Good governance competencies in public health to train public health physicians

Objectives This study aimed at assessing public health residents’ perceived health system governance (HSG) training needs and to define a competency framework for “good governance” to improve Public Health physicians’ curricula. Methods A questionnaire was administered to all Italian medical residents on postgraduate courses in Hygiene and Preventive medicine. Twenty-five (78.1 %) of the 32 Italian Schools of Public Health and 299/535 residents (55.9 %) took part in this survey. The public health governance competency framework was developed from roles and responsibility at different levels of governance in the Italian Health System context. Results The questionnaire revealed that residents felt the need for more training on all the proposed HSG-related topics. Different governance functions, strategic planning, operational planning, and operational programming were considered when defining roles and responsibilities. Conclusions More efforts should be made to provide organic training plans tailored to the needs of local and national health system. The competencies framework for good governance could be useful for planning professional training in both the academic and the health system settings.


Introduction
In the context of a public health system in which healthcare is a right and not a privilege, good governance ensures that the health system's rules and institutions are beneficial to the population. At every level, the aim of public health system governance is to ensure that any action taken is always constantly focusing on providing added value for the individuals and groups being served by allocating and using the available resources to maximum benefit, and by minimizing waste (i.e. anything that does not add value to the outcome) (Gray 2013). Public health professionals should govern health systems from a population medicine perspective (Gray 2013). In 2000, the WHO introduced the concept of health sector ''stewardship,'' which is closely related to leadership and governance. It defined stewardship as ''the careful and responsible management of the well-being of the population'' (Boffin 2002). Strategic planning involves defining the principles of the health system, its objectives for the population being served, and a framework or setting by means of which to achieve these objectives, including the allocation of budgets and resources at regional or local level. The operational programming function at a given center of responsibility has to translate the strategic plan into activities, which might cover the whole range of operations involved in health care provision, i.e. organizing services and providing the staff, facilities and equipment needed to reach the assigned goals. Programs and projects are the tools used in this operational programming process.
Despite the growing body of literature on the concepts of public health governance, there is still a shortage of clear and consistent tools available to help health system stewards in defining competences to carry out the governance function with its strategic planning and operational programming function (Barbazza and Tello 2014;Brinkerhoff and Bossert 2014).
There is also quite a considerable variability in the tools used on different levels (national, regional and institutional), and there may be a diversity of approaches between operators with different levels of authority and mandates from those serving in stewardship roles (Barbazza and Tello 2014).
Although the terms ''governance'' and ''stewardship'' are increasingly being used to draw attention to a number of factors affecting the quality, efficacy, and reach of social services, no consensus has emerged on their definitions, the related frameworks, and how they apply to the health sector in particular (Savedoff and Network 2011).
With a view to assuring a future for public health systems and improving public health professional training programs, the Institute of Medicine of the US Academies has highlighted the need to enhance policy training, which should be part of structured management training programs for public health residents (Gebbie et al. 2003). Such structured management training programs need to be tailored to the functions and roles required of public health managers in each national health care system. Many competency frameworks have been developed to support public health operators, (Czabanowska et al. 2014a). Such frameworks attempt to promote high standards in professional public health practice and serve as a guide to design public health curricula. Although the importance of policies has long been recognized, training is rarely provided on how to analyze, develop, and implement policies (Oni et al. 2010). Bjegovic-Mikanovic et al. (2013) claim in their article that public health education in Europe is wholly inadequate in preparing workers for the ''real world'' of changing health risks, increasing health disparities, and newly developing health technologies (among other pressing challenges). Educational programs should have some degree of flexibility in specifying rotations at different health care services, so as to provide a more comprehensive practical experience of public health issues. In Italy, over the course of 4 years of training in Public Health, residents learn to apply and develop a set of skills under the guidance and mentorship of senior managers (Inter-ministerial decree 2015). Such rotations should provide these trainees with the opportunity to nurture their governance and leadership skills under expert supervision. Directors running such training programs may interpret these needs differently, however, and residents may sometimes receive no training at all on certain issues.
To provide a better understanding of the structured governance of health care systems during training programs, the first aim of this study was to assess public health residents' perception of the training they had received on health system governance (HSG) and their perceived HSG resting training needs. The second aim of our work was to develop a competency framework for the ''good governance'' of a health system, which could guide the design of new Public Health physicians' curricula. Our ultimate goal was to improve public health professionals' ability to govern health services.

