Health care managers’ perspectives on workforce licensing practice in Ethiopia: A qualitative study

Eshetu Cherinet Teka; Meron Yakob Gebreyes; Endalkachew Tsedal Alemneh; Biruk Hailu Tesfaye; Firew Ayalew Desta; Yohannes Molla Asemu; Ermias Gebreyohannes Wolde; Wondimu Daniel Ashena; Samuel Mengistu; Tewodros Abebaw Melese; Fikadie Dagnew Biset; Bezawit Worku Degefu; Bethlehem Bizuayehu Kebede; Tangut Dagnew Azeze; Wudasie Teshome Shewatatek; Melese Achamo Seboka; Abera Bezabih Gebreegzi; Mekonnen Desie Degebasa; Tsedale Tafesse Lemu; Yeshiwork Eshetu Abebe; Matias Azanaw Alayu; Fatuma Ahmed Ebrahim; Eden Workneh Sahlemariam; Genet Kifle woldesemayat; Hailemaryam Balcha Admassu; Bethlehem Shikabaw Chekol

doi:10.1371/journal.pone.0302122

. 2024 Apr 18;19(4):e0302122. doi: 10.1371/journal.pone.0302122

Health care managers’ perspectives on workforce licensing practice in Ethiopia: A qualitative study

Eshetu Cherinet Teka ^1,^*, Meron Yakob Gebreyes ^1,^*, Endalkachew Tsedal Alemneh ^1,^*, Biruk Hailu Tesfaye ¹, Firew Ayalew Desta ², Yohannes Molla Asemu ², Ermias Gebreyohannes Wolde ¹, Wondimu Daniel Ashena ¹, Samuel Mengistu ³, Tewodros Abebaw Melese ¹, Fikadie Dagnew Biset ¹, Bezawit Worku Degefu ¹, Bethlehem Bizuayehu Kebede ¹, Tangut Dagnew Azeze ¹, Wudasie Teshome Shewatatek ¹, Melese Achamo Seboka ¹, Abera Bezabih Gebreegzi ¹, Mekonnen Desie Degebasa ¹, Tsedale Tafesse Lemu ¹, Yeshiwork Eshetu Abebe ¹, Matias Azanaw Alayu ¹, Fatuma Ahmed Ebrahim ¹, Eden Workneh Sahlemariam ¹, Genet Kifle woldesemayat ¹, Hailemaryam Balcha Admassu ¹, Bethlehem Shikabaw Chekol ¹

Editor: Bereket Yakob⁴

¹Health Professionals’ Competency Assessment and Licensing Directorate, Ministry of Health, Addis Ababa, Ethiopia

²Health Work Force Improvement Program, Jhpiego, Addis Ababa, Ethiopia

³Health Work Force Improvement Program, Ethiopian Medical Association, Addis Ababa, Ethiopia

⁴The Uniersity of British Columbia, ETHIOPIA

Competing Interests: There is no competing interest among the authors.

^✉

* E-mail: eshecher2005@gmail.com (ECT); meron@moh.gov.et (MYG); endalkachew@moh.gov.et (ETA)

Roles

Eshetu Cherinet Teka: Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Meron Yakob Gebreyes: Formal analysis, Investigation, Methodology, Writing – original draft

Endalkachew Tsedal Alemneh: Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Biruk Hailu Tesfaye: Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Firew Ayalew Desta: Methodology, Writing – original draft, Writing – review & editing

Yohannes Molla Asemu: Conceptualization, Formal analysis, Methodology, Visualization, Writing – original draft, Writing – review & editing

Ermias Gebreyohannes Wolde: Investigation, Methodology, Writing – original draft, Writing – review & editing

Wondimu Daniel Ashena: Investigation, Methodology, Writing – original draft

Samuel Mengistu: Investigation, Methodology, Writing – original draft

Tewodros Abebaw Melese: Methodology, Project administration, Supervision, Writing – original draft

Fikadie Dagnew Biset: Investigation, Project administration, Writing – original draft

Bezawit Worku Degefu: Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing

Bethlehem Bizuayehu Kebede: Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Tangut Dagnew Azeze: Investigation, Methodology, Writing – original draft

Wudasie Teshome Shewatatek: Investigation, Methodology, Writing – original draft

Melese Achamo Seboka: Investigation, Methodology, Writing – review & editing

Abera Bezabih Gebreegzi: Investigation, Methodology, Writing – review & editing

Mekonnen Desie Degebasa: Formal analysis, Methodology, Writing – original draft

Tsedale Tafesse Lemu: Formal analysis, Methodology, Writing – original draft

Yeshiwork Eshetu Abebe: Investigation, Methodology, Writing – original draft

Matias Azanaw Alayu: Investigation, Methodology, Writing – original draft

Fatuma Ahmed Ebrahim: Investigation, Methodology, Writing – original draft

Eden Workneh Sahlemariam: Investigation, Methodology, Writing – original draft

Genet Kifle woldesemayat: Investigation, Methodology

Hailemaryam Balcha Admassu: Investigation, Methodology, Writing – original draft

Bethlehem Shikabaw Chekol: Investigation, Methodology, Writing – original draft

Bereket Yakob: Editor

PMCID: PMC11025822 PMID: 38635735

Abstract

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.

Background

Globally, particularly in the private sector, where there is little or no administrative regulation, the public is served by incompetent health care workers [1]. The health workforce regulators in low- and middle-income countries (LMICs) lack the capacity to effectively implement and maintain the system [2,3]. Regulatory agencies in Ethiopia were not effectively discharging their responsibilities due to poor follow-up and inadequate professional registration and licensure practices [4]. Registration and licensing practices in regions are not supported by an automated human resource management information system. Besides, the subnational regulators lacked the capacity to implement registration and licensing functions properly with gaps in skilled human resources, budget, and information technology infrastructure [5].

