Forms AP 4x...........................4114.4.1 List of Individuals who provide health services - Form AP 4.1./HPr/09.........................................................................................4114.4.2 List of Public and Private Facilities Form AP 4.2./HF/09.....4114.4.3 List of Training Providers in Health - Form AP 4.3./HF/09...41

14.5 Selection Accreditation (Sub)Committees ((S)AC) Forms AC 6x42

14.5.1 Selection Accreditation Committees (AC) Nurses- Form AC 5.1./N/09.............................................................................................4214.5.2 Selection Accreditation Committee (AC) Midwifes (M) – Form AC 5.2./M/09.............................................................................4214.5.3 Selection Accreditation Subcommittee (AC) General Practitioner (GP) – Form ASC 5.3./GP/09..................................4214.5.4 Selection Accreditation Subcommittee (ASC) Specialised Physicians – Form ASC 5.4./SP/09.............................................42



14.5.5 Selection Accreditation Subcommittee (ASC) • Basic and Continuous Medical/Health Education/Trainings - Nurses - Form ASC 5.5./HT/N/09...............................................................................4214.5.6 Selection Accreditation Subcommittee (ASC) Basic and Continuous Medical/Health Education/Trainings - Midwifes - Form ASC 5.6./HT/M/09...............................................................................4214.5.7 Selection Accreditation Subcommittee (ASC) Basic and Continuous Medical/Health Education/Trainings – Physic. - Form ASC 5.7./HT/PH/09.....................................................................................4214.5.8 Selection Accreditation Subcommittee (ASC) Basic and Continuous Medical/Health Education/Trainings – Pharm. - Form ASC 5.8./HT/PH/09.....................................................................................4314.5.9 Selection Accreditation Subcommittee (ASC) Basic and Continuous Medical/Health Education/Trainings - laboratory Technicians – Form ASC 5.9./HT/LT/09....................................4314.5.10 Selection Accreditation Subcommittee (ASC) Basic and Continuous Medical/Health Education/Trainings - Other cadres – to be specified – Form ASC 5..XX./HT/XX/09.................................4314.5.11 Selection Accreditation Committee Appeal – Form ASC 5.11./App/09.......................................................................................43

14.6 Assessment Tools (AT) Health Professionals.............................4414.6.1 Assessment tool (AT) – Nurses/Self Assessment (SE) – Form AT 6.1. /N/SE/09.......................................................................4414.6.2 Assessment tool (AT) – Nurses/External Assessment (EE) – Form AT 6.2./N/EE/09........................................................................4414.6.3 Assessment tool (AT) – Auxiliary Nurse /Self Assessment (SE) – Form AT 6.3./AN/SE/09......................................................................4414.6.4 Assessment tool (AT) – Auxiliary Nurses/External Assessment (EE) – Form AT 6.4./AN/EE/09..................................................4414.6.5 Assessment tool (AT) –Midwife/Self Assessment (SE) – Form AT 6.5./M/SE/09........................................................................4414.6.6 Assessment tool (AT) – Auxiliary Midwife/External Assessment (EE) – Form AT 6.6./AM/EE/09....................................................4414.6.7 Assessment tool (AT) – Laboratory Technician/Self Assessment (SE) – Form AT 6.7./LT/SE/09....................................................4414.6.8 Assessment tool (AT) – Laboratory Technician/External Assessment (EE) - Form AT 6.8./LT/EE/09..................................4414.6.9 Assessment tool (AT) – Pharmacists/Self Assessment (SE) – Form AT 6.9./PH/SE/09......................................................................4414.6.10 Assessment tool (AT) – Pharmacists/External Assessment (EE) – Form AT 6.10./PH/EE/09................................................44



14.6.11 Assessment tool (AT) – General Practitioner/Self Assessment (SE) – Form AT 6.11./GP/SE/09..................................................4414.6.12 Assessment tool (AT) – General Practitioner/External Assessment (EE) - Form AT 6.12./GP/EE/09...............................4414.6.13 Assessment tool (AT) – Ophthalmologist/Self Assessment (SE) – Form AT 6.13./OP/SE/09.................................................4414.6.14 Assessment tool (AT) – Ophthalmologist/External Assessment (EE) – Form AT 6.14./OP/EE/09...................................................4414.6.15 Assessment tool (AT) – Internal Medicine/Self Assessment (SE) – Form AT 6.15./SE/09.......................................................4514.6.16 Assessment tool (AT) – Internal Medicine/External Assessment (EE) – Form AT 6.16./IM/EE/09...............................4514.6.17 Assessment tool (AT) – Surgeon/Self Assessment (SE) – Form AT 6.17./SU/SE/09....................................................................4514.6.18 Assessment tool (AT) – Surgeon/External Assessment (EE) – Form AT 6.18./SU/EE/09....................................................................4514.6.19 Assessment tool (AT) – others – to be extended – Form AT 6.XX/XX/09...........................................................................45

14.7 Assessment Tool (AT) Health Service Providers........................4614.7.1 Assessment tool (AT) – Health Post/Self Assessment (SE) – Form AT 7.1./HP/SE/09......................................................................4614.7.2 Assessment tool (AT) – Health Post/External Assessment (EE) – Form AT 7.2./HP/EE/09......................................................................4614.7.3 Assessment tool (AT) – Health Centre/Self Assessment (SE) – Form AT 7.3./HC/SE/09......................................................................4614.7.4 Assessment tool (AT) – Health Centre/External Assessment (EE) – Form AT 7.4./HC/EE/09..................................................4614.7.5 Assessment tool (AT) – Mother and Child Health Centre/Self Assessment (SE) - Form AT 7.5./MCH/SE/09................................4614.7.6 Assessment tool (AT) – Mother and Child Health Centre/External Assessment (EE) - Form AT 7.6./MCH/EE/09.....4614.7.7 Assessment tool (AT) – Clinic/Self Assessment (SE) – Form AT 7.7./AT/CL/SE/09.................................................................4614.7.8 Assessment tool (AT) – Clinic/External Assessment (EE) – Form AT 7.8./CL/EE/09......................................................................4614.7.9 Assessment tool (AT) – Secondary Level Hospital (SLH)/Self Assessment (SE) - Form AT 7.9./SLH/SE/09...............................4614.7.10 Assessment tool (AT) – Secondary Level Hospital (SLH)/External Assessment (EE) - Form AT 7.10./SLH/EE/09......4614.7.11 Assessment tool (AT) – Tertiary Level Hospital (TLH)/Self Assessment (SE) - Form AT 7.11./TLH/SE/09.............................46



14.7.12 Assessment tool (AT) – Tertiary Level Hospital (TLH)/External Assessment (EE) - Form AT 7.12./TLH/EE/09......4614.7.13 Assessment tool (AT) – Pharmacy/Self Assessment (SE) – Form AT 7.13./PHa/SE/09..................................................................4614.7.14 Assessment tool (AT) – Pharmacy/External Assessment (EE) – Form AT 7.14./Pha/EE/09...................................................................4614.7.15 Assessment tool (AT) – Laboratory/Self Assessment (SE) – Form AT 7.15./AT/Lab/SE/09..............................................................4714.7.16 Assessment tool (AT) – Laboratory/External Assessment (EE) – Form AT 7.16./Lab/EE/09.......................................................47

14.8 Assessment Tool (AT) Basic and Continuous Medical/Health Education and Trainings........................................................................48

14.8.1 Assessment tools (AT) – Institutions/schools/Self Assessment (SE) – Form AT 8.1. /Ins/SE/09..................................................4814.8.2 Assessment tools (AT) – Institutions/schools/External Assessment (EE) - Form AT 8.2./Ins/EE/09.................................4814.8.3 Assessment tools (AT) Tutors - Self Assessment (SE) – Form AT 8.3./Tu/SE/09.......................................................................4814.8.4 Assessment tools (AT) – Tutors/External Assessment (EE) – Form AT 8.4./Tu/EE/09.......................................................................4814.8.5 Assessment tools (AT) Curriculum for basic education in health - Self Assessment (SE) - Form AT 8.5./Cu-BE/SE/09.........4814.8.6 Assessment tools (AT) – Curriculum for basic education in health/External Assessment (EE) - Form AT 8.6./Cu-BE/EE/09.......4814.8.7 Assessment tools (AT) Curriculum for continuous education in health - Self Assessment (SE) - Form AY 8.7./Cu-CE/SE/09..........4814.8.8 Assessment tools (AT) – Curriculum for continuous education/External Assessment (EE) - Form Y 8.8./Cu-CE/EE/09....4814.8.9 Assessment tools (AT) Examination process - Form AT 8.9./EM/09..........................................................................................48

14.9 Assessment Reporting Template - Template /Rep/09...............4914.10 Licensing Forms Process - Form LI 10./Pr/09.........................5014.11 Registration Forms Process - Form RE 11./Pr/09....................5014.12 Re-assessment Form Process - Form RA 12./Pr/09..................5014.13 Appeal (AP).................................................................................50

14.13.1 Appeal Form - Form AP 13.1./Fo/09...............................5014.13.2 Appeal Protocol Form - Form AP 13.2./Pr/09..................50

14.14 Fee Collection Form process - Form FE 14./09......................50

FIGURE 1: RELATION BETWEEN NHPC (RE-) ESTABLISHMENT WG, STEERING COMMITTEE AND MOHL...........................................................11FIGURE 2: RELATIONSHIPS BETWEEN NHPC AND MOHL........................14



FIGURE 3: SEQUENCE AND FLOW...............................................................32



ABBREVIATIONS CPD Continuing professional developmentED Executive DirectorEPHS Essential package of health servicesGoS Government of SomalilandH(M)IS Health (management) information system HPC Health Professions CouncilHR Human ResourceMCH Mother and Child HealthM&E Monitoring and evaluationMoHL Ministry of Health and LabourMOU Memorandum of UnderstandingNHPC National Health Professions CouncilRHO Regional Health Office SLNMA Somaliland Nursing and Midwifery AssociationSC Steering CommitteeSMA Somaliland Medical Association TOR Terms of referenceUNICEF United Nations Children’s FundWG Working Group WHO World Health Organisation

DEFINITIONS

Several different definitions of accreditation, licensing and registration are internationally in use. The NHPC WG aims at harmonising these definitions and formulates the following in the context of regulating health care in Somaliland:ACCOUNTABLE: - A liable health professional is responsible for the decisions made and can justify them.

