Cambodia
As a result of the country’s civil war and genocide, the 1990s revealed a critical shortage of health workers in administration, education, and clinical settings in Cambodia [
11]. Since then, political stability and an enabling policy environment have stimulated economic growth. In 1999, the country joined ASEAN.
Given its youthful population, health and education had become key development priorities [
12]. Education was also identified as offering opportunities for investment; the number of private nursing institutions increased from one in 2003 to 12 by 2016. Only six of these institutions were under the control of the Cambodian Ministry of Health (CMOH) [
13]. In 2000, the CMOH was the main stakeholder for regulating the quality of health professionals and services, and all eight functions were minimally developed (Stage 0). The accreditation of preservice education (Function 2) and competency assessment (Function 3) were significant concerns.
Growing concerns regarding the competency of health workers resulted in the adoption of the Royal Decree on Accreditation of Higher Education in 2003. This decree was followed by Sub-Decree 21 on Health Education in 2007, which stipulated conditions and criteria for the accreditation of educational institutions for health professionals in public and private sectors and the establishment of national entrance and exit examinations for higher education. The standard nursing curriculum was developed as a 3-year Associate Degree of Nursing (ADN) and 4-year Bachelor of Science in Nursing (BSN) in 2007 and 2008, respectively. The curricula outlined minimum standards, including admission requirements, study duration, and educational content (Stage 1). Based on these standards, since 2008, the CMOH has authorized the educational programs of each school (Stage 2). The Accreditation Committee of Cambodia, the authority accrediting all higher education institutions, comprises relevant departments of the CMOH and Ministry of Education, Youth and Sport. It issued nine minimum quality standards for the accreditation of higher education. These standards, however, do not cover important aspects of clinical education and training, such as teacher to student ratio [
14]. In 2017, regular audits of the schools and educational programs were still not undertaken on a consistent basis.
Regarding Function 3, the Core Competency Framework for New BSN Graduates was developed in 2012 to guide preparations for the National Exit Examination (Stage 1), which started in 2013 and governed the quality of education in the public and private sectors (Stage 2). By 2016, the CMOH started National Entrance and Exit Exams for all bachelors and associate degrees in all 16 health professional disciplines. The examination was not yet used as the basis for registration and licensure in 2017 (Stage 3).
In 2007, the Cambodian Council of Nurses (CCN) was established by Royal Decree. This Decree required that nurses be registered to practice (Stage 1 in Function 4) and was implemented in the public sector in 2008 (Stage 2 in Function 4). Despite the commencement of registration, the number of registered nurses did not increase as expected. The CCN could not take on all expected regulatory functions due to limited capacity. The CMOH is responsible for the accreditation of preservice education and competency assessment. Both CMOH and CCN utilized the limited availability of technical support from development partners to advance their capabilities. In 2003, CMOH issued the SOP for hospital nurses (Stage 1 in Function 6), defining task-based nursing activities following the French approach, but this SOP was not fully introduced in clinical settings. It was updated in 2015 (Stage 2) along USA professional lines [
15]. Although the updated SOP described all categories of nurses (i.e., primary nurse, ADN, and BSN), it is not fully aligned with either the curricula or the competency framework (Stage 3).
In 2016, an iatrogenic outbreak of human immunodeficiency virus (HIV) infection in a rural province created the political momentum to further strengthen the regulatory framework, resulting in the passage of the Law on Regulation for Health Practitioners [
16]. This was a breakthrough in accelerating regulatory framework developments (Stage 2 in Function 1), as it led to the adoption of comprehensive legislation for all health professionals in the same year (Stage 1 in Function 1) [
17,
18]. This Law on Regulation established registration and licensure and their renewal as mandatory requirements for all practicing health professionals including nurses (Stage 3, Function 4). Since the adoption of this Law on Regulation, the CCN has benefitted from a joint secretariat created to support the administrative functions of the five health professional councils.
The registration function has been strengthened, and by 2017, 68% of the nurses (predominantly working in the public sector) had been registered with CCN (Stage 3, Function 4) [
19]. However, registration is somewhat inefficient and is paper-based, with data from the provinces collected and sent to the national level (Stage 1, Function 5).