The Ministry of Health, Ethiopia focuses on regulating health professionals as a strategic initiative in its Health Sector Transformation Plan-II (HSTP-II) [6]. Health professionals’ Competency Assessment and Licensure Directorate (HPCALD) has been developing and administering National Licensing Examination (NLE) as a health workforce regulation mechanism since 2019. This is to assess the competence of new bachelor degree graduates of health workforce and to provide licences only for competent health professionals [7–9]. Similarly, the Ministry of Health and the Ministry of Education have developed a training standard and assessment tool for graduates from technical and vocational level since 2009. Like the Bachelor of Science (BSc) graduates, the technical and vocational level graduates have been expected to pass an occupational competence assessment as a prerequisite of issuing a license and workforce entry. Competent Bachelor of Science (BSc), technical and vocational level graduates will receive the license from the regional health bureaus [10].

Ethiopia adopted various health profession regulatory frameworks, though their implementation has fallen behind, partly due to the inadequacy of the number, experience, and qualifications of human resource managers [11]. Ethiopia, as a Sub-Saharan African (SSA) country, has a shortage of human resources for health (HRH). In some countries, this shortage is so severe as to constitute a crisis in the health sector and to have a direct effect on the achievement of the sustainable development goals (SDGs) and particularly the realisation of universal health coverage (UHC) [12].

Beyond anecdotal information, little is known about health professionals’ licensing practices and its challenges in LMICs, including Ethiopia. Therefore, this study aimed to explore the perspectives and challenges of health work force licensing among health care managers in Ethiopia.

Methods

Study design and setting

A cross-sectional study design with a descriptive phenomenology approach was employed to collect qualitative data in a naturalistic setting. This study was conducted in Ethiopia, a country in Africa with an estimated population of 110 million [13]. After re-structuring in 2020, there are 10 administrative regions as well as the two city administrations of Addis Ababa and Dire Dawa. Regions are subdivided into 98 zones and further into 923 woredas, which in turn are divided into the lowest administrative unit, the kebele, which has around 5000 inhabitants [14]. At each administrative level, the health workforce is managed by a human resources manager and a regulatory manager. Each upper administrative level is responsible for the management, coordination, and distribution of technical support to the lower level [15]. All health care cadres are expected to handle licences during recruitment. Currently, the major health cadres of the country that are assessed by licensure exam to have a license are medicine, laboratory, nursing, public health officer, midwifery, pharmacy, anaesthesia, radiology, dental medicine, psychiatry and nursing specialities [16].

Study population and sampling procedure

The target population for this study were health care managers working at different administration levels in Ethiopia. A total of 32 purposively selected human resources and regulatory body managers were interviewed between March 26, 2021, and April 30, 2021.

The reason behind using purposive sampling in this study is to select a sample of health care managers who can most likely provide the perspective regarding the health work force licensing practice in Ethiopia needed to answer the research question. Purposive sampling is often used when the population of interest is small, and we used purposive sampling because we wanted to focus in depth on relatively small samples. We used it because we wanted to access these key informant health workforces that shared their experiences with us. Participants were recruited along the flow of the Ethiopian health administration system, which included 24 participants from regional level (12 regional-level human resource managers and12 regional-level regulatory managers), 4 participants from Zonal level(4 zonal-level human resource managers, and 4 participants from district level (4 district-level human resource managers). The twelve regions including city administrations included for the study were Tigray, Afar, Amhara, Oromia, Somali, Benishangul Gumuz,Gambela, Sidama, South Nations Nationalities and peoples of Ethiopia(SNNP),Dire Dawa, Addis Abaaba, and Harari. In this study, twelve regions a, four zones and four districts were selected. The twelve regions were selected because there were 12 regional states in Ethiopia during the data collection period. The four zones and four districts were selected purposively based on their burden of licensing practice problems based on the national data. To prevent unauthorised access or use, data have been stored securely. Interviewees who had less than one year of work experience in their position were excluded from the study.

Data collection and quality assurance

A qualitative interview guide was prepared by the authors and a team who were involved in the study. The guide was comprehensive and covered all parts of the objectives we wanted to explore. It encouraged participants to share their experiences in their own words and in their own way without being forced by categories or classifications imposed by the interviewer. It was prepared in English and translated into Amharic. The tool was back-translated into English by an expert to ensure its consistency. The interview guide was pretested and refined to improve its clarity. Sixteen of the authors (eight females and eight males), who were public health professionals in their professions, competency assessment and licensure experts in their occupations, and experienced in qualitative research data collection methods, were recruited for the data collection activity. There was no special relationship between data collectors and participants. Data collectors were trained on techniques of qualitative data collection (interviewing, note-taking, and probing) before deployment to data collection.

Ahead of the interview, a schedule was arranged with participants for the data collection. Data were collected using a semi-structured face-to-face individual interview. Probing questions were applied to find out a detailed idea. The interviews were conducted at the participant’s workplace using Amharic since all the study participants were known to have the skill of the language. No one else was present besides the participants and researchers during the interview to enhance the freedom of the participant to give ideas freely. For an interview, two data collectors were assigned: one interviewer and the other note-taker.

The investigators supervised the data collection process thoroughly. Data collection was started at the regional level, then at the zonal level, and finally at the district level. Human resource managers and regulatory managers at the regional level, human resource managers at the zonal level, and human resource managers at the district level were interviewed. Interviews lasted from 45 to 55 minutes. Data saturation was discussed and ended at the 32nd interview. There was no refusal or dropout from participating in the study. Audio recordings were transcribed verbatim into Amharic by the investigators and translated into English on the same day to avoid the loss of details. Four (10%) of the transcripts were cross-checked with the audio for completeness and accuracy. Besides these, a member check was done by sharing the summary result among four respondents to check the credibility of the result [17].