ACCREDITATION: is the process of assessing and confirming the qualifications of health care practitioner (person or institution) seeking to get a license to practice..



SERVICE USER: is anyone who uses or is affected by the services

STANDARDS OF PROFICIENCY: formulate the requirements which ensure that a profession is practiced safely and effectively. Health professionals and institutions must meet these standards to become registered.

FIT FOR PRACTICE: refers to the skills, knowledge, competence and character to work safely and effectively.

SCOPE OF PRACTICE: defines the range of responsibilities within which activities can and have to be carried out by a health professional (e.g. “what does a nurse do or not do and what does a doctor do or not do, what a laboratory technician or a physiotherapist etc”) and for which they should be fit for practice.

HEALTH CARE SYSTEM: this term refers to a country's system of delivering services for the prevention and treatment of diseases and for the promotion of physical and mental well-being. Of particular interest to a health care system is how medical care is organised, financed, and delivered.

HEALTH CARE: any care, treatment, service or procedure to maintain, diagnose, treat, or otherwise affect an individual’s physical or mental condition, and includes medical care

HEALTH CARE (SERVICE) PROVIDER: A person, a body, organisation or institution administering health care in the ordinary course of business or practice of a profession and should be licensed, certified or otherwise authorised or permitted by the laws of this state to perform.HEALTH FACILITY: includes health posts, health centres, MCH clinics, secondary and tertiary hospitals, private clinics etc. where medical, dental and other health services are provided.LICENSE: is a formal registered permission from a constituted authority to perform a business/professional/trade activity.



1PURPOSE OF THIS DOCUMENT

This paper documents the CURRENT STAGE IN THE DEVELOPMENT of the Accreditation/Licensing/Register system in the health sector in Somaliland. It lays out the progress and identifies the areas of work which still need to be addressed, by whom and during which time frame it will be completed before the NHPC commences its work.This paper will evolve even further until the three implementation modules (see below) are completed in three phases, initial experiences are captured and utilised for adequate adjustments. This paper is set out to illustrate the present status in the design of accreditation, licensing and registration.

Hereby the document aims at informing and improving understanding of the (future) NHPC staff, the health workers and institutions, the key stakeholders as well as potentially the public on the purpose and process of accreditation and licensing.

Simultaneously it contains the tools, forms, process steps etc for practical application by the users.



2BACKGROUND

In 1999 an Act of the Republic of Somaliland Parliament was passed to establish a Health Professions Council (HPC). The Act defined the function of the Council which was planned to register health professionals and facilities. Although the HPC was constituted in 2001, it was not sustained and the Council was disbanded. During consultations in November 2006 (as part of the development of a broader health systems strengthening initiative), stakeholders confirmed the importance of and need for the HPC. In 2008, efforts were made to reconstitute the HPC and changes were made and/or envisioned to be made to minimise past short comings and utilise the previous positive and constraining experiences.Despite the challenges, the HPC continued to be seen as a key platform in the health sector for the overall promotion of standards and a central body for regulatory issues in the longer term. It has become clear however that, while many of the ambitions of the Act remain as relevant and valid today as in 1999, not only the Act needs to be updated, but also the overall concept and the strategy of a HPC to reflect changes that have taken place in the health sector including, for example, but not only, the emergence of professional associations and changes in the broader regulatory and health service governing and delivering environment.In view of the overall aim of the HPC as a statutory body with a mandate to protect the public, all consumers of health care services, and to provide guidance on educational, professional and ethical issues to practitioners, the need was formulated to review the Health Professions Council concept, strategy and legislation, i.e. the Somaliland HPC Act (1999), and prepare the required amendments to update the Act. Therefore a sustainable plan was required, with realistic and achievable targets, for the start-up of the HPC.Previous experiences in establishing the Council in Somaliland emphasised that, in order to minimise the risk of another drawback, the foundation of the Council has to be first well designed and formulated while ensuring consensus among the relevant stakeholders. Furthermore, progress has to slow but steady after jointly designed steps are fully

agreed andFIGURE 1: RELATION BETWEEN NHPC (RE-) ESTABLISHMENT WG, STEERING COMMITTEE AND MOHL accepted. This calls for the realisation through a consensus-seeking



process in the development of each of the elements and documents required, which was followed so far in the development and will be followed throughout in the design of the HPC components and systems.In February 2009 a working group was formed to re-establish the Council, reporting to a Steering Committee which consists of the Honourable Minister of Health and Labour, Mr. Abdi Haybe, the SMA- Chairman and the SLNMA- Executive Director. The Working Group comprised two physicians, two nurses, one laboratory technician, one pharmacist, one representative of MoHL, with support of the legal Advisor (on request) and an administrator (permanent).The name of “Health Professions Council” was changed during a Stakeholder Workshop on 15th February 09 to “National Health Professions Council” to emphasise the national, country wide, mandate. The name also reflects that it addresses regulations of not only health professionals but will equally include equally facilities, institutions and bodies in health care service delivery and health/medical education and training. The NHPC Working Group and Steering Committee agreed on a work-plan with the objective to create the foundations during 2009 and have the NHPC commence its function in January 2010. This preparatory work, establishing the foundation of the NHPC, includes in particular the design of the Accreditation/Licensing/Registration System.

3PURPOSE OF THE ACCREDITATION AND LICENSING SYSTEM

Accreditation, licensing and registration are the pillars of the NHPC mandate. The purpose of accreditation is to preserve, protect and defend the community’s right for quality health care and to establish also for the health service providers a safe framework in carrying out their responsibilities. Hence it has to ensure that competency based standards of quality curative, preventative and promoting health care are given to the public on primary, secondary and tertiary level in both, the public and the private sector. Hereby it aims at protecting the right for quality health care of the consumers as well as of the providers in carrying out their duties.However, it is foremost a personal responsibility to make sure that the best interests of service users are promoted and protected. Therefore factors affecting care or services must be respected and taken into account.The accreditation is the public mechanism to regulate that accredited and licensed health institutions and individuals meet at least minimum quality standards in carrying their practice, allowing the public getting the quality health care.In order to save the community’s health and provide the maximum appropriate care to the community, practitioners should be up to the



standard. They are accredited and should be able to provide high quality health care to the community and are hereby accountable and responsible for their decisions.The application of those standards determines who may or may not deliver health service, how they are delivered and where and what kind of health services are offered. Licensing health care institutions sets a minimum standard for each facility and their personnel as a group, and applying the standard determines whether the institution may operate lawfully or not. The licence is based on the accreditation process which in its turn refers to the minimum standards for qualification, as will be elaborated in the following chapters.The license is an official, legal permission that is indicating fit for practice and/or fit for purpose as well as signifying the capacity to practice and hereby formalising accountability of service providers.



4METHODOLOGY USED IN DESIGNING THE ACCREDITATION, LICENSING AND REGISTER SYSTEM

4.1 ADHERENCE TO THE PRINCIPLES OF NHPCThe accreditation, licensing and registration system is by nature complex, at the same time new to the country and will require time to be understood, digested and well accepted by the service providers and also by service consumers in order to prevent dangers and face challenges in the utilisation and continuity of these systems.Therefore the methodology in the design of the system keeps to the principles in the (re-) establishment of the NHPC as stated in the Concept paper (April 2009): “The NHPC requires a sound foundation and formulation prior to its actual commencement, to prevent repetition of previous short comings which contributed to the halt of previous attempts to establish a Council. That necessitates following thoroughly three guiding key principles:”

SIMPLE AND START SMALL FIRST GET THE FOUNDATION RIGHT BASED ON CONSENSUS

These means in the present context in particular that the accreditation system should not enter sophistication at the

beginning, and rather focus on a PRACTICAL, PRAGMATIC way forward, while staying AMBITIOUS, ROBUST and STRATEGIC.

Getting the foundations right aims at the NHPC being perceived and seen by the public as well as by health professionals as a RELIABLE body, with professional and institutional CREDIBILITY, underlined by TRANSPARENCY and CONSISTENCY.

The collaborative process used to elaborate and reach CONSENSUS in the work of the NHPC WG must be transparent to all contributors in the collaboration as well as to the public.

