Essential core competencies for health policy graduates: a multi-method consensus type study

Abstract

Background

In light of the multi-faceted challenges confronting health systems worldwide and the imperative to advance towards development goals, the contribution of health policy graduates is of paramount importance, facilitating the attainment of health and well-being objectives. This paper delineates a set of core skills and competencies that are requisite for health policy graduates, with the objective of preparing these graduates for a spectrum of future roles, including both academic and non-academic positions.

Methods

The study was conducted in three phases: a scoping review, qualitative interviews and the validation of identified competencies through brainstorming with experts. In the initial phase, a scoping review was conducted on the databases. The following databases were searched: PubMed, Scopus, Web of Science and Google Scholar search engine. Additionally, the WebPages of universities offering health policy programmes were manually searched. In the second phase, 36 semi-structured interviews were conducted with students, graduates and distinguished academics from Iran and other countries. These interviews were conducted in person or via email. In the third phase, the draft version of the competencies and their associated learning objectives, derived from the preceding stages, was subjected to independent review by an expert panel and subsequently discussed. In light of the expert panel’s findings, the authors undertook a subsequent revision of the list, leading to the finalization of the core competencies through a process of consensus.

Results

In the scoping review phase, the analysis included six studies and nine university curricula. The results of the scoping review could be classified into five domains: health system understanding, health policy research, knowledge translation, multidisciplinary work and knowledge of public health. In the second phase, six core competencies were extracted from the interviews and combined with the results of the first phase, which were then discussed by the expert panel at the third phase. The final five core competencies, derived from the brainstorming session and presented in no particular order, encompass health policy research, policy analysis, educational competencies, decision-making and multidisciplinary work.

Conclusions

It is essential that the curriculum is appropriate and contextually tailored, as this is crucial to foster multi-dimensional competencies that complement the specific disciplines of future health policy scholars. These scholars must possess the ability to genuinely serve their health systems towards achieving health-system goals and sustainable development.

Background

Health policy is a multidisciplinary field with a principle focus on the investigation of activities and initiatives that have an impact on public health, and which are typically planned or implemented by governmental bodies [1]. A graduate in health policy must develop an interdisciplinary understanding and a set of skills that will enrich and deepen the knowledge and practice base in the healthcare system [2]. Over the past three decades, there has been a notable increase in the number of universities worldwide offering doctoral programmes in health policy. The overarching objective of these programmes is to cultivate the specific competencies and expertise required for research and teaching roles within the academic community, as well as in public and private sector organizations. While the majority of traditional programmes equip students with an understanding of the theoretical and empirical approaches, competency-based training has recently emerged as a key area of interest for educational planning experts [3, 4]. This approach incorporates the fundamental elements of core competencies, curriculum and teaching programme design, and the development of transparent, reliable, valid and defensible assessment instruments. It is of the utmost importance to create a transparent and comprehensive outline of core competencies to guarantee that the curriculum is aligned with these competencies, objectives and assessments [5].

The formulation of an appropriate educational programme may be facilitated by the adoption of certain guidelines. To illustrate, the Leadership Competency Framework, as devised by the National Public Health Leadership Development Network [6], offers a valuable set of guidelines for the development and enhancement of the programme. These include the identification of competencies and educational content; the creation of needs assessments, baselines and performance standards; and the evaluation of educational outcomes. The framework is subject to ongoing refinement and evaluation to ensure its continued relevance in the context of performance. It is recommended that the following competencies be included: transformation, legislation and politics, organization and team and group dynamics. It is possible to create society-based educational programmes that are fundamental to the functioning of third-generation universities by integrating materials and skills from a variety of perspectives [7]. Nevertheless, it may prove challenging for students to identify the optimal curriculum from the array of skills and techniques endorsed in interdisciplinary programmes[8, 9]. Core competencies are defined as a set of the necessary practical knowledge, skills and techniques that empower students and other trainers to perform the given responsibilities in an effective manner [10]. In the health sector, competency-based education is concerned with the desired performance characteristics of health professionals. This is achieved through the design and implementation of evidence-based standards, performance indicators and quality outcomes. To reach a status quo, it is necessary to review existing programmes and shift from traditional approaches to novel approaches and new forms of education [11]. Nevertheless, there has been a paucity of attention devoted to the modification of the higher education curriculum in numerous countries, including Iran [12, 13]. This has highlighted the need for an advanced education curriculum to enhance the quality of the educational system, particularly at the higher level, such as in the fields of health policy and health services research [14]. Competency-based frameworks have been developed as a practical tool for assessing students’ competencies and as a basis for evaluating the effectiveness of curricula [15, 16]. Competencies are a crucial element of professional education, as they serve to identify and acknowledge the specific outcome expectations for graduates in relation to the health system’s requirements [17]. The process of developing competencies is contingent upon the availability or absence of relevant pre-existing frameworks [18, 19], as well as the nature and purpose of the competencies [20]. It is customary to examine pertinent literature and existing competencies to establish a foundation for new competency frameworks [21, 22]. A variety of methods may be employed in the process of developing competencies, including a consensus-building approach, Delphi techniques [23, 24], the input of qualified experts and comprehensive consultation with stakeholders through, for example, the use of a world café design [25].