Data management and analysis

We used thematic content analysis to analyze the result. Verbatim transcripts were read and investigators agreed upon a coding frame. Coding was done by eight of the investigators (authors). Codes were given for emerging ideas. We ensured variation in coding and analyzing the data by having multiple coders to identify discrepancies and maintain consistency. Inter-coder reliability is established by comparing results from multiple coders. Disagreements are identified and resolved to maintain consistency. A senior researcher (among the authors) reviewed the coding and analysis process to ensure it aligns with the research question and results are reliable and valid. Then, codes were categorized into broader thematic areas. Quotes were extracted and collected under identified codes. There were four themes namely awareness on licensing practices, enforcement of licensing practices, Systems for assuring the quality of licensing practices, and challenges to licensing practices. Under the theme named challenges of licensing practices, there were three sub themes named as fraudulent academic credentials, shortage of resources (HR, finance, equipment, and supplies) and weak follow up and coordination system. A report on qualitative results was prepared. Outliers and contradictory findings were checked and consensus was reached on distribution of key themes [18]. In this study, health care managers were represented by regulatory managers and human resource managers in Ethiopia.

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Ethiopian Public Health Institute, Institutional Review Board, with certificate ref. no. EPH 6.13/34.E. Before starting data collection, permission and support letters were collected from the Ministry of Health, regional health bureaus, and zonal health departments. Written informed consent was obtained from each study participant after a clear explanation of the study objectives. Privacy and confidentiality of participants’ were kept anonymous, including their right to withdraw at any time. The name of the study participant in relation to the finding was not disclosed at any time. All methods applied in this study were performed in accordance with the relevant guidelines and regulations. The research will be published in an international, reputable open-access journal.

Results

Socio demographic characteristics

The mean age of key informants was 38.3, with a range of 20 to 60 years. Twenty-four (75%) of the participants were from a regional level. Twelve (37.5%) participants worked for 6–10 years in their current position, while the least two (6.25%) worked for 16–20 years. Twenty-eight (87.5%) participants never received relevant formal training (Table 1).

Table 1. Socio demographic characteristics of study participants, Ethiopia, 2021.

Characteristics	Number	percentage
Age in years 20–29 30–39 40–49 50–59 60–69	2 18 9 2 1	6.3 56.2 28.1 6.3 3.1
Working level of participants
Regional Health Bureau	24	75
Zonal Health Department	4	12.5
District Health Office	4	12.5
Work experience with current position 1–5 6–10 11–15 16–20	11 12 7 2	34.3 37.5 21.8 6.25
Ever received formal RHIS/HMIS/M&E training Yes No	4 28	12.5 87.5

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Themes and subthemes

There were four themes namely awareness on licensing practices, enforcement of licensing practices, Systems for assuring the quality of licensing practices, and challenges to licensing practices. Under the theme named challenges of licensing practices, there were three sub themes named as fraudulent academic credentials, shortage of resources (HR, finance, equipment, and supplies) and weak follow up and coordination system.

Awareness of licensing practices

More than half of the health care managers replied that they had no clear information about health professionals’ licensure exams. They simply heard about it without a detailed understanding.

‘‘I do not have much clarity about it. I heard information disseminated from the zonal level, and even I did not know when it was started.” (District human resource manager)

Some health care managers even have not heard about health professionals’ licensure exam, that was one of the criteria to issue a licence according to Ethiopian law.

’’I have never heard about health professionals’ licensure exams or even who is responsible for organising it.But I have a little understanding about the exam organised by regions.” (Zonal human resource manager)

Enforcement of licensing practices

Respondents mentioned that they tried to pay serious attention to important fulfilments while issuing a license. They made an activity of authentication of documents and asked the applicant to fulfil the mandatory criteria.

‘‘—-firstly, the applicant to be issued a licence has to apply and bring credentials with the original and copy starting from grade eight up to the highest level of education, and we cross-check the copy with the original. We will check the medical; he or she will pay for the service, bring two passport-size photos, an identity card, and all the other requirements. Finally, he or she will be given the licence.’’ (Regional FMHACA head)

As per the response of health care managers, employed health professionals were asked to bring additional documents to issue a licence other than the documents asked for the newly graduated health professionals.

‘‘serving for two years and bringing a support letter from their working institution are also criteria for having a licence if they have working experience.” (District human resource manager)

Health care managers pointed out that the regulatory body is given the mandate to issue a license. Relicensing currently requires continuous professional development (CPD).

‘‘Licence is already given by the regulatory body. Health professionals will be relicensed if they score 30 continuous educational units (CEUs) in a year, and the initiative has begun this year. “(Regional Human Resource Manager)

Respondents replied that a professional licence was issued for a limited number of professions at the BSc level after taking the licensure examination and being competent.

‘‘The professions that have taken the exam were seven. They can be listed as medicine, anaesthesia, nurses, midwives, etc., because they are directly related to the main job, but all health professionals need a icense.’’ (Regional human resource manager)

Though the issue of licensing is too critical as per the ministry’s direction, health care managers have been reluctant to take action against those health professionals who breach the law and regulations.

‘‘For those professionals working without licence, we didn’t start to take any measures. We simply communicate with zonal-level authorities.” (Regional FMHACA manager)

Systems for assuring the quality of licensing practices

Some Health care managers mentioned that they did not know any monitoring tool to solve the issue of working without a license.

‘‘…We know that there are health professionals who are working without license. I do not know how to make all working health professionals have a license.” (Regional human resource manager)

Most Health care managers didn’t give much concern about the licensing status of health professionals. They did not have a plan to inspect the license at the health care sectors/facilities.