At the initial stage the efforts will be central in Hargeisa, but with the intention not to be centralised, i.e. when well established and if funding permits, NHPC could be AVAILABLE and ACCESSIBLE also through offices the provinces, although in realistic terms, this is not likely to be possible in the near future.

4.2 DESIGN IN CONSENSUS WITH PARTNERS AND STAKEHOLDERS

IT IS ESSENTIAL NOT ONLY IN THE ESTABLISHMENT OF THE NHPC, BUT ALSO IN THE DESIGN OF THE VARIOUS ELEMENTS OF THE NHPC, LIKE THE ACCREDITATION AND LICENSING, THAT THE PROCESS IS NEITHER TAKEN OVER, NOR DRIVEN BY EXTERNAL SUPPORT OR CONSULTANTS, NOR THAT



DOCUMENTS ARE BASED ONLY ON “LOCAL CONSULTATION”, BUT THAT THE PROCESS IS STRONGLY IN THE HAND AND LED BY THE NHPC WG, SC AND THEREAFTER BY THE ACTUAL NHPC, WHO IN THEIR TURN HAVE TO ADOPT AN APPROACH WHICH ENSURES THAT THE KEY STAKEHOLDERS ARE UPDATED ONGOING AND ALSO ACTIVELY INVOLVED IN THE DESIGN.So far in the process there is a largely consensus among the main stakeholders on the key role the accreditation, licensing and registration systems resume in the future progress of the health sector of Somaliland in view of QUALITY CONTROL, PROTECTION OF CONSUMERS, RIGHT TO QUALITY HEALTH CARE AND THE PROTECTION OF THE HEALTH CARE PROVIDERS.

Regular meetings and events are required to be initiated by the NHPC WG to brief and update partners and stakeholders on the progress and at the same occasion to ask for and receive comments, questions on uncertainties and to incorporate productive input after giving space for discussions, clarification and modifications.

Therefore the accreditation, licensing and registration system requires, as foreseen in the overall concept of NHPC, a strong marketing approach based on a well thought through outlined, appropriately timed strategic approach for the various target groups, i.e. health workers and service providers, politicians and general population.

4.3 UTILISATION OF EXPERIENCES THROUGH LITERATURE REVIEW AND SITE VISITS

The NHPC and in particular the Accreditation/Licensing/Registration shall not be designed in isolation. Experiences from other countries, in particular on the African continent, will be utilised through literature review and possibly, if funding permits, through site visits.However, using experiences should not be mistaken as a copying exercise, but rather to identify principles, pros and cons of methods and approaches as well as of institutional, organisational and managerial set-ups and to use, avoid or adjust experiences as fit for Somaliland.

4.4 IN RESPECT AND SUPPORT OF THE RELATIONSHIPS BETWEEN NHPC AND MOHL

A particular point for clarity is the position of NHPC as an independent body, but cooperating closely with the Ministry of Health. It has to be strongly emphasised that the roles of MoHL and NHPC are NOT OVERLAPPING, BUT COMPLEMENTARY. This implies being managerially and financially INDEPENDENT FROM MOHL, WHILE IN CLOSE COOPERATION in related policy development in the recognised mandate of the MoHL as the policy making, Governmental body.



FIGURE 2: RELATIONSHIPS BETWEEN NHPC AND MOHL

NHPC negotiates and dialogues – requires mutuality

NHPC regulates and controls quality - requires independenceThe NHPC needs to be relying, in particular for its accreditation and options for its enforcement, on a comprehensive health human resource policy and strategy with strong political commitment for

carrying this strategy. Hereby the NHPC has to do both, reply on MoHL to design the HR strategy and also to advocate and contribute to its development.

At the time of writing this paragraph the relation between MoHL and NHPC was in the process to be discussed and formulated based on a recent draft of a Human Resource Policy paper. The paragraph needs to be completed (by Ahmed and Abdullahi) after this agreement is formalised.

4.5 MANDATE OF SMA AND SLNMA The above applies also to SMA and SLNMA. Their role in

respect to NHPC will be addressed and articulated during and within the same process as the relation between MoHL and NHPC. The paragraph will be completed thereafter (by Ahmed and Abdullahi).


Policy and Strategy

Health Care

provisionPublic

Financing

Minister

MoHL

NHPC


5IMPLEMENTATION PHASES AND MODULES – NHPC CONCEPT PAPER APRIL 09

5.1 STILL OUTSTANDING PREPARATORY STEPS OTHER THAN THE ACCREDITATION SYSTEM DURING 2009

The above implies that a series of PREPARATORY STEPS are required to establish, govern and maintain the structure DURING 2009 (see also work-plan 2009 from February 2009):

1. SUBMISSION OF THE AMENDMENTS OF THE HPC ACT 99 TO THE PARLIAMENT

The legal advisor to the NHPC WG / SG needs to review this document and suggest if and which aspects require to be reflected in the Act Amendment.

2. STRATEGY AND OPERATIONAL PLAN 2010 3. ANNUAL OPERATIONAL PLAN 20104. NHPC MARKETING STRATEGY 5. IT SYSTEMS FOR ACCREDITATION, LICENSING AND REGISTRATION 6. TERMS OF REFERENCES for

Board Chair of Board Executive Director Each technical unit NHPC administration NHPC finance Various committees and sub-comittees

7. A transparent RECRUITMENT PROCESS for the Executive director, NHPC personnel.

8. A transparent NOMINATION/ELECTION PROCESS for the Board members, Chair of the Board.

9. NHPC Office Organisational / Operational Manual10.NHPC Finance Management System and Manual.

5.2 MODULES AND PHASES

The above also demands a complex process of high workload with some degree of specificity. Since the NHPC is being established as a new organ



in the country it is not feasible to include all interventions, targets groups and procedures at once. This asks for a phased approach in modules:

5.2.1MODULES MODULE 1 TARGET GROUPS:

Health Professionals: Physicians incl. specialists Nurses with breakdown in type and level of nurses Midwifes with breakdown in type and level of nurses Pharmacists

Basic and Continuous Medical/Health Education and Trainings:

Nursing schools Midwifery schools Continuous trainings

Health Service Providers: Primary care level, public and private, including clinics of

physiciansMODULE 2 TARGET GROUPS:

Health Professionals Laboratory technicians and other cadres working in laboratories,

private and public “Dentists” Community Health Workers Other cadres working in the health sector in Somaliland, (x-ray

technicians, orthopaedic technicians, physiotherapists, psychotherapists etc), all of which are low in numbers; public and private

Basic and Continuous Medical/Health Education and Trainings: Medical schools and University health faculties Schools of other health cadres in Somaliland

Health Service Providers Secondary and tertiary level, public and private

MODULE 3 TARGET GROUPS: Health Professionals

Traditional Healers “Alternative medicine” Traditional birth attendants – depending policy of MoH (to be

developed) Basic and Continuous Medical/Health Education and

Trainings Fill gaps from module 1 and 2

Health Service Providers Fill gaps from module 1 and 2



5.2.2PHASES PHASE 1Includes:

Governance and Management:Set up of governance and management structure, management

systems, office set up, staff Module 1 in urban areas (capital, regional and provincial centres) Marketing Advocacy Grievances Health HR development Capacity building NHPC M&E and audit

Timeframe: January 2010 – December 2011PHASE 2:Includes:

Module 1 in rural areas Module 2 in urban areas (capital, regional and provincial centres) Marketing Advocacy Grievances Health HR development Capacity building NHPC M&E and audit

Timeframe: January 2012 – December 2012 PHASE 3:Includes:

Module 2 in rural settings in all provinces Module 3 in entire country Marketing Advocacy Grievances Health HR development Capacity building NHPC M&E and audit

Timeframe: January 2013 – December 13



6STANDARDS OF TARGET GROUPS

The term “standard” in this context refers to the minimum qualifications, competencies, capacities and conditions, respectively scope of work and quality of performance, as applicable for each category of health professionals, medical/health education- and training institutions and courses and health care providing institutions, in the public as well as private sector. These standards are setting the norm in Somaliland which have to be complied with in order to get accredited and receive a licence.These standards and norms are not to be set in isolation but in close collaboration and consensus among the key stakeholders, with reference to international standards, however not copied but rather adjusted to the realities in Somaliland.At this stage only few of these references exist in Somaliland as further elaborated below.

6.1 INDIVIDUAL HEALTH PROFESSIONALS 6.1.1NURSES AND AUXILIARY NURSES

Two groups of nurses are existing in Somaliland: qualified nurses (senior and junior) and auxiliary nurse (short term trainings and/or long time service exposure). Most of the health services in the country depend on these two professions. However, their qualification and experience vary markedly. Under the initiative and lead of the Somaliland Nursing and Midwifery Association the following references were developed:

Code of Conduct for Nurses; SLNMA Professionals Standards of Nursing Practice (2006)

The SLNMA have also conducted a survey on existing staff and it is the only group of health professions with recent, updated information.

Standards of the nursing professions will be defined based on the consensus among key stakeholders under the lead of the NHPC WG and endorsed by MoHL till end October 2009 (due to expected delays during the Ramadam period end August – end September, the upcoming political campaign and elections).

6.1.2MIDWIFES AND AUXILIARY MIDWIFES

Similar as above applies for midwifery and it is referred to the same document mentioned above. The above mentioned survey included midwifes and auxiliary midwifes.

