Regulation of the global orthotist/prosthetist workforce, and what we might learn from allied health professions with international-level regulatory support: a narrative review

In the absence of international agreement on the definition of ‘core’ practitioner regulatory standards, the standards defined by the Australian Health Practitioner Regulation Agency (AHPRA) [22] were used. AHPRA is the body responsible for Government regulation of medical and allied health professions in Australia and is recognised as a leading health workforce regulator by the WHO Collaborating Centre [15, 23].

There are 11 standards applied to the AHPRA regulated professions that are defined through legislation [24] and profession-specific registration requirements [25]. Of the 11 standards, 9 were included in the core standards (Table 1). Criminal history declarations and professional indemnity insurance were excluded given their setting-specific nature [22].

For the purpose of this environmental scan, the following definitions were applied:

To help ensure that global efforts to regulate the orthotist/prosthetist profession were captured, these definitions were applied in two search strategies executed in June 2019. First, the Health Regulation Worldwide database [27] was searched to identify countries with a listed orthotic/prosthetic national association and/or regulator, using the database’s pre-defined search term for the profession, ‘Prosthetists & Orthotists’. Secondly, recognising that some orthotic/prosthetic national associations may be emerging (i.e. informal and/or still in their infancy) and therefore not recorded on the Health Regulation Worldwide database, additional searches using Google and social media sites were conducted for all countries not identified in the first search. The search strategy used country name in combination with the following terms and their synonyms:

Countries were included where the national association and/or regulator had publicly available information in English and was considered to be active based on web content, active social media, or responded to an email request for clarification. Where no national association and/or regulator was identified, no further investigation was conducted, such as investigation of system or organisational-level credentialing programmes. For all countries meeting the inclusion criteria, an environmental scan was conducted to determine the extent to which the orthotist/prosthetist profession was regulated. This included searching for the presence of the nine core standards in all publicly available information by one investigator (LP) with review by a second investigator (LC), or a request for clarification by email.

Given that Low- and Lower-Middle- Income Countries [28, 29] often lack the resources needed to establish professional regulation [16, 18], each identified country was categorised by income status (i.e. High-, Upper-Middle-, Lower-Middle-, and Low-Income countries) according to the World Bank classification [30, 31]. Therefore, the following data were extracted: country, name of association and/or government regulator, income status, model of existing regulation (i.e. self- or government-regulated), and whether each core standard was ‘present’ or ‘not present’.

For the purpose of this environmental scan the following definitions were applied:

To ensure that international-level professional bodies providing regulatory support to allied health professions were captured, these definitions were applied in two search strategies executed in June 2019. First, the Health Regulation Worldwide database [27] was searched to identify allied health profession with a listed international-level professional body. Recognising that some professions may have emerging international bodies, a second search using Google was conducted for all allied health professions that were not identified in the first search. This search used profession name (e.g., physiotherapy) combined with the following search terms and their synonyms:

For each identified international professional body, an environmental scan of publicly available information, published in English, was conducted. The following data were extracted by one investigator (LC): organisation name, number of member organisations (i.e. national associations), whether support was provided for each core standard (defined as ‘in place’ or ‘absent’).

Data from Part 1 described the number of countries with orthotist/prosthetist regulation, and the extent to which national-level regulation occurred. Data from Part 2 described the number of allied health professions with an international-level professional body, and the extent to which the body provided regulatory support to its member associations. Names of countries and national associations were de-identified given the aim was to provide a summary of global orthotist/prosthetist regulation, rather than rank countries based on implementation of the core standards.

The majority of countries had adopted a self-regulation model for orthotist/prosthetists (n = 20; 67%). Nine countries had government regulation of orthotist/prosthetists. One country had both regulatory models in place whereby specific states/regions had a government regulator (Fig. 1).

Of the 6 countries with all core standards in place, three employed a self-regulatory model overseen by a national association. Australia is one of these countries where orthotist/prosthetists are self-regulated by AOPA.

AOPA was first established in 1975. It was not until 2013 that the process to establish self-regulation of orthotist/prosthetists began; a process that took 5 years to implement all nine core standards.