‘‘… We don’t monitor the availability of license for each profession. We don’t have schedule for it for any intervention.” (Regional human resource manager)

There were few Health care managers that could monitor routinely the availability of a license. They informed health professionals without a license to avail in their individual record.

‘‘To make sure the availability of license for a health professional on the job, we audit their recruitment document/ file. Those professionals without license were informed to bring it soon.” (Zonal human resource manager)

Few of the Health care managers replied that they monitor the availability of license by digital system (database) that makes it easy and fast.

‘‘Often, there may be unlicensed health professionals. We enter their file in a computer. By using it, we renew the license as per the exact date’.’(Regional regulatory manager)

‘‘We have a human resource manager is-data system to work with their license. When the license is out of date, the system announces by itself.” (Regional human resource manager)

About four of the health care managers reported that health professionals could get promotion in their professional career every 3 years that needs basic criteria to have an active license. ‘‘…especially this year, professional career is one of the criteria to have a professional license. Anyone without a licence can’t get career promotion. To process Job Evaluation and Grading (JEG), license is mandatory.” (Regional human resource manager)

Health care managers expressed that health professionals were revoked their license because of different malpractices. They heard it from the upper level by circular letter.

‘‘…….firstly, a person with a revoked license has been announced by BSC meeting platform. Secondly, it is announced by circular letter from the upper administrative level.” (Regional human resource manager)

Challenges of licensure practice

Respondents mentioned several reasons for poor licensing practice, presented below: fraudulent academic credentials, shortage of resources (HR, finance, equipment, and supplies), and weak follow-up and coordination systems.

Fraudulent academic credentials

Health professionals had forged professional licence that seemed prepared by the regulatory body. Those who were in charge were under the control of the court.

‘‘Many forges are increasing in number. There are many cases under the process of the court. The Food and Drug Authority (FDA) is controlling the process” (regional human resource manager)

‘‘… now, there are many private health institutions. But it is difficult to say that all health professionals have a license. A forged licence was made by the titter of our former authorised colleague who passed away’’ (Regional FMHACA manager).

According to the responses of health care managers, employment by forged licence was done mainly at the district level. Regional-level regulatory bodies could distinguish the forged licence from the original.

‘‘At the district centres, there is a situation of employment by forged license. We can easily identify whether the licence is forged or not when they are bringing it to us.” (Regional regulatory manager)

In two regions, it was reported that health professionals commonly got the wrong professional nomenclature, making them the most senior without deserving it.

’’—the gap here is that the newly graduated health professional was named ‘expert professional’ [a nomenclature reserved for those who practiced for nine years] without deserving it due to the lack of accountability of the regulatory personnel who issued the license.’’ (Regional human resource manager)

Shortage of resources (human resources, finance, equipment, and supplies)

The imbalance between available human resources and the workload, especially in larger regions, was repeatedly mentioned as a challenge. Besides, they were limited in their ability to practice health professionals’ licensing effectively due to a lack of transportation.

‘‘There is a shortage of human resources, especially when we compare the area of the region. Moreover, there is a shortage of vehicles for transport. Both the two are unsolved problems still now.” (Regional regulatory manager)

Health care managers indicated that they could not create awareness among health professionals because of budget deficiencies and a lack of vehicle for transportation.

‘‘…for employed health professionals, we do not have a budget and transportation to create awareness about licensing.’’ (Regional regulatory manager)

Respondents in some regions replied that health professionals could not afford to cover expenses such as transportation cost when they were going to a regional regulatory body from their local area to take a license, and even they could not access transportation.

‘‘Some professionals coming to take a licence from district level suffered from transportation inaccessibility and shortage of transportation fee.’’ (Regional regulatory manager)

Health care managers reported that they lacked information and communication materials and trained professionals.

‘‘We have only one computer. It needs frequent maintenance, and we cannot perform our routine activities. The printer is non-functional, and we are going to another office to print. We do not have internet service, a scanner, or an information technology officer.” (District human resource manager)

Weak follow-up and coordination system

There was poor follow-up to search for those employed health professionals who did not take the Centre of Competency (COC) exam in 2004/2005. Besides, there was a gap in the identification of individuals who did not take the exam.

‘‘There were health professionals who started jobs around 2013. So, during that time, there was a gap to follow as to whether they took the COC exam or not. Moreover, there was also a gap in checking the data of COC-taker health professionals from non-takers.”(Regional human resource manager)

Health care managers replied that they had an interest in seeing if the licensing of health professionals could be decentralised to zonal and district levels. But this could not get an answer from the superior authorities.

‘‘…as it is known, the authority to issue a licence is practiced only at the regional level, and it is not decentralised to the zonal and district levels. Despite our request to decentralise the structure to the zonal and district levels, it has not gotten a solution until now.’’ (Regional regulatory manager)

According to health care managers, the Ministry of Health gave direction to all regions to practice health professionals’ licensing uniformly, despite the actual implementation differences from one region to the other.

The other issue is the difference from one region to another when issuing a license. When we went in the right direction, they asked us, "What is the difference between your rule and that of another region?" (Regional regulatory manager)

A district human resource manager reported that the human resource department and regulatory body lacked coordination when licensing health professionals, despite working together on materials and supply control.

‘‘…. Most of the time, we worked co-ordinately on controlling materials but not on health professionals’ licensing.’’ (District human resource manager)

Discussion

This phenomenological qualitative investigation explored and described the lived experiences of 32 health care managers on health professionals’ licensing practice and its main challenges in Ethiopia. Not including the perspectives of non-managers or practitioners in this study might lead to a limited understanding of the licensing practice at hand and lack of diversity in the data collected and analysed. The data analysis identified four themes: awareness of licensing practices, enforcement of licensing practices, systems for assuring the quality of licensing practices, and challenges to licensing practices. The challenges of licensing practices were categorized in to three sub-themes: fraudulent academic credentials, shortage of resources (HR, finance, equipment, and supplies), and weak follow-up and coordination system. The findings of this study will hopefully influence policymakers, program managers, development partners, health care managers, and health workers in the future to improve efforts towards improving the practice of health professionals’ licensing.