As above, the standards of the midwifery professions will be defined based on the consensus among key stakeholders under the lead of the NHPC WG and endorsed by MoHL till end October 2009 (due to expected delays during the



Ramadam period end August – end September, the upcoming political campaign and elections).

6.1.3PHYSICIANS ( GENERAL PRACTITIONER, SPECIALISTS (SURGEON, OPHTHALMOLOGIST, INTERNAL MEDICINE, OTHERS)

This group of staff with its specialised subgroups entail currently largely two types, i.e. seniors and juniors). Seniors may be those graduated from the Somali National University and those from outside country Medical Education Institutions, while this may be the case for all juniors. Therefore, an evaluation of the non–Somaliland degrees in terms of authenticity and recognition of the sources/ institutions by the respective National Health Authority are essential. Also, the duration of the academic year for a doctor to be accredited for a speciality presents an additional crucial factor.

As of to date, no such policy or Act is available in country and needs to be established on consensus between MoHL, the Universities and SMA under the lead of the NHPC WG within the remaining calendar year.

The SMA published however a reference, though not as definition of the professional standard: Medical Ethics Manual; First Publication; Somaliland Medical Association; prepared by Dr. Suleiman Abdi Guleid; Chairman of SMA; May 2008

The standards will be defined based on the consensus among key stakeholders under the lead of the NHPC WG and endorsed by MoHL till mid October 2009.

6.1.4PHARMACISTS AND LABORATORY TECHNICIANS In a brief summary, by and large, these two categories can be seen collectively as a group under the title of allied health sciences. These cadres differ from the above since there is currently no recognised institution in country that would produce them at national level. However, there are very few graduates from overseas institutions and seniors from the Somali National Health Institution, however decades ago). Allied sciences available now in the both private and public health facilities are either assistants (short term training) or auxiliary (field service exposures). As of today, there is no policy or Act for these groups. It is therefore apparent that there is a need to develop evaluation tools and to conduct a survey to establish an updated number of particularly for these groups.

The standards for the pharmacists will be defined based on the consensus among key stakeholders under the lead of the NHPC WG and endorsed by MoHL till till end October 2009 (due to expected delays during the Ramadam period end August – end September, the upcoming political campaign and elections).



The standards for the professions of other allied health sciences will be defined based on the consensus among key stakeholders under the lead of the NHPC and endorsed by MoHL following the phases and modules designed in the NHPC re-establishment concept.

6.1.5OTHER HEALTH CADRES WORKING IN SOMALILAND

Little is known as of to date about the variety of other cadres, their type, quantity and location of operations.

Equally here a survey and a standard policy are required, which is foreseen to be accomplished during the second half the first working year of the NHPC.

6.1.6CADRES USING TRADITIONAL HEALING PROCEDURES

Cadres using herbals and traditional healing procedures are working mostly of unknown origin in terms of qualification, background etc

It is foreseen that these cadres will be addressed during the-second half of the second phase in order to be ready for accreditation during the third phase of the functioning of NHPC - see below.

6.2 HEALTH SERVICE DELIVERY FACILITIES 6.2.1PRIMARY LEVEL -PUBLIC AND PRIVATE: HEALTH POSTS, HEALTH

CENTRES, MOTHER AND CHILD HEALTH CENTRES (MCHS), CLINICS ETC

To be completed till end October 2009 (due to expected delays during the Ramadam period end August – end September, the upcoming political campaign and elections).

6.2.2SECONDARY LEVEL, PUBLIC AND PRIVATE

See below – to be completed following the NHPC Concept phases and modules

6.2.3TERTIARY LEVEL, PUBLIC AND PRIVATE Similar to above applies for the health service delivery facilities, no standards exist in Somaliland and need to be designed, agreed in consensus and endorsed by MoHL.

This should be completed in the same approach as above, as a consensus among key stakeholders under the lead of the NHPC WG and endorsed by MoHL, up to mid November 2009.



6.3 BASIC AND CONTINUOUS MEDICAL/HEALTH EDUCATION AND TRAININGS

6.3.1NURSING AND MIDWIFERY SCHOOLS AND THEIR CONTINUOUS EDUCATION

To be completed till end October 2009 (due to expected delays during the Ramadam period end August – end September, the upcoming political campaign and elections).

6.3.2OTHER INSTITUTIONS/SCHOOLS; PUBLIC AND PRIVATE


6.3.3TUTORS See below – to be completed following the NHPC Concept

phases and modules

6.3.4CURRICULUM FOR BASIC EDUCATION IN HEALTH


6.3.5CURRICULUM FOR CONTINUOUS EDUCATION IN HEALTH


6.3.6EXAMINATION PROCESS

Also in respect to health trainings and training institutions, only few standards were described so far:

An overview of the related, existing standards will be completed till end October 2009 (due to expected delays during the Ramadam period end August – end September, the upcoming political campaign and elections).

A substantial amount of time and efforts will have to be invested till the standards and hereby the references for accreditation are formulated and officialised.

These will be addressed over time and following set priorities, in consensus among key stakeholders under the lead of the NHPC and endorsed by MoHL following the phases and modules designed in the NHPC re-establishment concept (see in annex).

6.4 “TRADITIONAL HEALTH SYSTEM” IN SOMALILAND

To be defined probably during second half of phase 2 in order to be ready for phase 3.



7IN PREPARATION OF THE ACCREDITATION

7.1 LISTING OF INDIVIDUALS AND SERVICES CURRENTLY PROVIDING HEALTH CARE SERVICES / TRAINING

7.1.1HEALTH PROFESSIONALS A list of the individuals providing health care in Somaliland in their various capacities will serve as the baseline reference for the NHPC being able to estimate the Council’s progress in coverage and the extend of reaching the health workers for accreditation.It might also assist in the management of the initial, first round in accrediting individuals, the required time, financial and human resources.However first hand collection or survey will only be needed for those professions where no reliable, secondary information exist. Possible secondary data could be searched from MoHL, health service providers, SMA, SLNMA etc. However at this stage only SLNMA can offer adequate updated data with required accuracy and reliability for nurses and midwifes.

Surveys to establish baseline information on existing physicians and pharmacists in Somaliland needs to be conducted in the first quarter of the functioning of NHPC in cooperation with the SMA.

Surveys of all other health cadres will be conducted by the NHPC, following the outlined modules and phases of the target groups (see below).

7.1.2BASIC AND CONTINUOUS MEDICAL/HEALTH EDUCATION AND TRAININGS

This sub-chapter deals with the following training related components The basic medical/health training institutions/schools Continuous education Formal and informal training programmes including types and

curricula of the health institutions Trainers, teachers and tutors

A list of all basic and continuous training providers in health in Somaliland will serve as the baseline reference for the NHPC to estimate the Council’s progress in coverage and the extent of reaching those providers.It might also assist in the management of the initial, first round in accrediting institutions, the required time, financial and human resources.



However first hand collection or survey will only be needed if existing, secondary information is not or insufficient reliable, comprehensive and accurate. Possible secondary data could be searched from MoH, health education/training providers, SMA, SLNMA etc. However at this stage only SLNMA can offer adequate updated data on nursing schools.

7.1.3HEALTH SERVICE PROVIDERS

A list of all primary, secondary and tertiary health facilities in the public and in the private sector including pharmacies, clinics etc providing health care services in Somaliland will serve as the baseline reference for the NHPC being able to estimate the Council’s progress in coverage and the extend of reaching the health facilities for accreditation.It might also assist in the management of the initial, first round in accrediting facilities, the required time, financial and human resources.However first hand collection or survey will only be needed for those facilities, where no reliable, secondary information exist. Possible secondary data could be searched from MoHL, SMA, SLNMA etc.

Therefore surveys will be conducted by the NHPC, as far as necessary (see below).

7.2 ASSESSMENT VALIDATION CRITERIA BASED ON THE STANDARDS

As on the first assignments after the Board of the NHPC appoints the Accreditation Committee (see below), the Committee will identify the criteria, based on the standards and which will also serve as the documentation to be filed and archived for each individual.

7.2.1HEALTH PROFESSIONALS The Accreditation Committees will initially set criteria specific for each profession corresponding to the standards. For professions for whom such criteria already exist up to the time the Accreditation Committee commences work, as e.g. for the nurses and midwifes, the Accreditation Committee will make use of those, in light to stay harmonised and in close cooperation with the key partners, the SMA, SLNMA, MoHL and the Universities.Specific approaches will be elaborated for cases which require specific clarifications, as e.g. new/recent graduates, lost certificates, or certificates from institutions in foreign countries etc. This will be looked at case by case and the approach approved by the board of the NHPC and carried out by the Accreditation Committee.The selection of the criteria will, reflecting the standards:

1. Educational level: to be specified per each cadre, i.e. doctors, nurses, auxiliary nurses,, paramedical etc., i.e. degree, diplomas



from recognised University and/or Health/Medical Education Institutions.