Contextualization is of paramount importance in the development of a constructivist competency-based approach to education. This is particularly pertinent in interdisciplinary subjects such as health policy, where the challenge is to identify the courses that will best enable students to enhance their level of competency and skills [1]. Strategies such as situation-based group learning are employed to facilitate learners’ development of the intrinsic resources that are essential for the integration of competencies [26]. The prioritization of educational needs can facilitate the enhancement of students’ curriculum effectiveness, particularly when educational content is consistently identified by stakeholders from diverse disciplines [27]. Some scholars have proposed that the educational content of health-related disciplines be subjected to review to ensure that it responds to the societal health needs [28]. Furthermore, in light of the rapid advancements in the field of health sciences and the imperative to enhance the competencies of graduates, it is imperative for institutions to offer courses that are continuously updated. Additionally, the multifaceted and intricate nature of health challenges, coupled with the pivotal role of health in the development of health systems [29], underscores the necessity for training a cadre of experts with cutting-edge skills and a nuanced understanding of interrelated disciplines. This approach is essential to achieve an inclusive impact [30].

The first health policy curriculum in Iran was developed over a decade ago by a group of scholars, all of whom had obtained their degrees from pioneering universities in the United Kingdom. The doctoral programme was developed for a four-year period and comprised a minimum of 48 core credit courses, including health economics and economic evaluation, health policy analysis, public policy, basic and advanced research methods, qualitative research methodology, health policy seminar, global health, health insurance, and health financing. Additional courses were incorporated into the curriculum on the basis of students’ backgrounds and needs. The curriculum was drawn from a range of disciplines, including nursing, medicine, midwifery, health education, social welfare and rehabilitation, health services management and other management and paramedical sciences. The doctoral programme was initially established at the School of Public Health in Tehran University of Medical Sciences, and the School of Health Management and Medical Information in Iran University of Medical Sciences. Two further medical universities (Tabriz and Kerman) subsequently joined the programme.

In Iran and other countries with comparable contexts, graduates in health policy are frequently unable to secure positions that align with their qualifications and training. Alternatively, if they are placed, they may lack the requisite competencies. A review of the literature reveals that no previous study has investigated the core competencies required of health policy scholars in the future. The objective of this study is to identify the skills and competencies required for health policy graduates to prepare them for a spectrum of future roles, including both academic and non-academic positions. The findings presented herein may assist policy-makers and educational planners in Iranian higher education institutions in developing competency-based health policy curricula, thus enabling them to respond to the evolving societal needs pertaining to the sustainable development of health in Iran, and possibly in other settings.

Methods

Design

This is a multi-method study comprising three phases: a scoping review, qualitative interviews and validation and finalization of identified competencies through face-to-face expert consensus. A schematic representation of the research phases is provided in Fig. 1.