According to this study, health care managers hired health professionals without a license which was against the laws and proclamations of the country [19] A sim.ilar finding was observed in Cambodia [20] and India [21]. This was due to the fact that health professionals’ licensing was not a priority; poor awareness about health professionals’ licensing, corruption, shortage of the regulatory work force and negligence to obey the regulation played the role.

A gap in regular monitoring of the licensing status of health professionals was observed. A similar finding was observed in the Lao People’s Democratic Republic [22]. This was because of the shortage of the health work force at regulatory offices; thus, they are busy with office work and consider the licensing status of employed health professionals a secondary issue.

Unlike the regulatory managers, human resource managers at all levels, predominately district and zonal levels, faced a knowledge gap on the mechanism of tracking forged license. A similar condition was expressed in the human resources for health strategy 2016–2025 [7]. This was due to a lack of training for human resource managers because of the insufficient budget allocated for capacity building, workforce motivation, and performance support. This gap could be tackled by providing on-the-job training about health professionals’ license because it can boost their knowledge, skills and could motivate them.

Shortage of resources such as trained human resources, budget, and information communication materials were the most important determinants that could affect the licensing practice at all levels of the health system. This finding is supported by World Health Organization that stated the problem is expanding to developed countries. This is a big challenge in this era in which the number of private health facilities is expanding, the emergence of new employment opportunities, humanitarian crises, and increasing patient demand and expectation for high-quality service. This needs a short-term and long-term plan that involves development partners and those who have an interest in the area.

In most of the regions, there was a loose coordination between the human resource department and regulatory body. This finding is supported by a study conducted in India [21]. This poor coordination played a role in hindering effective implementation of licensing practice. This was because human resource managers provide license to employees without fulfilling essential regulatory requirements, and the human resource managers did not communicate with the regulatory body about their supervision results that needed the consultation of the regulatory body. This could be solved by sensitising them to have a culture of working together since the issue of health professional licensing is their mutual task.

Moreover, there was an observed regional variation in the implementation of health professionals’ licensing practices. This finding is supported by a study conducted to compare regional regulation variation among the USA, England, Canada, and Australia [23]. It was because the regional regulatory bodies customised the rules and regulations of the ministry as per their regional context. This implementation variation is challenging, and the source of complaints among candidates could have a negative impact on their psychology. This can be solved by having a discussion between the Ministry of Health and regional regulatory directors.

In summary, a strong monitoring system is essential to be developed to close the gaps between unlicensed working health professionals, forged license, and undeserved naming.

Strengths and limitations

This study has strengths as it included samples from all regions of Ethiopia (except areas with security problems during the data collection period). Besides, the study included participants from the regional level to the district level and aimed to explore practices and challenges at all levels of the health system. The in-depth interviews were conducted by experienced public health professionals. However, the study had limitations as it did not include key informants at the national level or in the private sector.

Conclusions

This study reported a suboptimal health professionals’ licensing practice in Ethiopia. Health care managers did not have regular monitoring of employed health professionals to check the availability of license. The issue of licensing health professionals was not the priority of health care managers. The challenges to the poor practice of health professionals’ licensing were fraudulent academic credentials, resource shortages, and a weak follow-up and coordination system. Further awareness of licensing practice should be created, especially for lower-level employers. Regulators shall establish a reliable digital system to consistently assure the quality of licensing practice. Health care managers should 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 practice. Further study is needed to explore the licensing practice by participating in other diverse study groups and methodologies.

Supporting information

S1 File

(DOCX)

pone.0302122.s001.docx^{(16.5KB, docx)}

S2 File

(DOCX)

pone.0302122.s002.docx^{(25.7KB, docx)}

Acknowledgments

The Ministry of Health-Ethiopia and the Ethiopian Public Health Institute deserve our gratitude for allowing us to conduct this national study. We would like to convey our heartfelt gratitude and appreciation to Jhpiego-Ethiopia for their technical support in giving us constructive suggestions and intellectual comments. We would like to express our gratitude to the regulatory staff of the regional health bureaus for their outstanding coordination and administrative actions throughout data collection. Finally, we thank the study participants for taking part in this research process and sharing their experience.

Abbreviations

CEUs: Continuous Educational Units
COC: Center of Competence
CPD: Continuous Professional Development
EPHI: Ethiopian Public Health Institute
FMHACA: Food, Medicine, and Healthcare Administration and Control Authority
HMIS: Health Management Information System
IRB-: Institutional Review Board
JEG: Job Evaluation and Grading
MD: Medical Doctor
NMLE: National Medical Licensure Examination
PhD: Philosophic Doctorate
RHIS: Routine Health Information System
SD: Standard Deviation

Data Availability

The data are all contained within the manuscript. Further communication with the first author can be made if need more data. There are no supporting information files uploaded alongside our paper at this time. In this qualitative study, reflections of participants were analysed from verbatim transcriptions. We did not include any quantitative data. Therefore, quantitative expressions such as means, standard deviations and other measures were not reported. Similarly, graphs were not built; points were not extracted from images for analysis. Since our study is original and had not utilized data set from others, there are no ethical, legal, or third-party restrictions.

Funding Statement

There was no funding for this study. The study was conducted by the voluntary contribution of authors at any of the research and manuscript processing. No one of the authors received salary since there was no funder. The authors received no specific funding for this work.