2. Knowledge: Personal knowledge to be examined by the Accreditation Committee

3. Skills: Personal skills to be examined by the Accreditation Committee; certificates and/or testimonial provided by a known and recognised health institutions

4. Competencies to be examined by the Accreditation Committee

7.2.2BASIC AND CONTINUOUS MEDICAL/HEALTH EDUCATION AND TRAININGS

The Accreditation Committees will initially set specific criteria corresponding to the standards, which, as stated above, will be set in cooperation with MoH, MoE, University, SMA and SLNMA.If such criteria already exist up to the time the Accreditation Committee commences work, the Accreditation Committee will make use of those in light to stay harmonised and in close cooperation with the key partners, the SMA, SLNMA, MoHL and the Universities.This will be looked at case by case and the approach approved by the board of the NHPC and carried out by the Accreditation Committee.The selection of the criteria will, reflecting the standards, include:

1.Teaching staff to be specified per each cadre, i.e. doctors, nurses, auxiliary nurses,, paramedical etc.

2.Curricula: Personal knowledge to be examined by the Accreditation Committee

3.Infrastructure4.Teaching material and equipment 5.Number of students6.Enrolment procedure and requirements7.Examination procedures

7.2.3HEALTH SERVICE PROVIDERS

The Accreditation Committees will initially set criteria specific for each type of facility corresponding to the standards. For facilities for which type such criteria already exist up to the time the Accreditation Committee commences work, the Accreditation Committee will make use of those, in light to stay harmonised and in close cooperation with the key partners.The selection of the criteria will, reflecting the standards, include:

1.Staff composition and competencies2. Infrastructure and equipment3.Management systems4. Competencies



7.3 ASSESSMENT TOOLS

In this context the Assessment tools are the checklists, forms and examination documents.

They need to be prepared by the Accreditation Committee and will also serve as the documentation to be filed and archived for each individual.

7.4 SELECTION MODALITIES OF THE ACCREDITATION COMMITTEE MEMBERS

The Committees should be based only on technical capacities of the committee members, irrespective their position and their professional affiliations (e.g. preferably if they belong to an Association, University, working privately etc). Since the Accreditation Committee needs to be specifically competent for each cadres it does not require to be multidisciplinary, but rather give weight to its sound capacity for each discipline.

The Board of the NHPC will select three Accreditation Committee Members for each cadre using agreed criteria which reflect technical capacities only.

Among the Committee members the colleague with the longest work experience shall serve as the Committee lead and spokes person.

Hereby the selection is should depicts competence, fairness and transparency.



8LICENSING AND RE-LICENSING SYSTEM AND PROCEDURE

Licence is the official and by the MoHL recognised document - through its recognition of the NHOC’s mandate -, which certifies that a person or institutions are fit for practice, fit for purpose and that they warrant to provide service, specified by capacity and the time period. Under certain circumstances a conditional licence for a shorter period might be issued after which it will be assessed if the conditions were met.The licence is based on the accreditation process which in its turn refers to the minimum standards for qualification, as elaborated in the previous chapters.

8.1 PURPOSE AND OBJECTIVES OF LICENSING1

The PURPOSE OF LICENSING is to ensure that licensed and approved health facilities and professionals remain up to date and continue to be fit to practice. Licensing has three elements:

A.To confirm that licensed health professionals practice in agreement with the NHPC general standards.

B. To confirm that health training institutions meet the standards appropriate for their trainings.

C.To identify that health care providing bodies deserve to continue their work, and that they are fit for purpose, fit for practice according the NHPC standard2.

For this purpose the licensing aims at achieving the following objectives:I. To ensure public safety.

II. To signify who is a health professional. III. To categorise health care facilities and professionals IV. The development of high quality public health service.V. The protection of public from harm.

VI. The prevention of crime and disorder.Licensing also:

Licensing is one the several mechanisms to improve the quality of the health care and health service of the community.

Gives further focus and motivation to health professionals in their desire to keep up to date and improve their practice through continuous professional development and reflective practice.

1 Expanded from the Health Professional Council of the United Kingdom, sector of accreditation, licensing and registration.2 Expanded from the Health Professional Council of the United Kingdom, sector of accreditation, licensing and registration.



Aims to enhance and sustain public confidence in the profession as a whole by providing periodic declaration that health professionals continue to be fit to practice.

Provides a process through which health professionals who may fall short of professional standards in some respects can be supported.

Identifies the (hopefully small) proportion of professionals who are unable to work after important shortfall in their practice and remove them from the register of their profession.

8.2 ACCREDITATION AND LICENSING RELATION

The fundamental requirement of a functional accreditation system is that the system is trustworthy and recognised by all, i.e. by the medical schools, the students, the professions, the public and the private health care sectors and the public.Trust must be based on the academic competence, efficiency and fairness of the system. These characteristics of the system must be known by the users and consequently the system. ACCREDITATION will assess strength from CREDIBILITY, which comes from CONTENT and that depends on COMPETENCE for which CAPABILITY is necessary. The accreditation is the guidance, leader and instructor of the license, i.e. it will indicate if the person or institution is fit for practice, fit for purpose and deserve licensing3. The licence will be based on the outcome of the accreditation which will declare that either the person and institution will be awarded or revoked, and if awarded which sort of license will be awarded. The accreditation unit, based on the recommendations for the accreditation committee, are the decision makers for the license.

8.3 TYPES OF LICENSE

8.3.1LEVEL AND GRADING OF LICENSING

A complete and comprehensive licensing system foresees also different levels and grading. Since the health system in general, its human resources and the (re-)establishment of the National Health Professional Council still face challenges to be well understood by authorities in its conceptualisation and numerous managerial, financial and in case of the NHPC also political constraints, both the introduction of levels and grades as well as the their licensing would be overburdening and complicating the process and is therefore premature. At a later stage, when circumstances are more stabilised and well founded the accreditation and licensing can move to a more advance and complex structure.

8.3.2INDIVIDUAL LICENSURE The granting of a legal permit that is personal and cannot be transferred to another person. The individual seeking the licensure must meet the 3 See Essential Package of Health Service; 2008



standards for practice as established by the National Health Professions Council. In most instances the initial license is granted upon successful completion of an examination administered by the Accreditation Committee.

8.3.3INSTITUTIONAL LICENSURE It is the licensing of an organisation, institution or similar body providing medical/nursing/paramedical education and/or continuous training or a health care service in health care to the public in the public sector or in the private sector. This can be general hospitals or private clinics of health professionals such as physicians, nurses, laboratory technicians etc or for the supply of medical products.

8.3.4SUITABILITY

This aspect dictates a license will be granted, conditions identified or the license refused. The suitability mentions the category deserved and found appropriate which can be different from or the same as the previous license.

8.4 TIME PERIODS AND CONDITIONAL LICENCE

8.4.1UNCONDITIONAL LICENCE

A complete licence is valid for three years, after which period it has to be renewed.

8.4.2TEMPORARY / CONDITIONAL LICENCE

A conditional and temporary license can be issued for an institution or an individual when the accreditation committee does not grant full performance of the desired standards. Its purpose is to declare that this individual or institution is accredited but there is a weakness which has to be addressed as a condition to receive the full license. The accreditation committee will set a period of time during which the individual or the institution has to fulfil the conditions and will be re-assessed. The period will vary according to the condition specified. If the conditions are not met, the license will be rejected, respectively suspended.After the accreditation process the accreditation committee submits its report including its decision to the licensing unit of the NHPC which is processing the license issue according to the decision taken by the accreditation committee.

8.4.3REJECTED LICENCE

If the accreditation committee concludes that the assessment shows an un-improvable outcome or the required improvements made are not satisfactory, the licence can be rejected without options of conditions.



8.5 RELICENSING The licences have a time frame of validity and require relicensing. A relicense can be issued to a person or an institution which can be different to the previous one. If the type of the licence remains the same, the previous licence will be renewed. A licence has to be renewed every three years on the dates set by the NHPC. A licence subject to renewal or relicensing shall be re-issued on or before the date set by the council on the licence. If this not completed in time the licence lapses. In time means within one month starting from the license expired date.

8.5.1PROCEDURAL STEPS

1. The accreditation and licence has to be initiated by the applying person or body with the completion of the application form, copies of documents etc and payment4. Only after the licence unit of NHPC receives the completed application form, the payment and the required documents as specified in the application form, the accreditation and licensing process will commence.

2. The NHPC licensing unit shall require the following minimum information from each individual or institution as part of the first license and as part of any renewal of such license:-a) The name, the address, and telephone number of the licensee;b)Facility or professional names used by the licensee;c) Addresses, telephone numbers, and the names of contact persons

for all facilities used by the licensee for the storage, handling, and distribution, if applicable.

d)The type of ownership or operation (i.e., partnership, corporation, or sole proprietorship); and

e) The name(s) of the owner and/or operator of the licensee, including:

i. If a person, the name of the person, if a partnership, the name of each partner, and the name of the partnership;

ii. If a corporation, the name and title of each corporate officer and director, the corporate names, and the name of the State of incorporation.

3. Within two working days the NHPC licensing unit will forward the file to the accreditation unit, which in its turn has to be commence processing the file within two working days.

4. License renewal must be initiated by the applicant not less than 30 days before the license period ends through submission of the application form for the renewal of the license and the payment.

5. If an application accompanied by the renewal fee is not brought to the licensing unit by that date the license expires, the license is

4 THE PAYMENT MECHANISM AND THE MANAGEMENT OF THE COLLECTED FEES WILL BE ELABORATED IN THE NHPC OFFICE ORGANISATIONAL MANUAL AND THE NHPC FINANCE MANAGEMENT SYSTEM.



irrecoverable unless the application, fee and additional “delay fee” are received within 14 calendar days.