Fig. 1

Schematic diagram of research phases

Phase 1: Scoping review

In the first phase of this study, we conducted a scoping review in accordance with the guidelines set forth by the Joanna Briggs Institute [31]. The objective was to synthesize the essential competencies for health policy graduates as delineated in the scientific literature. Given the exploratory nature of this research, which aims to identify the core competencies for health policy graduates, a scoping review was deemed a more appropriate methodology than a systematic review. The findings from the initial phase, in conjunction with those from the subsequent phase, were then presented to the expert panel for the purpose of finalizing the core competencies. The search was conducted on the following databases: PubMed, SCOPUS, Web of Sciences and Google Scholar search engine (the first 100 results were screened). The search strategy employed was as follows: (graduat*[Title/Abstract]) AND ((((competenc*[Title/Abstract]) OR (skill*[Title/Abstract])) OR (capability[Title/Abstract]) AND ("health policy"[MeSH Terms]) OR ("health policy"[Title/Abstract]) OR ("health policies"[Title/Abstract]). The databases were selected on the basis of their relevance to the topic and the researcher’s access to them. The inclusion criteria were defined in accordance with the Population (P), Concept (C), and Context (C) (PICO) criteria, which are pertinent to the conduct of scoping reviews. The population under consideration were those who had completed a course of study in health policy. The concept of interest was the set of skills and competencies that are typically required of individuals who have completed such a course of study. The inclusion criteria for the context were all universities and countries in which individuals who have completed a course of study in health policy are found. The search was limited to English-language sources and no date restrictions were imposed. The review included journal articles comprising both quantitative and qualitative published studies. Furthermore, we requested the assistance of known faculty members in health policy, who were asked to nominate universities offering health policy programmes or related disciplines on a global scale. The resulting nominations were then subject to a manual search of the Internet using search engines, with the aim of identifying schools offering health policy programmes. A total of nine universities (seven from the United States, one from Canada, and one from the United Kingdom) were selected for review of their education programmes, including Johns Hopkins University, University of Kansas, The George Washington University, Harvard University, McMaster University, Swansea University, Temple University, The Pennsylvania State University and University of Illinois. A descriptive qualitative content analysis approach was employed to summarize the textual data on health policy graduates’ competencies, extracted from this phase in narrative form. This phase of the study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. The categories extracted in the preceding phase were then subjected to discussion in the third phase, with a view to reaching a consensus on the core competencies. A database search and a hand search were conducted in April 2023 and updated in May 2024. Two independent authors (N.K. and L.D.) undertook the initial screening of the search results in accordance with the pre-established inclusion and exclusion criteria. The same authors conducted an independent extraction of the pertinent data from the included studies, utilizing a standardized data extraction form. The extracted data comprised the following elements: citation, publication year, country, aim of the study, study design, study methods, participants and sample size. The primary conclusion that was reached was the identification of the core competencies for health policy graduates.

Phase 2: Qualitative study

In this phase, a qualitative study was conducted on the basis of semi-structured interviews with health policy professionals and students, as well as other stakeholders from different levels of the health system. The COREQ Checklist for reporting qualitative research was completed and is provided in the supporting information. (Supplementary 1).

A heterogeneous sampling and snowball approach was employed to identify well-known experts in the field of health policy. These experts were selected on the basis of their scientific journal publications, media interviews and teaching courses, as well as their involvement in developing health-related policies at the national level, particularly in Iran. The majority of these experts are currently employed in executive governmental roles. Furthermore, interviews were conducted with students engaged in the study of health policy, as it was thought that this approach might facilitate the identification of relevant competencies. The interviews with Iranian participants were conducted in person. Due to logistical constraints, participants from other countries were interviewed via the online platform Google Meet, as physical access to them was not feasible. In the case of virtual interviews, permission was sought to record the session on video. Foreign interviewees were invited via email. A follow-up email was also sent to participants on three consecutive occasions, requesting feedback. All participants completed the informed consent form. The interview guide was developed on the basis of the study objectives and was piloted and adapted in the first three interviews. The interview guide was developed using the results of the initial phase of the study, as well as the input of research team members and three health policy academics. The characteristics of interviewees are presented in Table 1.