References

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PLoS One. doi: 10.1371/journal.pone.0302122.r001

Decision Letter 0

Bereket Yakob

10 Apr 2023

PONE-D-22-33343Health care managers’ perspectives on workforce licensing practice in Ethiopia: A qualitative studyPLOS ONE

Dear Eshetu Cherinet ,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

ACADEMIC EDITOR:

I agree with the reviewers' comments and advise the authors to address all of them or provide justifications
Indicate the contributions of each author based on the ICMJE | Recommendations | Defining the Role of Authors and Contributors here (https://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html )
Qualitative research studies should be reported in accordance to the Consolidated criteria for reporting qualitative research (COREQ) checklist or Standards for reporting qualitative research (SRQR) checklist. Further reporting guidelines can be found in the Equator Network's Guidelines for reporting qualitative research. Complete and attach a relevant checklist for the qualitative study.
Seek language editing support to improve the readability and clarity of the paper.

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PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is an interesting paper that would add knowledge to the HRH regulation and healthcare safety.

Please find comments for further development.

Title: the study doesn’t include national-level managers and accreditors. As such, I would add “subnational level”

Authorship: 26 authors are much for such type of articles. Also, check authors’ contributions according to the International Committee of Medical Journal Editors (ICMJE) recommendations.

Abstract: lines 46-47 and 54-55 specify the results and key home-take recommendations

Background

1. The problem statement and rationale of the study is not clear.

2. Paragraphs 1, 3, and 5 are only single sentences that do not fulfil the principle of paragraphing. In addition, please limit your citations to low-and-middle-income countries. As such, you may drop the 3rd paragraph.

3. I would reorganize the Introduction section for smooth flow. Describe the problem statement in the first paragraph; the second paragraph could be about national HRH regulation standards and strategies; the third paragraph would focus on the HRH regulation shortfalls (including HRH shortages); and the fourth paragraph could be knowledge gaps and rationale of this study.

Methods

1) Settings: I would describe the profile of major health cadres of the country for external readers.

2) Any software used for data analysis?

3) Comparative analysis to compare variations as a multiple case study approach amongst HR managers and accreditors would be helpful. For instance, awareness of licensing practices could not be a theme among accreditors

4) Limitations: What would be the limitations of not including non-managers/practitioners’ perspectives in this study? I would reflect on this in the Discussion section

Results

1. Lines 179-189 are about the implementation fidelity of the licensure or implementation challenges. I don’t think it is related to awareness of licensure

2. Lines 206-217, the way presented here is about challenges rather than enforcement mechanisms

3. Lines 237-248 better fits “Systems for assuring the quality of licensing practices”

4. Sub-themes of the “Challenges of licensing practice” are broad and vague, and some of the paragraphs are not directly related. For instance, lines 276-281 are not related to organizational problems. Similarly, lines 301-307 are not also technical challenges. Rather it is a fraud, an individual behavior. I would recategorize the challenges as 1) fraudulent academic credentials, 2) poor coordination and network between the human resource department and regulatory body, 3) shortage of resources (HR, finance, equipment, and supplies), 4) lack of training or SBCC about licensing, and 5) weak support and governance system

Discissions

1. Often in scientific writing, the first paragraph is dedicated to a summary of key findings and then subsequent paragraphs would compare each key finding with previous literature and discuss implications

2. Lines 359-364 and 377-380 looks like repetitions of results and good to drop

References: Check the references again reference # 22, 23, and 31 are not complete

Language: it has multiple grammatical errors that should be fixed; would benefit from experienced editors

Reviewer #2: Workforce licensing practice in Ethiopia: A qualitative study

Date 6 April 2023

Dr. Mengistu Meskele

General comment

This is original research and a very important area of research in the health system quality in Ethiopia. It will befit for policy and program aspects. It is well written and triangulated with mixed methods research, is a strength. However, I have the following few comments.

1. Abstract: The word count should not exceed 300/350, as your abstract word count was 380. I think that exceeds the journal requirement. Also, include keywords at the end of the abstract.

2. In the abstract section, the author has to include the sample size and techniques for qualitative study and the brief scientific rigours (credibility, dependability and transferability ). How they come across to maintain the quality of the study has to be included.

3. In line 48 the heading has to only ‘’conclusion’’ and word recommendation should be removed.

4. Line 51” a reliable system to continuously assure the quality of licensing practice ‘’ Kindly put the reliable system that your research found. Otherwise, it is still broad and does not explicitly indicate the solution to policymakers. What is a reliable system?In line 55, encouraging interventions are recommended to respond to the above-identified challenges’’ has to be removed as it does not indicate the other intervention proposed.

Background

Line: 64 ‘’US’’ I think it is the United States, and all the rest abbreviation has to be written in full at the first encounter and the beginning of the sentences. Consider this comment for all the rest abbreviations. Example Line 80 LMICs

Line 55’’Other

Line 140 -144 has to be moved to the result section as how many themes you have identified.

Line 145: Phenomenological analysis framework??? What is that? Have you used Framework analysis / Collazi phenomenological? Not clear?

Line 115: Under quality control, no scientific rigors are included and maintained in this qualitative research (Trustworthiness, credibility, dependability, reflexibility, transferability). Also, no reference were mentioned from where the author got the data collection tool were developed.

Kindly fill the: Consolidated criteria for reporting qualitative research (COREQ) for this research???

Results

Kindly describe themes after the sociodemographic sections

Discussion: Revisited

Some paragraphs are not supported with body of articles.For example 381-384. Kindly support your discussion points with references from other research.

References

Are not complete, and editorial and typographical errors. URL and Accessed date were not included for the grey literature. For example, Reference numbers: 19,21,20,22,23,27,31 etc, are not correct.