6. A further delay for reasons other than force majeur will result in having to commence the process as a new applicant till which time the licence is not valid.

7. The license is a legal document so that no part of this document may be reproduced. It indicates that the person or institution is legally recognised to provide services to the community.

8. The NHPC licensing authority may provide for a single license for a facility unit operating more than one facility within that position or for a facility with various sub-facilities when activities are conducted at more than one location.



9REGISTER SYSTEM

9.1.1DEFINITION The accreditation and licensing system is outlined above in line with the concept paper of NHPC (April 09). In this chapter a few significant points are being emphasised. “Register” in this context is defined as i. To register ONLY LICENSED HEALTH PROFESSIONALS by their

categories.ii. To register ONLY THE LICENSED HEALTH FACILITIES AND BASIC AND

CONTINUOUS MEDICAL/HEALTH EDUCATION AND TRAININGS in Somaliland by category.

iii. To update the reassessed, previously licensed, registered, categorised health facilities and health professionals through standardised criteria.

9.1.2CONDITIONS TO GET REGISTERED

Fulfilment of the preconditions and requirements of eligibility to be licensed and receipt of the licensure as a health professional or health service providing facility or health training institute.

9.1.3MAINTENANCE OF REGISTER

The NHPC/registration unit is responsible to establish, maintain and update continuously the register systems.The latest three working days after a licence has been issued, the unit has to enter the new information/data into the register system.The unit is also responsible of reviewing of both licensing and registration of all health professionals and health care providing facilities and training institutions producing health cadre of different disciplines, on periodic, i.e. quarterly bases.

9.1.4PAPER BASED AND IT DATA BASE The NHPC WG will initiate the design and installation of a simple, user friendly and robust electronic as well as, initially, paper based data base.

The initial work plan had foreseen to have this systems completed by mid year 2009. Due to funding delays the deadline has to be postponed till end October 2009, accepting that this will have be carried out in addition to the activities already planned for this period without postponing these activities.



10 ACCREDITATION PROCESS

The process of accreditation follows several steps before the register unit of NHPC can issue a licence. Upon receiving an application the Accreditation Unit and the License Unit carry the administratively the process with decision making by a technically posted Accreditation Committee, which applies to all three groups:

1.Self assessment2.External assessment3.Decision and report by Accreditation Committee4.Licensing or possible appeal5.Registration

10.1SELF ASSESSMENT Self assessment is a step providing self compliance, in which a self improvement process is expected to be initiated. After receipt of an application the applicant will be invited to conduct this assessment, based on a form, specific for each group and category:

Self assessment forms, specific for each category in the 1st

phase will be developed under the lead of the NHPC WG will until end October 2009 (due to expected delays during the Ramadam period end August – end September, the upcoming political campaign and elections).

10.2EXTERNAL ASSESSMENT Within 12 working days after the receipt of the filled self assessment, the Accreditation Committee will communicate to the applicant a date and time for the external assessment, within 8 working weeks.The communication will state the location and process foreseen for the external assessment, which differs between health professionals, training institutions and service providers.

The external assessment process will be designed and specified by the Accreditation Committees within the first 12 working days of their appointments, with logistic and administrative support and collaboration by the NHPC.

10.3DECISION The conclusion and decision of the Accreditation Committee will be communicated to the NHPC Accreditation Unit in writing, following a specific format, within two working days after the assessment is completed.



The Accreditation Unit will communicate the decision, following the format, and after re-verifying that the procedure was followed, to the applicant within two working days after receipt of the Committee’s decision.Simultaneously, within NHPC, the file of the applicant will be handed to the Licensing Unit to process licensing and archiving.

Until end October 2009 the NHPC WG will design templates for the Accreditation Committees’ invitations of applicants, a template for the reports and the letter of outcome to the applicant.

10.4LICENSING

According to the NHPC concept April 2009. The offices of NHPC proceed and offer the ward of licensing upon meeting criteria.Applicants will be assessed in order for eligibility for licensing criteria. The Licensing Unit will issue the license to the applicant within two working days, after re-verifying that all fees were paid, and archive the file.

During the first quarter of its operation the NHPC will design and establish a safe, robust and easy to use archiving system.

10.5REGISTRATION

As stated above, only those applicants or applying institutions that are accredited and receive a license will enter the registration system. This is the last step in the process.

During the first quarter of its operation the NHPC will design and establish a safe, robust and easy to use archiving system.

FIGURE 3: SEQUENCE AND FLOWSequence and flow

Applicant NHPC

sends application

LU

prepares and hands over file

AU

prepares and hands over file

AC sends invitation with date of assessment



self assessment and self assessment formsends self

assessment AC meets AC assessment

decision

prepares report and hands over file

LU

issue licence

prepares and hands over file to

RU enters data to register archives file

LU Licensing Unit AU Accreditation UnitAC Accreditation CommitteeRU Register Unit



11 APPEAL FOR DISPUTED ASSESSMENTS

Decisions of the accreditation and licensing should have options to be appealed again because erroneous decisions might be biased. Errors can occur and unfavourable decisions are rather accepted through convincing and removal of possible biases than only through and authoritative decisions, even if the decision is correct.

11.1PROCEDURE The decision of the Accreditation Committee can be appealed by submitting a letter, stating the reasoning of the appeal, within two weeks after receipt of the Committee’s decision. The letter has to be addressed to the NHPC licensing unit with copy to the chair of the board of the NHPC.An Appeal Committee will review the process and the conclusion of the Accreditation Committee within 12 working days calendar days after receipt of the appeal, and will invite the applicant for the opportunity to reason the appeal in person within 12 working days after submission of the invitation.The Appeal Committee might seek advice from the legal advisor to the NHPC Board if deemed necessary.The Appeal Committee cannot overturn the decision of the Accreditation Committee, but can decide to forward the appeal to the Accreditation Committee for a review with either

to revisit and change of the decision with justification of the alterations, or

provision of the a sounder foundation of the decision, or invite the applicant to re-take all or part of the assessment process.

The Accreditation Committee has to communicate to the applicant on the further process within six working days. In any case the Accreditation Committee and the Appeal Committee have to reach a joint decision within four working weeks. If the Committees fail to do so, the case shall be presented and discussed in the NHPC board with the spokes persons of both committees and the final decision made within four working weeks after the board being presented with the case (receipt of the file).

11.2APPEAL COMMITTEE

The Appeal Committee will be constituted of three of four members to be appointed by the NHPC.For disputes by health professionals and Teaching Institutes/school and continuous education: the members of the Appeal Committee are the



highest representative of the respective cadres/category in respect to their education (e.g. the Dean of the medical faculty for the physicians), to their professional representation (e.g. Chair of the SMA) and the Head of Human Resources in MoHL. Until the other health professionals are well organised and can represent themselves, the Chair of the SMA or the executive director of the SLNMA will fulfil this role in the Appeal Committee also for the other health professions. In case the decision is disputed by a health care provider, the Head (for doctors) or Matron (for nurses) of the Teaching Hospital, the Head of the Health Services in MoHL and both, the Chair of SMA and the Executive Director of the SLNMA will form the Appeal Committee.

The Terms of Reference for the Appeal Committee have to be drafted by the NHPC WG, agreed by the NHPC (Re-)establishment Steering Committee and key stakeholders, and finalised by end October 09.

11.3COUNSELLING

Since accreditation and licensing will be newly introduced in the country it might happen that unfavourable decisions with consequences on the professional life of individuals occur. In such cases NHPC will offer counselling and (non financial) support in the search of alternative paths of life. Naturally no promises can be made for satisfying solutions, but an effort will made not to let affected persons feel being dropped without at least the attempt to assist, although those identified as cheating or forging will not be able to receive much attention.

12 ACCREDITATION, LICENSING AND REGISTRATION TOOLS

The terms “tools” refers in this context to all forms, templates, IT software required for a standardised and systematic process of assessment, accrediting, licensing, registration and the involved communication.

The completion of these tools has to be completed for module 1 before the operationalisation of the NHPC commences – see annexes. Those for module 2 and 3 will be designed and established over time, but not later than the start of the work on the modules – see annexes.



13 ACCOMPANYING MECHANISMS

13.1CAPACITY BUILDING OF NHPC ACCREDITATION UNIT

Since a functional NHPC and its responsibilities are new to the country, its professionals and the population, it can be assumed the staff to be recruited, the Executive Director and possibly the Board might benefit from technical and/or managerial support and advice.

The specifics of such capacity building, in addition to a thorough briefing on NHPC, can be identified and planned for after the recruitment is completed and a detailed needs assessment of the NHPC and its Board is conducted. Therefore its inclusion in the first year’s work-plan and budget has to be generously estimated when budget requirements have to be calculated before the needs are assessed.

13.2SITE VISITS OF NHPC STAFF AND COMMITTEE MEMBERS Site visits to other countries’ Councils, especially South Africa or Rwanda, were foreseen already for the NHPC WG and SA. So far funds did not permit to conduct these visits.

Following the above, such site visits need to be planned for the NHPC staff, the Board and possibly the Committees.

13.3ESTABLISHMENT OF FEE COLLECTION SYSTEM

The payment mechanism and the management of the collected fees will be elaborated in the NHPC office organisational manual and the NHPC finance management system before the end of the year.