Context
The Italian healthcare system is essentially region-based and organized on three levels: national, regional, and local. Under the Italian Constitution, responsibility for health care is shared by the central government and 20 regional authorities (Constitution of Italian Republic 1948).
Only the former has the power to establish 'essential levels of care' or basic packages that must be available to all residents throughout the country, and it is responsible for ensuring that the general objectives and fundamental principles of the national health system are met. The regional authorities are virtually entirely responsible for organizing and administering public-financed health care. Responsibility for health care planning is shared by the central government and the regional authorities. Regional/ local planning is based on national health plans, and regional authorities have to integrate national directives in their regional/local health plans (Ferré et al. 2014). Responsibility for health service delivery lies with the geographically distributed local health enterprises (Aziende Sanitarie Locali, ASLs), which are public-owned companies legally forming part of the regional authorities. The ASLs are responsible for assessing needs and providing comprehensive care to their local population, using either their own staff and facilities or contracting the services out to public hospital enterprises and for-profit and non-profit independent hospitals and specialist outpatient service providers. Private providers must be accredited and have a contract with the ASL. Tax contributions allocated to the National Health Fund have been redistributed horizontally between the regions using a weighted capitation mechanism. ASL services are financed by the regional governments. Each ASL is managed and governed by a general manager appointed by the regional department of health, based on his/her professional qualifications and technical skills. This general manager appoints a financial manager and a medical director. Services are structured according to a typical division-based model. Each division has financial autonomy over and technical responsibility for one of three different health care system areas (Legislative decrees No. 502/1992 andNo. 229/1999): • directly managed acute care and rehabilitation hospitals provide hospital-based acute inpatient, outpatient, and rehabilitation care; • health districts are sub-ASL geographical units responsible for coordinating and providing primary care, nonhospital-based specialist medicine, and residential and semi-residential care to their assigned populations; district physicians provide home care services, drug abuse prevention services, and care for terminal AIDS patients; • health promotion divisions are responsible for promoting health and preventing infectious and other diseases in the community; these divisions also provide services for monitoring environmental hazards, preventing occupational injuries, and supervising the production, distribution and consumption of food and beverages. • ASL divisions are organized as departments and run by healthcare professionals, who must have the clinical and managerial expertise needed to provide the health services, design an annual plan of activities, and allocate the resources obtained by means of negotiations with the ASL's general manager, consistently with regional and local plans and service programs. A department's activities are programmed, implemented, and monitored with the active participation of health professionals assigned to the department. The questionnaire was sent by e-mail; it consisted of 33 questions, with a brief socio-demographic section and three parts concerning the following domains: (1) work experience gained in some key HSG areas during the entire period of training; (2) perceived need for training in HSG areas. Answers were given on a 5-point Likert scale for training received (where 1 meant 'never', and 5 meant 'most of the time'), and for perceived training needs (where 1 = very low, and 5 = very high). An appropriate descriptive analysis was conducted, and absolute and relative frequencies were reported for categorical variables.
Health system governance framework design The second aim of the project, after describing the present situation in Italy as concerns training on HSG issues, with a view to helping directors of courses of specialization in hygiene and preventive medicine to cover all the competences required in HSG, was to define what the ''good governance'' of a public health system entails, in terms of the roles and responsibilities involved. Our public health system governance framework was developed based on the roles and responsibilities at various levels of governance in the context of the Italian health system. In defining roles and responsibilities, we considered 'planning' with two different functions: strategic planning and operational programming.
For each role, we identified the basic functions of the public health system's steward-managers, considering their respective positions in the ASL's divisional model and the activities required of each function. Competence integrates multiple components such as knowledge, skills, values and attitudes and changes with time, experience, and setting (Frank et al. 2010). We defined the competences needed for the various activities. We then generated a list of governance competencies that public health professionals need to have acquired in relation to their position within the health system, competencies that need to be learned by means of courses of specialization in public health, hygiene and preventive medicine, and higher-level continuing professional development schemes.

Results
Twenty-five (78.1 %) of the 32 Italian postgraduate schools of public health took part in this survey, and 299 (55.9 %) of the 535 public health residents attending courses in 2011 completed the questionnaire. Respondents were of a mean age of 32.4 ± 4.5 years (median 31 years), and 65.9 % of the sample were females. Ninety-four residents (31.4 %) were attending the first year of the course, 41 (13.7 %) the second, 52 (17.4) the third, and 112 (37.5 %) the fourth. Table 1 shows the percentage distributions (for each year of the course) of the public health issues never or almost never covered by the training that residents had received on HSG issues and that do not need further educational investments. The number of residents who had never or almost never received training on a given topic dropped over the 4 years of the course, but the topic of inequality-reducing strategies had never or almost never been covered by more than half of the residents, not even those in their last year of training. The questionnaire revealed that residents felt the need for more training on all the proposed HSG-related topics, and especially on mass media communication, health service programming, and human resource management.
The competencies needed for a good health system governance, based on the roles and responsibilities of medical doctors working for the Italian National Health Service (NHS), were defined for each of the different levels of governance involved in this system. Two different governance functions, health system governance and health service governance, were considered when defining roles and responsibilities. The planning process consists of different stages and requires the following activities at each stage: situation analysis and priority setting, considering the options, programming, implementation, monitoring, and assessment. From the governance perspective, a health system should be assessed considering specific parameters: appropriateness, efficiency, efficacy and effectiveness, accessibility, equity, continuity of care, promptness, humanization, and ethical worth (Fig. 1). Table 2 lists the subjects involved in health system governance: the Regional Health Directorate, the ASLs, and the managers and public health professionals who run a given health service. Tables 3, 4, and 5 show the activities and competences relating to each level of governance.