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PLoS One. 2024 Apr 18;19(4):e0302122. doi: 10.1371/journal.pone.0302122.r002

Author response to Decision Letter 0

27 Jul 2023

All responses are separately attached.

Attachment

Submitted filename: Response to reviewer.docx

pone.0302122.s003.docx^{(36.5KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0302122.r003

Decision Letter 1

Bereket Yakob

24 Nov 2023

PONE-D-22-33343R1Health care managers’ perspectives on workforce licensing practice in Ethiopia: A qualitative studyPLOS ONE

Dear Dr. Teka,

Please see the comments below and submit your revised manuscript by Jan 08 2024 11:59PM.. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Bereket Yakob, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments

General comments

- The manuscript requires thorough grammar and punctuation editing. There are many typos, and it will be difficult for the audience to follow the content. Language editing is highly recommended to ensure clarity and readability.

- List of authors: Confirm the contributions of every author. Follow PLOS One authorship guidelines. You can find it here https://journals.plos.org/plosone/s/authorship#loc-authorship-requirements

Abstract:

- Background: State the problem in the background. It only seems your study was about the importance of professional licensing bodies, not the barriers.

- Please improve the grammar and readability of the text in the abstract. For instance, 1) in the methods, “An interview guide was prepared in English, translated to” this must be changed into “translated into.” 2) results: “awareness on licensing practices” needs to be changed into “awareness of licensing practices.”

- Did you use any software to analyze the qualitative data, or did you do it manually?

- “Lack of awareness among managers was reported especially at lower-level employers.” Lack of awareness of what? Please specify it.

- “While regulators were clear on the requirements, employers placed an unwarranted emphasis on ensuring their employees met government licensing requirements.” This is unclear! Please state it in a simple language.

- “Lack of a quality assurance mechanism was reported.” By whom? Quality assurance of what?

- Reorganize and present the results to the four themes. Now, they are scattered all over.

- Embolden the participants' lived experiences by showcasing not only the challenges but also their positive experiences.

- Conclusions: “This study reported a sub-optimal health professionals’ licensing practice in Ethiopia.” You did not tell us what the optimal licensing practices would be or were that were unpracticed. But here, you are saying it was sub-optimal.

- Some of the recommendations were far-fetched and were not from the study results. For instance, the lack of digital systems and the lack of collaboration and communications between regulators and employers were not in the results.

- What is the distinction between “regulators” and “employers”? Who were the employers? Who were the regulators?

Background:

- General, seek editing services and improve language in the manuscript. Otherwise, it is difficult to follow it.

- Line 74: “The Ministry of Health and Education” – Is/was there any ministry called this way? These are separate entities and must be called by their formal names, such as the Ministry of Health and the Ministry of Education.

- Lines 91-92: “Therefore, this study aimed to explore the practice 92 and challenges of health professionals' licensing among Health care managers in Ethiopia.” The practice was not given due attention in the manuscript. The focus was simply on the challenges. You need to revise the above sentence or ensure sufficient details about the practices are included in the manuscript.

Methods

- Insert references for notable methods borrowed from elsewhere.

- Edit language and address typos.

- Lines 112-114: What was the rationale for selecting 12 regional HR and 12 regional regulatory managers? Why only 4 zonal and 4 district HR managers? What was the rationale for the sampling strategy, and what was the purpose of the purposive sampling? Discuss this further.

- What were the roles of zones and districts regarding licensing and regulation? Discuss this further.

- What was the reason for excluding the national licensing and regulatory bodies from the study? Do you need to revise the study topic accordingly?

- Lines 114-116: “Authors had access to information that could identify individual participants can be identified during or after data collection by their labelling as (regional regulatory manager 1 etc.).” The sentence is unclear! How did you ensure the ethical issues about this? Didn’t this endanger the confidentiality and privacy of the participants? Why did you not anonymize the data before sharing it with all authors? Discuss and correct it if there is a reasonable ground for you to share identifiable data with all authors.

- Line 119: Who prepared the interview guide? How did you ensure its content validity?

- Line 153: “We used thematic content analysis to analyse the result.” Discuss the method in brief and insert references. This must come early when you talk about the methods.

- Did you use any software to assist with handling and analyzing the qualitative data?

- Line 145-146: “Coding was done by 146 eight of the investigators (authors). Codes were given for emerging ideas.” Too many people coded the data! How did you ensure variations in coding and analyzing the data? How did it impact interpretation?

- Line 154: It seems something is misplaced or missing.

- Lines 157-158: “In this study, health care managers were represented by regulatory managers 158 and human resource managers in Ethiopia.” The sentence is unclear!

Results

- Lines 171-172: “The highest proportions 172 (75 %) of participants were from the regional level.” Rephrase the sentence.

- Lines 195-196: Were the themes there, or did they emerge during the analysis and interpretation? How distinct are the themes from each other? For instance, what was the difference between “enforcement of licensing practices” and “Systems for assuring the quality of licensing practices”? Were they not more or less similar?

- Lines 212-244: Nothing here seemed to be “enforcement of the licensing practice.” It was simply procedures the licensing bodies followed to grant licensure to healthcare workers. Define what you meant by “enforcement” and discuss its attributes. Show appropriate exhibits as evidence for it.

- Lines 245-280: What is written here is more about the availability and practices of regulatory mechanisms. However, the data were not synthesized to a higher-level theme. Further analysis, synthesis, and interpretation will be helpful.

- Line 281+: Besides what is said in this section, many challenges are mentioned in lines 212-280. For instance, lack of awareness and orientation for staff on licensure procedures and regulatory mechanisms, unavailability of digital systems, poor planning and execution, etc.” Further synthesis, theme development, and interpretation need to be done.

- Lines 320-324: How has this become a health system problem?