Table 1 Characteristics of interviewees

Two female researchers, both of whom held PhD degrees and occupied academic positions, were responsible for conducting the semi-structured interviews. They were conversant with qualitative interviews and utilized an interview guide. All interviews were conducted at the interviewees’ workplaces, with no other participants or researchers present. The interviews averaged approximately 50 min in length and were recorded and transcribed verbatim. The point of data saturation was reached when the most recent interviews yielded no new information. A total of 36 semi-structured interviews were conducted using an interview guide. A preliminary phase was initiated with the administration of three pilot interviews. Following the analysis of the pilot interviews, only minor amendments were made to one question. The interviews were recorded digitally and subsequently transcribed. Field notes were taken during and after each interview. A qualitative content analysis was conducted as part of the data analysis process. The transcripts were subjected to a process of coding and categorization by two authors, resulting in the identification of seven core competencies and their associated learning objectives for health policy students. The findings from phases 1 and 2 were collated and a final list of core competencies was prepared. In the third phase, the expert panel convened to finalize the core competencies required for health policy graduates on the basis of the list that had been previously discussed.

Phase 3: Brain storming

Two brainstorming sessions were conducted to finalize the list of competencies. The principal criterion for participation in the expert panel was expertise in health policy and the requisite competencies.

The expert panel was invited to review the draft version of the final competencies, which included 11 competencies (5 from the first phase and 6 from the second phase) and their associated learning objectives. The panel comprised four experts from the Iranian Ministry of Health and Medical Education, three health policy professionals and two health policy scholars. The same individuals participated in both brainstorming sessions. In the initial session, participants evaluated the 11 competencies in terms of their perceived importance, necessity, and relevance on a scale of 1–9, with 1 indicating the lowest level of compliance and 9 indicating the highest. The findings were collated by one of the researchers and the final list of competencies, along with their respective scores for each criterion, were presented in the second session of brainstorming for discussion. In the second session of the expert panel, any discrepancies were resolved by one investigator, and six core competencies were consolidated with others. The authors subsequently revised the list, and the final version of the core competencies was derived by consensus and is presented in this manuscript.

The study objectives were explained to all participants, and informed consent was obtained from all interviewees and experts in phases 2 and 3. Furthermore, participants were informed that their responses would be anonymous and that any information disclosed during the course of the interview would be kept strictly confidential.

Results

Phase 1

In the initial phase of the scoping review, a total of 623 documents were identified through the primary search. Following the removal of duplicates, a total of 529 titles and abstracts were subjected to screening, and 44 were deemed eligible for full-text review. Of these, 29 were excluded for various reasons, including the absence of relevant data, the presence of a systematic review protocol, the use of a non-English language and the unavailability of the full text. In conclusion, the scoping review phase included six journal articles and nine university curricula. Figure 2 illustrates the process of study selection, while Table 2 outlines the key characteristics of the included studies and their principal findings. In light of the findings from this phase, the core competencies for health policy graduates can be grouped into five domains: health system understanding, health policy research, knowledge translation, multidisciplinary work and knowledge of public health policy. Additionally, Table 3 presents the essential competencies for doctoral graduates in health policy, as identified by the selected universities.

Fig. 2

PRISMA flow diagram for study selection and inclusion process

Table 2 Main characteristics of included studies in the scoping review

Table 3 Required competences for health policy graduates asserted by universities

Phase 2

In phase 2, six core competencies were identified as being essential for graduates in health policy, namely, research, education, policy analysis, decision-making, globalization and communication.

Research

The qualitative interviews revealed a significant discrepancy between researchers and decision-makers, which impedes the establishment of a unified language for planning and implementing health-related programmes.

“It is evident that there is a necessity to cultivate a shared vocabulary between researchers and policy-makers. On occasion, policy-makers have well-considered plans for implementation, but they are unable to present their ideas in a manner that is accessible to a scientific audience” [P14: a senior health policy-maker].

It was anticipated that the graduates would be able to identify relevant databases and conduct a systematic search through the appropriate use of quality data relevant to policy issues, while assessing the methodology and quality of research results.

“I am able to search the internet, but I would prefer to do so in a systematic and effective manner, which would allow me to gain insights from the experiences of other countries and health systems” [P8: a ministry advisor].

