Adaptations in models of urological regulation and their application to sub-Saharan Africa.

Regulation of medical care is something that has grown from humble roots in professional craft groups to huge establishment in well-resourced, high-income countries. Self-regulation was the preferred method of determining appropriate behaviour initially, but a lack of public trust in this, and the desire of patients to contribute to the establishment of the standard of care that they receive, has meant that most Anglophone countries have adopted some form of independent regulation. Regulators are responsible for the registration of doctor's qualifications, licensing them to practise, accrediting institutions to provide undergraduate and postgraduate education and certifying the attainment of accepted standards of achievement by some form of assessment process. Regulators also have powers to sanction individuals whose practice falls outside expected levels of competence. Both centralized and devolved models of regulation have evolved. Much of the accreditation for postgraduate education and training has been handed down to collegiate bodies, or non-governmental organizations, who can also certify completion of training. Evidence-based medicine and clinical practice guidelines have enforced an informal tier of regulation in high-income countries; guideline-derived practice is now widely regarded as an accepted standard of care. In low- and middle-income countries in sub-Saharan Africa the governmental and legislative structures and finance available to provide the regulation espoused in more privileged environments is rarely available. The workforce is structured in a completely different way and some care groups are totally unregulated. Medical councils in sub-Saharan Africa fulfil a registration and licensing function but surgical collegiate bodies provide the structure for postgraduate training. The East and West African Colleges of Surgeons have developed into robust organizations, who have verifiable, quality-assured, accreditation systems that have helped improve standards of care for the large populations for which their member surgeons are responsible. Formal regulation of continuing practice and sanctions are challenges that are, at present, largely unaddressed.