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #2: All comments that has provided to revise during the previous time were well addressed.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Mengistu Meskele

**********

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Attachment

Submitted filename: Review comments.docx

pone.0302122.s004.docx^{(17.1KB, docx)}

PLoS One. 2024 Apr 18;19(4):e0302122. doi: 10.1371/journal.pone.0302122.r004

Author response to Decision Letter 1

22 Jan 2024

No comment.Thank you!

Attachment

Submitted filename: Response to reviewers- line by line- 4.docx

pone.0302122.s005.docx^{(32KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0302122.r005

Decision Letter 2

Bereket Yakob

6 Feb 2024

PONE-D-22-33343R2Health care managers’ perspectives on workforce licensing practice in Ethiopia: A qualitative studyPLOS ONE

Dear Dr. Teka,

==============================

ACADEMIC EDITOR:

Lines 72 – 75: FMHACA was reformed to a different organization. Which organization or health agency was responsible for managing health workers' licensure when the study was done? Discuss how FMHACA (or another organization) and the MOH streamline the licensure practice. Based on your presentation, who was responsible for the task is unclear.

Line 88: Remove the unnecessary parenthesis and full stop.

Lines 100-101: “This study was conducted in Ethiopia, a 101 country in Africa with an estimated population of 110 (15).” Something is missing here – Did you mean 110 million?

Lines 107 – 111: Cite references.

Line 105: Remove “o” at the end of the sentence.

Lines 118-120: Cite references

Lines 122 – 128: How many participants from regions, zones, and districts were included in the study? Mention the names of the regions that participated in the study or justify not mentioning it. If there were good reasons for hiding the details, use codes to represent the regions and other structures and present the data. At least provide summaries of the number of regions, zones, and woredas that participated and the number of people who participated from each region and structure. Align this with Table 1 (Line 204).

Line 128: “We anonym zed the data by removing any identifying…” The word anonymized was broken, and there were typos.

Lines 206 – 359: The results happen to be raw. A high-level conceptualization and synthesis might be useful.

==============================

Please submit your revised manuscript by Mar 22 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Bereket Yakob, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Check typos and address them. There are errors in almost all sections. The manuscript may benefit from proofreading and editing services.

PLoS One. 2024 Apr 18;19(4):e0302122. doi: 10.1371/journal.pone.0302122.r006

Author response to Decision Letter 2

22 Mar 2024

The responses to reviewer or editor are attached .

Attachment

Submitted filename: Line by line response to 5th.docx

pone.0302122.s006.docx^{(19.8KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0302122.r007

Decision Letter 3

Bereket Yakob

28 Mar 2024

Health care managers’ perspectives on workforce licensing practice in Ethiopia: A qualitative study

PONE-D-22-33343R3

Dear Dr. Eshetu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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PLoS One. doi: 10.1371/journal.pone.0302122.r008

Acceptance letter

Bereket Yakob

8 Apr 2024

PONE-D-22-33343R3

PLOS ONE

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File

(DOCX)

pone.0302122.s001.docx^{(16.5KB, docx)}

S2 File

(DOCX)

pone.0302122.s002.docx^{(25.7KB, docx)}

Attachment

Submitted filename: Response to reviewer.docx

pone.0302122.s003.docx^{(36.5KB, docx)}

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Submitted filename: Review comments.docx

pone.0302122.s004.docx^{(17.1KB, docx)}

Attachment

Submitted filename: Response to reviewers- line by line- 4.docx

pone.0302122.s005.docx^{(32KB, docx)}

Attachment

Submitted filename: Line by line response to 5th.docx

pone.0302122.s006.docx^{(19.8KB, docx)}

Data Availability Statement

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PERMALINK

Health care managers’ perspectives on workforce licensing practice in Ethiopia: A qualitative study

Eshetu Cherinet Teka

Meron Yakob Gebreyes

Endalkachew Tsedal Alemneh

Biruk Hailu Tesfaye

Firew Ayalew Desta

Yohannes Molla Asemu

Ermias Gebreyohannes Wolde

Wondimu Daniel Ashena

Samuel Mengistu

Tewodros Abebaw Melese

Fikadie Dagnew Biset

Bezawit Worku Degefu

Bethlehem Bizuayehu Kebede

Tangut Dagnew Azeze

Wudasie Teshome Shewatatek

Melese Achamo Seboka

Abera Bezabih Gebreegzi

Mekonnen Desie Degebasa

Tsedale Tafesse Lemu

Yeshiwork Eshetu Abebe

Matias Azanaw Alayu

Fatuma Ahmed Ebrahim

Eden Workneh Sahlemariam

Genet Kifle woldesemayat

Hailemaryam Balcha Admassu

Bethlehem Shikabaw Chekol

Roles

Abstract

Background

Objective

Methods

Results

Conclusions

Background

Methods

Study design and setting

Study population and sampling procedure

Data collection and quality assurance

Data management and analysis

Ethics approval and consent to participate

Results

Socio demographic characteristics

Table 1. Socio demographic characteristics of study participants, Ethiopia, 2021.

Themes and subthemes

Awareness of licensing practices

Enforcement of licensing practices

Systems for assuring the quality of licensing practices

Challenges of licensure practice

Fraudulent academic credentials

Shortage of resources (human resources, finance, equipment, and supplies)

Weak follow-up and coordination system

Discussion

Strengths and limitations

Conclusions

Supporting information

Acknowledgments

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Bereket Yakob

Roles

Author response to Decision Letter 0

Decision Letter 1

Bereket Yakob

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Author response to Decision Letter 1

Decision Letter 2

Bereket Yakob

Roles

Author response to Decision Letter 2

Decision Letter 3

Bereket Yakob

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Acceptance letter

Bereket Yakob

Roles