14 ANNEX:

14.1STANDARDS (ST) HEALTH PROFESSIONALS FORMS ST 1X

14.1.1 NURSES (N) – FORM ST 1.1./N/09 To be completed until end October 2009 (due to expected

delays during the Ramadam period end August – end September, the upcoming political campaign and elections).

14.1.2 AUXILIARY NURSES(AN) - FORM ST 1.2./AN/09 To be completed until end October 2009 (due to expected


14.1.3 MIDWIFES (M) - FORM ST 1.3./M/09 To be completed until end October 2009 (due to expected


14.1.4 AUXILIARY MIDWIFES (AM) - FORM ST 1.4./AM/09 To be completed until end October 2009 (due to expected


14.1.5 GENERAL PRACTITIONER (GP)- FORM ST 1.5./GP/09 To be completed until end October 2009 (due to expected


14.1.6 INTERNAL MEDICINE (IM) - FORM ST 1.6./IM/09 To be completed until end October 2009 (due to expected




14.1.7 OPHTHALMOLOGIST (OP) - FORM ST 1.7./OP/09 To be completed until end October 2009 (due to expected


14.1.8 SURGEON (SU) - FORM ST 1.8./SU/09 To be completed until end October 2009 (due to expected


14.1.9 TO BE COMPLETED (OTHERS - FORM AC/ST/PH/XX/09 To be completed until end October 2009 (due to expected


14.1.10 PHARMACISTS (PH) - FORM ST 1.9./PH/09 To be completed until end October 2009 (due to expected


14.1.11 LABORATORY TECHNICIANS (LT) - FORM ST 1.10./LT/09 Those for module 2 and 3 will be designed and established

over time, but not later than the start of the work on the modules.

14.1.12 LABORATORY TECHNICIANS/MICROSCOPISTS (MI) - FORM ST 1.11./LT/MI/09 Those for module 2 and 3 will be designed and established


14.1.13 OTHER CADRES WORKING IN SOMALILAND - FORM AC/ST/XX/09 Those for module 2 and 3 will be designed and established




14.1.14 TO BE COMPLETED (OTHERS - FORM AC/ST/PH/XX/09 Those for module 2 and 3 will be designed and established




14.2STANDARDS (ST) HEALTH SERVICE DELIVERY FACILITIES (HF) FORMS ST 2X

14.2.1 HEALTH POST - FORM ST 2.1./HP/09 To be completed until end October 2009 (due to expected


14.2.2 HEALTH CENTRE - FORM ST 2.2./HC/09 To be completed until end October 2009 (due to expected


14.2.3 MOTHER AND CHILD HEALTH CENTRES (MCHS) – FORM ST 2.3./MCH/09 To be completed until end October 2009 (due to expected


14.2.4 CLINICS - FORM ST 2.4./CL/09 To be completed until end October 2009 (due to expected


14.2.5 SECONDARY LEVEL, PUBLIC AND PRIVATE - FORM ST 2.5./SL/09

Those for module 2 and 3 will be designed and established over time, but not later than the start of the work on the modules.

14.2.6 TERTIARY LEVEL, PUBLIC AND PRIVATE - FORM ST 2.6./TL/09 Those for module 2 and 3 will be designed and established




14.3STANDARDS (ST) • BASIC AND CONTINUOUS MEDICAL/HEALTH EDUCATION AND TRAININGS (HT) FORMS ST 3X

14.3.1 NURSING SCHOOLS; PUBLIC AND PRIVATE - FORM ST 3.1/NS/09 To be completed until end October 2009 (due to expected


14.3.2 MIDWIFERY SCHOOLS ; PUBLIC AND PRIVATE FORM ST 3.1/MS/09 To be completed until end October 2009 (due to expected


14.3.3 MEDICAL SCHOOLS ; PUBLIC AND PRIVATEFORM ST 3.1/MDS/09


14.3.4 OTHER INSTITUTIONS/SCHOOLS; PUBLIC AND PRIVATE - FORM ST 3.1/IN/09


14.3.5 TUTORS - FORM ST 3.2./TU/09 Those for module 2 and 3 will be designed and established


14.3.6 CURRICULUM FOR BASIC NURSING EDUCATION - FORM ST 3.3/BNE/09

To be completed until end October 2009 (due to expected delays during the Ramadam period end August – end September, the upcoming political campaign and elections).



14.3.7 CURRICULUM FOR BASIC MIDWIFERY EDUCATION - FORM ST 3.3/BME/09 To be completed until end October 2009 (due to expected


14.3.8 CURRICULUM FOR CONTINUOUS MEDICAL/HEALTH EDUCATION – FORM ST 3.4./CE/09 To be completed until end October 2009 (due to expected


14.3.9 EXAMINATION PROCESS - FORM ST 3.5/EM/09 Those for module 2 and 3 will be designed and established




14.3.10 “TRADITIONAL HEALTH SYSTEM” IN SOMALILAND - FORUM ST 3.10./TM/09 To be completed during second phase, not later than the start

of the work on the third module.



14.4ACCREDITATION PROCEDURE (AP) FORMS AP 4X

14.4.1 LIST OF INDIVIDUALS WHO PROVIDE HEALTH SERVICES - FORM AP 4.1./HPR/09

To be completed until end October 2009 (due to expected delays during the Ramadam period end August – end September, the upcoming political campaign and elections), if reliable secondary data are existing.

To be completed through a survey during the first quarter of NHPC.

14.4.2 LIST OF PUBLIC AND PRIVATE FACILITIES FORM AP 4.2./HF/09

To be completed during survey in the first quarter of NHPC, unless reliable secondary data are existing.

To be completed through a survey during the first quarter of NHPC.

14.4.3 LIST OF TRAINING PROVIDERS IN HEALTH - FORM AP 4.3./HF/09 To be completed during survey in the first quarter during first

quarter of NHPC unless reliable secondary data are existing.



14.5SELECTION ACCREDITATION (SUB)COMMITTEES ((S)AC) FORMS AC 6X

14.5.1 SELECTION ACCREDITATION COMMITTEES (AC) NURSES- FORM AC 5.1./N/09 To be completed until end October 2009 (due to expected


14.5.2 SELECTION ACCREDITATION COMMITTEE (AC) MIDWIFES (M) –

FORM AC 5.2./M/09 To be completed until end October 2009 (due to expected


14.5.3 SELECTION ACCREDITATION SUBCOMMITTEE (AC) GENERAL PRACTITIONER (GP) –

FORM ASC 5.3./GP/09 To be completed until end October 2009 (due to expected


14.5.4 SELECTION ACCREDITATION SUBCOMMITTEE (ASC) SPECIALISED PHYSICIANS –

FORM ASC 5.4./SP/09 Those for module 2 and 3 will be designed and established


14.5.5 SELECTION ACCREDITATION SUBCOMMITTEE (ASC) • BASIC AND CONTINUOUS MEDICAL/HEALTH EDUCATION/TRAININGS - NURSES - FORM ASC 5.5./HT/N/09 To be completed until end October 2009 (due to expected


14.5.6 SELECTION ACCREDITATION SUBCOMMITTEE (ASC) BASIC AND CONTINUOUS MEDICAL/HEALTH EDUCATION/TRAININGS - MIDWIFES - FORM ASC 5.6./HT/M/09 To be completed until end October 2009 (due to expected




14.5.7 SELECTION ACCREDITATION SUBCOMMITTEE (ASC) BASIC AND CONTINUOUS MEDICAL/HEALTH EDUCATION/TRAININGS – PHYSIC. - FORM ASC 5.7./HT/PH/09 To be completed until end October 2009 (due to expected


14.5.8 SELECTION ACCREDITATION SUBCOMMITTEE (ASC) BASIC AND CONTINUOUS MEDICAL/HEALTH EDUCATION/TRAININGS – PHARM. - FORM ASC 5.8./HT/PH/09 To be completed until end October 2009 (due to expected


14.5.9 SELECTION ACCREDITATION SUBCOMMITTEE (ASC) BASIC AND CONTINUOUS MEDICAL/HEALTH EDUCATION/TRAININGS - LABORATORY TECHNICIANS –

FORM ASC 5.9./HT/LT/09 Those for module 2 and 3 will be designed and established


14.5.10 SELECTION ACCREDITATION SUBCOMMITTEE (ASC) BASIC AND CONTINUOUS MEDICAL/HEALTH EDUCATION/TRAININGS - OTHER CADRES – TO BE SPECIFIED –

FORM ASC 5..XX./HT/XX/09 Those for module 2 and 3 will be designed and established


14.5.11 SELECTION ACCREDITATION COMMITTEE APPEAL – FORM ASC 5.11./APP/09 Those for module 2 and 3 will be designed and established




14.6ASSESSMENT TOOLS (AT) HEALTH PROFESSIONALS Generic format to be completed until end October 2009 (due

to expected delays during the Ramadam period end August – end September, the upcoming political campaign and elections).