Education

Transitioning to methods that focus more on students, such as actively engaging them in learning tasks and providing training on contemporary teaching methods to enhance interactions with students and other learners, was suggested as a strategy to move away from the traditional teacher-centred approach in post-graduate education. Numerous participants in the study labelled the classroom as an ideal representation of the “real world” and emphasized the need to equip students with the abilities to effectively manage the class as a way to handle public matters in line with advancements in knowledge and globalization.

“I believe that, at the doctorate level, students desire more critical feedback from their mentor in order to develop their own perspectives on various topics” [P11: a faculty member].

Policy analysis

Analysing policies is a challenging skill that involves understanding theories and critically evaluating the process of policy-making, including identifying issues, creating policies, considering rules and regulations, examining stakeholders and implementing and reviewing policies. Health policy graduates must possess a strong grasp of public health paradigms to evaluate how health policies interact with the policies and procedures of other disciplines.

“The objective of health policy graduates is to analyse the current health plans in the health system and to interpret the probable consequences of the plans” [P22: a faculty member].

The capacity to interpret and analyse policies and plans can be enhanced through the acquisition of the requisite skills through training. A considerable number of policies are formulated without due consideration of the various underlying factors, including context, process, content and actors. As indicated by the respondents, the majority of policy-makers and key decision-makers lack sufficient knowledge regarding the formulation of policies based on diverse information and evidence.

Decision-making

The capacity to make effective decisions is a fundamental competency. It is similarly crucial for policy-makers to be able to utilize contemporary data to make well-informed decisions. It was highlighted that graduate students of health policy should be able to engage with stakeholders (including political and social actors) during the decision-making processes in a timely manner. “The health system involves various individuals who play essential roles in reaching population health objectives, therefore it is important for us, as prospective health policy graduates, to identify these key stakeholders and engage with them professionally” [P18: a health system specialist].

Communication and globalization

The health sector engages with a diverse array of stakeholders from a multitude of sectors and policy-making arenas. It is essential that there are well-established relationships (effective consultation and advocacy) within and across organizations and entities whose actions or inactions influence health.

“Therefore, not having strong connections with various entities, organizations, and individuals while working in a global community is not considered a political act, it is an essential requirement in today’s world” [P27: a health insurance specialist].

The present phase of globalization has increased health risks worldwide and made public health more complicated, leading to a greater need for global cooperation and coordination among all stakeholders. Health policy graduates need to work together and communicate effectively to develop a strong diplomatic response that will influence global policy.

Phase 3

During phase 3, five core competencies were chosen after considering the competencies identified in earlier phases, forming the basis for the initial core competencies drafted. Table 4 provides a summary of the main skills, additional skills and necessary abilities. Additionally, Fig. 3 shows the steps of discovering and solidifying skills in each of the three stages.

Table 4 The core competencies for health policy doctoral graduates

Fig. 3

Process of identifying and finalizing competencies in three phases

Discussion

The present study employs a multi-method consensus approach to identify the core competencies required of health policy graduates. In light of the findings, five core competencies were identified as follows: health policy research, policy analysis, educational competencies, decision-making and multi-disciplinary work. The capacity to conduct original research or to communicate effectively with researchers represents a fundamental skill for those pursuing a degree in health policy. It is evident that proficiency in knowledge management and an understanding of research methodologies are indispensable for those pursuing careers in health policy [38]. In recent years, there has been a proliferation of literature on the topic of translating research evidence into policy and practice. This literature aims to address the specific concerns of policy-makers to facilitate the process of knowledge translation and transfer [39, 40]. Nevertheless, a discrepancy persists between researchers and policy-makers regarding the methods for producing and utilizing evidence-based research to inform decision-making processes [41]. One potential solution for bridging the traditional gap between researchers and policy-makers is to equip health policy graduates at the doctoral level with the skills and tools to leverage research in support of evidence-based decision-making at both national and global levels [42].

