Health care managers’ perspectives on workforce licensing practice in Ethiopia: A qualitative study
Authors: Teka Eshetu Cherinet , Gebreyes Meron Yakob , Alemneh Endalkachew Tsedal , Tesfaye Biruk Hailu , Desta Firew Ayalew , Asemu Yohannes Molla , Wolde Ermias Gebreyohannes , Ashena Wondimu Daniel , Mengistu Samuel , Melese Tewodros Abebaw , Biset Fikadie Dagnew , Degefu Bezawit Worku , Kebede Bethlehem Bizuayehu , Azeze Tangut Dagnew , Shewatatek Wudasie Teshome , Seboka Melese Achamo , Gebreegzi Abera Bezabih , Degebasa Mekonnen Desie , Lemu Tsedale Tafesse , Abebe Yeshiwork Eshetu , Alayu Matias Azanaw , Ebrahim Fatuma Ahmed , Sahlemariam Eden Workneh , woldesemayat Genet Kifle , Admassu Hailemaryam Balcha , Chekol Bethlehem Shikabaw 
Published: April 2024

Background
Professional licensing bodies are valuable sources for tracking the health workforce, as many skilled health-care providers require formal training, registration, and licensure. Regulatory activities in Ethiopia were not effectively implemented due to poor follow-up and gaps in skilled human resources, budget, and information technology infrastructure.

Objective
The aim of this study was to explore and describe the lived experiences and challenges faced by health care managers in health professionals’ licensure practices in Ethiopia.

Methods
A cross-sectional study design with a phenomenological approach was employed between March 26 and April 30, 2021, to collect qualitative data. We conducted in-depth interviews with a total of 32 purposively selected health system managers. An interview guide was prepared in English, translated into Amharic, and then pretested. Audio recorded data was transcribed verbatim, translated, and analysed manually by themes and sub-themes. A member check was done to check the credibility of the result.

Results
The data revealed four major themes: awareness of licensing practices, enforcement of licensing practices, systems for assuring the quality of licensing practices, and challenges to licensing practices. Lack of awareness among managers about health workforce licensing was reported, especially at lower-level employers. Regulators were clear on the requirements to issue a licence to the health workforce if they are competent in the licensing exam, while human resource managers do not emphasise whether the employees have a licence or not during employment. As a result of this, non-licenced health workers were employed. Health care managers mentioned that they did not know any monitoring tools to solve the issue of working without a licence. Fraudulent academic credentials, shortage of resources (human resources, finance, equipment, and supplies), and weak follow-up and coordination systems were identified as main practice challenges.

Conclusions
This study reported a suboptimal health professionals’ licensing practice in Ethiopia, which is against the laws and proclamations of the country that state to employ all health workers only with professional licenses. Challenges for health professionals’ licensing practice were identified as fraudulent academic credentials, a shortage of resources (HR, finance, equipment, and supplies), and a weak follow-up and coordination system. Further awareness of licensing practices should be created, especially for lower-level employers. Regulators shall establish a reliable digital system to consistently assure the quality of licensing practices. Health care managers must implement mechanisms to regularly monitor the licensing status of their employees and ensure that government requirements are met. Collaboration and regular communication between regulators and employers can improve quality practices.