Specific tool to be completed by the Accreditation Committees



14.6.1 ASSESSMENT TOOL (AT) – NURSES/SELF ASSESSMENT (SE) – FORM

AT 6.1. /N/SE/09

14.6.2 ASSESSMENT TOOL (AT) – NURSES/EXTERNAL ASSESSMENT (EE) – FORM AT 6.2./N/EE/09

14.6.3 ASSESSMENT TOOL (AT) – AUXILIARY NURSE /SELF ASSESSMENT (SE) –

FORM AT 6.3./AN/SE/09

14.6.4 ASSESSMENT TOOL (AT) – AUXILIARY NURSES/EXTERNAL ASSESSMENT (EE) –

FORM AT 6.4./AN/EE/09

14.6.5 ASSESSMENT TOOL (AT) –MIDWIFE/SELF ASSESSMENT (SE) – FORM

AT 6.5./M/SE/09

14.6.6 ASSESSMENT TOOL (AT) – AUXILIARY MIDWIFE/EXTERNAL ASSESSMENT (EE) – FORM AT 6.6./AM/EE/09

14.6.7 ASSESSMENT TOOL (AT) – LABORATORY TECHNICIAN/SELF ASSESSMENT (SE) – FORM AT 6.7./LT/SE/09

14.6.8 ASSESSMENT TOOL (AT) – LABORATORY TECHNICIAN/EXTERNAL ASSESSMENT (EE) -

FORM AT 6.8./LT/EE/09

14.6.9 ASSESSMENT TOOL (AT) – PHARMACISTS/SELF ASSESSMENT (SE) – FORM AT 6.9./PH/SE/09

14.6.10 ASSESSMENT TOOL (AT) – PHARMACISTS/EXTERNAL ASSESSMENT (EE) –

FORM AT 6.10./PH/EE/09

14.6.11 ASSESSMENT TOOL (AT) – GENERAL PRACTITIONER/SELF ASSESSMENT (SE) –

FORM AT 6.11./GP/SE/09

14.6.12 ASSESSMENT TOOL (AT) – GENERAL PRACTITIONER/EXTERNAL ASSESSMENT (EE) - FORM AT 6.12./GP/EE/09

14.6.13 ASSESSMENT TOOL (AT) – OPHTHALMOLOGIST/SELF ASSESSMENT (SE) –

FORM AT 6.13./OP/SE/09STATUS AS OF 03 AUGUST 2009 AND TASKS FOR THE FURTHER DEVELOPMENT

52


14.6.14 ASSESSMENT TOOL (AT) – OPHTHALMOLOGIST/EXTERNAL ASSESSMENT (EE) – FORM AT 6.14./OP/EE/09



14.6.15 ASSESSMENT TOOL (AT) – INTERNAL MEDICINE/SELF ASSESSMENT (SE) –

FORM AT 6.15./SE/09

14.6.16 ASSESSMENT TOOL (AT) – INTERNAL MEDICINE/EXTERNAL ASSESSMENT (EE) – FORM AT 6.16./IM/EE/09

14.6.17 ASSESSMENT TOOL (AT) – SURGEON/SELF ASSESSMENT (SE) – FORM

AT 6.17./SU/SE/09

14.6.18 ASSESSMENT TOOL (AT) – SURGEON/EXTERNAL ASSESSMENT (EE) – FORM AT 6.18./SU/EE/09

14.6.19 ASSESSMENT TOOL (AT) – OTHERS – TO BE EXTENDED – FORM

AT 6.XX/XX/09



14.7ASSESSMENT TOOL (AT) HEALTH SERVICE PROVIDERS

Generic format to be completed until end October 2009 (due to expected delays during the Ramadam period end August – end September, the upcoming political campaign and elections).




14.7.1 ASSESSMENT TOOL (AT) – HEALTH POST/SELF ASSESSMENT (SE) – FORM AT 7.1./HP/SE/09

14.7.2 ASSESSMENT TOOL (AT) – HEALTH POST/EXTERNAL ASSESSMENT (EE) –

FORM AT 7.2./HP/EE/09

14.7.3 ASSESSMENT TOOL (AT) – HEALTH CENTRE/SELF ASSESSMENT (SE) – FORM AT 7.3./HC/SE/09

14.7.4 ASSESSMENT TOOL (AT) – HEALTH CENTRE/EXTERNAL ASSESSMENT (EE) –

FORM AT 7.4./HC/EE/09

14.7.5 ASSESSMENT TOOL (AT) – MOTHER AND CHILD HEALTH CENTRE/SELF ASSESSMENT (SE) - FORM AT 7.5./MCH/SE/09

14.7.6 ASSESSMENT TOOL (AT) – MOTHER AND CHILD HEALTH CENTRE/EXTERNAL ASSESSMENT (EE) -

FORM AT 7.6./MCH/EE/09

14.7.7 ASSESSMENT TOOL (AT) – CLINIC/SELF ASSESSMENT (SE) – FORM

AT 7.7./AT/CL/SE/09

14.7.8 ASSESSMENT TOOL (AT) – CLINIC/EXTERNAL ASSESSMENT (EE) – FORM AT 7.8./CL/EE/09

14.7.9 ASSESSMENT TOOL (AT) – SECONDARY LEVEL HOSPITAL (SLH)/SELF ASSESSMENT (SE) -

FORM AT 7.9./SLH/SE/09

14.7.10 ASSESSMENT TOOL (AT) – SECONDARY LEVEL HOSPITAL (SLH)/EXTERNAL ASSESSMENT (EE) - FORM AT 7.10./SLH/EE/09

14.7.11 ASSESSMENT TOOL (AT) – TERTIARY LEVEL HOSPITAL (TLH)/SELF ASSESSMENT (SE) -

FORM AT 7.11./TLH/SE/09

14.7.12 ASSESSMENT TOOL (AT) – TERTIARY LEVEL HOSPITAL (TLH)/EXTERNAL ASSESSMENT (EE) - FORM AT 7.12./TLH/EE/09

14.7.13 ASSESSMENT TOOL (AT) – PHARMACY/SELF ASSESSMENT (SE) – FORM AT 7.13./PHA/SE/09



14.7.14 ASSESSMENT TOOL (AT) – PHARMACY/EXTERNAL ASSESSMENT (EE) – FORM AT 7.14./PHA/EE/09

14.7.15 ASSESSMENT TOOL (AT) – LABORATORY/SELF ASSESSMENT (SE) – FORM AT 7.15./AT/LAB/SE/09

14.7.16 ASSESSMENT TOOL (AT) – LABORATORY/EXTERNAL ASSESSMENT (EE) –

FORM AT 7.16./LAB/EE/09



14.8ASSESSMENT TOOL (AT) BASIC AND CONTINUOUS MEDICAL/HEALTH EDUCATION AND TRAININGS Generic format to be completed until end October 2009 (due



14.8.1 ASSESSMENT TOOLS (AT) – INSTITUTIONS/SCHOOLS/SELF ASSESSMENT (SE) –

FORM AT 8.1. /INS/SE/09

14.8.2 ASSESSMENT TOOLS (AT) – INSTITUTIONS/SCHOOLS/EXTERNAL ASSESSMENT (EE) - FORM AT 8.2./INS/EE/09

14.8.3 ASSESSMENT TOOLS (AT) TUTORS - SELF ASSESSMENT (SE) – FORM

AT 8.3./TU/SE/09

14.8.4 ASSESSMENT TOOLS (AT) – TUTORS/EXTERNAL ASSESSMENT (EE) – FORM AT 8.4./TU/EE/09

14.8.5 ASSESSMENT TOOLS (AT) CURRICULUM FOR BASIC EDUCATION IN HEALTH - SELF ASSESSMENT (SE) -

FORM AT 8.5./CU-BE/SE/09

14.8.6 ASSESSMENT TOOLS (AT) – CURRICULUM FOR BASIC EDUCATION IN HEALTH/EXTERNAL ASSESSMENT (EE) - FORM AT 8.6./CU-BE/EE/09

14.8.7 ASSESSMENT TOOLS (AT) CURRICULUM FOR CONTINUOUS EDUCATION IN HEALTH - SELF ASSESSMENT (SE) -

FORM AY 8.7./CU-CE/SE/09

14.8.8 ASSESSMENT TOOLS (AT) – CURRICULUM FOR CONTINUOUS EDUCATION/EXTERNAL ASSESSMENT (EE) - FORM Y 8.8./CU-CE/EE/09

14.8.9 ASSESSMENT TOOLS (AT) EXAMINATION PROCESS - FORM AT 8.9./EM/09



14.9ASSESSMENT REPORTING TEMPLATE - TEMPLATE /REP/09 Generic format to be completed until end October 2009 (due





14.10 LICENSING FORMS PROCESS - FORM LI 10./PR/09 To be completed until end October 2009 (due to expected


14.11 REGISTRATION FORMS PROCESS - FORM RE 11./PR/09 To be completed until end October 2009 (due to expected


14.12 RE-ASSESSMENT FORM PROCESS - FORM RA 12./PR/09 To be completed until end October 2009 (due to expected


14.13 APPEAL (AP) 14.13.1 APPEAL FORM - FORM AP

13.1./FO/09 To be completed until end October 2009 (due to expected


14.13.2 APPEAL PROTOCOL FORM - FORM AP 13.2./PR/09 To be completed until end October 2009 (due to expected


14.14 FEE COLLECTION FORM PROCESS - FORM FE 14./09 To be completed until end October 2009 (due to expected



Development of NHPC Accreditation and Licensing System Status 09 08 03

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