In the absence of a systematic approach, CPD opportunities continue to be ad hoc (Stage 0, Function 7) [
14,
19,
20]. By 2017, a framework for CPD was being developed in relation to the maintenance of the professional license to practice (Stage 2). The CCN is expected to monitor professional misconduct according to the Code of Ethics for Nurses, but was not fully functional by 2017 (Stage 1, Function 8).
Vietnam
In 1986, a policy of “renovation” (
Doi Moi) was introduced to overcome the economic problems of the 1980s. This policy led to dramatic social and economic changes, including in the health and education sectors [
21]. The country became an ASEAN member state in 1995 [
21].
In 1998, an Education Act was enacted that stipulated standards for all educational levels (primary, secondary, and tertiary) and types (general and vocational) under the responsibility of the Vietnamese Ministry of Education and Training (VMOET). The VMOET was able to accredit 2- and 3-year courses as of 2000 (Stage 2, Function 2).
With an emphasis on improvement of skilled health workers to drive economic growth, in 2005, the Law on Education was amended to strengthen the relationship between education and job categories and to encourage private funding and investment in the educational sector [
22]. The number of nursing schools increased from 70 in 2005 to 150 in 2015, including a growing number of private schools [
23]. Similar to Cambodia, concerns regarding the quality of training in the higher education system became evident with the rapid expansion of higher education institutions, particularly those in the private sector. Based on the Act amended in 2005, the VMOET issued a Circular defining the standard curricula for vocational education [i.e., secondary schools (2-year course) and colleges (3-year course)] in 2010 and higher nursing education [i.e., universities (four-year course)] in 2012. According to the Law on Education (amended in 2009) and the Law on Vocational Training (amended in 2014), two Ministries were involved in Function 2. University education is accredited by the VMOET, and education at secondary schools and colleges is accredited by the Vietnamese Ministry of Labor, Invalids and Social Affairs (VMOLISA). The VMOET and VMOLISA have been responsible for monitoring the implementation of standard requirements (Stage 3, Function 2). The Vietnamese Ministry of Health (VMOH) has been responsible for reviewing the content of educational curricula since 2000 and has established and monitored the CPD system.
With an intent to further improve quality and safety of health services, in 2009, the Law on Examination and Practice was drafted, stipulating the need for health professionals to be registered and licensed (Stage 2, Function 1). This law was implemented in 2011 (Stage 3, Function 1), and registration and licensing functions were consolidated in both public and private sectors (Stage 3 since 2011, Function 4). However, standard curricula and programs for clinical training are still not fully developed. The process for license renewal was also not defined in the Law on Examination and Practice. As of 2017, paper- and electronic-based registration systems were introduced, but comprehensive data were not available at the central level (Stage 2, Function 5).
In 2009, competency standards were drafted by the Vietnamese Nursing Association (VNA) and issued in 2012 by the VMOH. However, as of 2017, the competency standards were not fully reflected in educational programs of vocational and higher education and nursing practices performed at clinical sites (Stage 1, Function 3). A regulation on competency assessment was under discussion as of 2017.
Regarding Function 6, a Scope of Work and Salary Scale for All Public Nurse Categories existed in 2000 (Stage 1); it was revised and implemented in 2005 (Stage 3) and linked to the nurses’ salary scale. SOP was defined for all nurse categories based on educational curriculum, but actual SOP performed at clinical sites did not yet correspond to nurses’ categories as of 2017.
The CPD requirement is defined in the Education Act amended in 2005. In 2009, national CPD guidelines for health professionals were developed by the VMOH. CPD was provided at hospital levels [
24] but not completely linked to the licensure and registration process. Following the execution of the Law on Examination and Practice, in 2013, CPD guidelines were amended to make CPD an official requirement for licensure (Stage 1, Function 7). VMOH and VNA developed the code of ethics in 2012. The conditions for the revocation of the license are mentioned in the Law on Examination and Practice (Stage 1, Function 8) but have not been fully implemented.
As of 2017, all regulatory functions were managed by the VMOH, except for Function 2, which is under the VMOET and VMOLISA.