The experience of implementing self-regulation of the orthotic/prosthetic profession in Australia was not without its challenges. Given the small membership (about 270 members in 2013), AOPA had limited financial resources and a lack of expertise in practitioner regulation. Fortunately, AOPA was successful in applying for government grants that allowed the employment of staff to develop the first core standards: AOPA’s Entry-level Competency Standards [35, 36], Course Accreditation Standards [37] and the associated Entry-to-Practice assessment processes. AOPA also received support from the National Alliance of Self-Regulating Health Professions (NASRHP), a peak organisation that supports self-regulation of the non-Government regulated allied health professions in Australia, including: speech pathology, dietetics, social work, and orthotics/prosthetics, as examples [38]. NASHRP promotes peer-to-peer mentoring between associations, which allowed shared learning from our allied health counterparts. It would not have been possible for AOPA to achieve full self-regulation without the support from government grants and NASRHP.

Many benefits were observed as a result of establishing regulation of orthotist/prosthetists in Australia. First, funding bodies including the Australian Department of Veterans’ Affairs and private health insurers had increased confidence in the profession, given regulated practitioners now met the required core standards. This resulted in greater recognition of orthotist/prosthetists [39] and subsequent changes to funding policies; for example, orthotist/prosthetists were allowed to deliver autonomous services without medical oversight which streamlined access to funded services for users. Second, establishing regulation of orthotist/prosthetists in Australia resulted in Government policy change that assisted workforce growth by facilitating entry to the profession of experienced internationally qualified orthotist/prosthetists. For example, in 2017 the Australian Government Department of Immigration reviewed the orthotist/prosthetist workforce profile and identified a critical workforce shortage. The orthotist/prosthetist profession was added to the Department of Immigration’s Skilled Occupations List [40], thereby permitting skilled migration of internationally qualified orthotist/prosthetists, subject to meeting the core Entry-to-Practice standards, with AOPA legislated as the assessing authority [40].

AOPA received regulatory support in the form of expertise and resources from NASRHP; a body with the express purpose to support self-regulation of the non-government regulated allied health professions in Australia. Bodies providing similar regulatory support at an international level are already in place across nearly two-thirds of all allied health professions. A benefit of offering regulatory support, rather than regulation oversight, is that this allows each country to implement a regulation framework appropriate to the local setting [13, 41], without being unnecessarily burdensome [19] or creating barriers that limit access [13, 16]. An early indication of the potential impact of such regulatory support is evident in the results of this study; the most common core standard implemented for orthotist/prosthetists was Course Accreditation which has been supported through the ISPO Accreditation Pathway [42] and endorsed by the WHO through published orthotic/prosthetic practice standards [2].

The WCPT provides an example of an international professional body providing comprehensive regulatory support to its 120 member associations, across 8 of the nine core standards. The WCPT clearly defines the role that national practitioner regulation plays in building confidence in the profession and ensuring the delivery of safe and effective services:

“WCPT encourages member organisations to work towards a system of regulation that focuses on the public interest. Such a system will promote trust and confidence in the profession” [43]

“. . . in some countries, the profession is regulated by physical therapists meeting membership criteria for the professional organisation . . . In many cases, effective regulation can be achieved by embedding standards of professional education, performance, conduct and competence within the system of regulation. These standards, together with mechanisms to monitor and foster practitioner compliance and manage non-compliance, provide the means by which the profession can protect the public interest [43].”

Other international professional bodies demonstrate the value of regulatory support through formal mentoring programmes to support countries with emerging regulation. For example, the International Federation of Social Workers has a mentor programme, known as “twinning” [44, 45] where a mature national association with well-developed regulation provides support to an emerging national association [46].

“The Moroccan association AMAS (Association Marocaine des Assistants et Assistantes Sociales) is still young, just like social work education in Morocco . . . Now both social work associations have decided to start twinning; to inspire each other. The still young association can be supported from the Netherlands, and Dutch social workers can learn from work in different circumstances and how to set up initiatives were [sic] governmental support is lacking or only providing a part of what is needed [45].”

The barriers to self-regulation experienced in Australia are likely universal, though exacerbated for those in Lower-Middle- and Low-Income countries due to the relative immaturity of health services and poor recognition of orthotist/prosthetists [2, 47]. The results suggest that Lower-Middle- and Low-Income countries had fewer standards in place than High- and Upper-Middle- Income countries and as such, these countries would particularly benefit from regulatory support provided by an international-level professional body.