However, with the introduction of national health insurance schemes and the move towards universal health coverage, there is increasing recognition of the need to address quality of care as part of these reforms.
Hospital accreditation has been established in many high-income countries, and some low and middleincome countries (LMICs), as an approach to improving the quality of care that combines the two elements of quality assurance and quality improvement.
While hospital accreditation was originally introduced and managed as a professional and industry voluntary self-improvement initiative, recent reforms, such as mandatory requirements, have tended to increase government control of accreditation schemes, and to shift towards a more explicit regulatory role.
This paper builds on the analysis and review of hospital accreditation systems and recent reforms in Australia and Indonesia, to examine the questions: To what extent have these reforms shifted accreditation towards a more regulatory role? What issues have arisen in using accreditation as a regulatory approach in the context of low and middle income countries (LMICs)?
In analysing accreditation programs from a regulatory perspective, we use the responsive regulatory framework developed by Ayres and Braithwaite in 1995. This framework views regulation as a series of regulatory actions or tools of varying degrees of intervention and cost, arranged in the shape of a pyramid. At the base of the pyramid are the least interventional and costly activities, such as self-regulation and persuasion, while progressively more intensive and costly interventions occupy successive levels of the pyramid.
At the apex are the sanctions and ruinous powers available to government. This approach proposes that regulation should focus on low cost and low intervention activities at the base of the pyramid, and only progressively escalate if these activities fail to have the desired effect.