The capacity of a government to address the health requirements of its population is contingent upon the proficiency of the entities and authorities responsible for the planning, management and ongoing enhancement of healthcare services [43]. The enhancement of the knowledge and abilities of healthcare professionals [44] and the refinement of the educational content within health-related disciplines may facilitate the fulfilment of the health requirements of the population [45]. It would be beneficial for those who have obtained a degree in health policy to possess the requisite educational and teaching skills to enhance the knowledge of the various target populations within the health system.

The findings of the present study indicate that policy analysis represents a fundamental competency requisite for those pursuing a degree in health policy. To reinforce the evidence-based approach to policy-making, it is essential to enhance the individual and institutional capabilities with regard to the knowledge of policy-making and policy analysis [46]. In 2009, the Association of Schools of Public Health (ASPH) put forth a model of core competencies deemed suitable for doctoral-level education in public health (DrPH). The team, comprising academics and practice participants, identified five core competencies, which encompass seven domains of skills. The aforementioned competencies are as follows: advocacy, communication, community/cultural orientation, critical analysis, leadership, management, professionalism and ethics. Furthermore, the findings were linked to doctoral-level education in public health, the analysis of the model presentation process and its implications, the potential future use of the model and the challenges associated with introducing and implementing it within academic settings. The ASPH’s objective is to stimulate public debate about the core competencies required by public health graduates to address public health challenges and to redefine the DrPH degree in a more optimal manner [47]. Our findings indicate that a number of universities have developed lists of core competencies that students and graduates of the field should possess. To illustrate, the core competencies of the health policy and management programme at Johns Hopkins University (United States) are broadly comparable to the research and educational competencies identified in our research [48]. In contrast, the list of core competencies of the health policy and management programme at the University of Kansas is more general [49]. Furthermore, studies have demonstrated a notable correlation between the educational content and the occupational competency of graduates from higher education institutions [50]. Additionally, there have been advancements in the development of core competencies for health policy and enhanced population health [51]. The findings of our study indicate that specific competencies, namely research and education, are applicable to all graduates. However, they appear to be of particular importance in the context of health policy studies, given the dynamic and evolving nature of health-related challenges faced by these graduates. To achieve sustainable health development, it is essential to consider “interdisciplinary/cross-cutting competencies” in comparison with “discipline-specific” competencies. These cross-cutting competencies encompass diversity and culture, professionalism, program planning, systems thinking, social and behavioural sciences and health policy and management. The formation of a global village and the existence of people of different nationalities and cultures in every society intensifies the need to foster such competencies. It appears that the cultivation of these competencies will facilitate the formulation of novel and creative strategies for enhancing community health.

Limitations and future research opportunities

The competencies identified in our study through the consensus-building process, based on the differences in country contexts, health systems and educational systems, may be subject to influence in terms of their applicability in health policy programmes. One limitation of this study was the inability to access related documents at some universities. It may be beneficial to conduct a larger number of studies to gain a more comprehensive understanding of the core competencies across a wider range of contexts. The results of the scoping review showed that few studies have been conducted in this field, as this review included only six studies, which may limit the comprehensive understanding of core competences across diverse settings. Multi-disciplinary approaches can provide valuable insights that inform the identification of core competencies and the development of curricula. Future studies could focus on the validation and refinement of competencies in a variety of health policy programmes, with the aim of evolving them over time, applying them in practice and effectively measuring their impact on health development. The development of appropriate assessment tools for the competencies of graduates could facilitate the necessary changes to health policy educational curricula and content on the basis of the workforce requirements in real-time settings and subsequent contributions to health systems. By addressing these limitations and exploring future research opportunities, researchers can contribute to the ongoing improvement of health policy education and its relevance to health system development.

Conclusions

The present study has identified the five core competencies that are required of those undertaking a health policy degree and has also shed light on specific aspects that should be included in the preparation of future scholars of health policy. The challenges facing public health are numerous, multi-faceted and complex. Effectively addressing these requires a range of cross-cutting competencies, many of which may not be adequately addressed in the current curriculum at many universities. While the majority of countries are striving for the Sustainable Development Goals or the achievement of health and well-being, it is crucial to cultivate the core competencies in health policy graduates to equip them to address the dynamic and complex nature of the policy environment along the ongoing and winding pathway towards health system goals.