Discussion
The findings of this study show that not all HSG-related topics were adequately covered during the 4 years of postgraduate training received by our sample. On the whole, the trainees reported feeling the need for more training on all the broad topics considered, and especially on health service organization, human resource management, health communication and advocacy, and communication with policy-makers (and this was still true, albeit to a lesser degree, for trainees nearing the end of their course). Judging from our results, even though the proportion of residents reporting that they had received training of advocacy and communication with policymakers increased over the years, more than 40 % of the residents in the last year of their training had still gained no experience of such matters. In their relations with the public health operators of tomorrow, policy-makers may have more than a passive role as recipients of the latter's communications. Education for public health operators should be provided within the academic and professional spheres, of course, but policy-makers should be involved too. Public health skills and concepts need to be disseminated and engage more with local communities and policymakers (Gebbieet al. 2003).
Another point of interest concerns the lack of incremental training on issues related to the adoption of strategies to reduce healthcare disparities during postgraduate training courses. This is an enormous shortcoming for any training on matters of HSG, bearing in mind that the 2020 vision for the education of our next generation of public health leaders recommends that all students be imbued with the fundamental value of the relationship between individual and community health (Koh et al. 2011). Public Health professionals have to consider social determinants in all aspects of their work with a view to achieving the far-reaching goals of equity in healthcare, eliminating disparities and improving the health of all social groups.
A population healthcare-oriented approach should be promoted when defining medical education programs to shape future public health professionals capable of serving as stewards and managing the system's resources (Gray 2013).
The need for a better education on all HSG-related topics reported by trainees in the last year of their postgraduate course could be interpreted as a failing of the schools of specialization. Our residents' perceived need for further education could, therefore, be seen in a less negative light and interpreted as an appropriate demand for continuing professional development. The US Institute of Good governance competencies in public health to train public health physicians 741 Medicine of US Academies states that education in the public health sector-management aspects includedshould aim to instill a culture of lifelong learning (Gebbie et al. 2003). The approach taken to public health professionals' education can go beyond the traditional task of transmitting information to the more challenging job of developing the skills needed to access, discriminate, analyze, and use knowledge (Gebbie et al. 2003). Now, more than ever, the duty of academic institutions is to teach students how to think creatively to master large flows of information in search of solutions. This survey can serve as a starting point for future research with a view to designing a training plan for public health professionals that is better tailored to local priorities. A crucial gap exists between current public health needs and the extent to which public health workers are trained during their basic health education (Paccaud et al. 2013). Berkenbosch et al. (2013) showed differences in the perceived educational needs of medical residents in various countries that were attributable to the different structure of the health care systems in which they worked. Paccaud et al. (2013) suggested that, to be better able to understand the needs of the workers, and to prepare our educational institutions to meet these needs, we need a more cohesive understanding of where public health graduates are going when they enter the workforce and what they are doing. Public health academics need to develop training plans that respond to the needs and priorities of sometimes very diverse local contexts. Bjegovic-Mikanovic et al. (2013) found that public health education in Europe suffers from deficits in modernity, especially as regards continuing education, and the size and total number of public health schools and departments in Europe is far from being sufficient when  Have a practical understanding of what is involved, the time and resources needed to undertake assessments, and ensure sufficient integration of the results in the planning and commissioning of local services Identify the importance of a need in terms of frequency or severity, the evidence of the efficacy of interventions, or the feasibility of change (from social, health and economic perspectives) Define criteria coherent with principles to prioritize needs Involve other organizations such as social services, local authorities, volunteer groups, etc.… in the process of defining priorities Defining health objectives Establish priorities/value-laden choices/address a broader range of relevant values, such as trust, equity, accountability and fairness that are of concern to other partners and, not least, to the populations concerned Model effective group process behavior including listening, exchanging opinions, negotiating, rewarding, encouraging, and motivating Establishing strategic objectives and initiatives Analyze relationships between needs, and the supply and demand of services, to ascertain met and unmet needs Involve other organizations such as social services, local authorities, volunteer groups, etc.… (adopting principles and priorities defined by strategic planners) Establish strategic objectives and initiatives, together with financial and organizational criteria for managing health care organizations (based on objectives and principles defined by strategic planners) Epidemiological and economic analysis: conduct the analysis in the same way as for any good or service, but bear in mind that it has peculiar features that may mean that the usual assumptions on the effects of markets on resource allocation do not hold Epidemiological and economic analysis: judge the degree to which scarce resources are employed according to two main criteria: efficiency and equity Translate broad strategies into practical terms for others; build alliances, partnerships, and coalitions to improve the health of the community or population being served; identify and engage stakeholders in interdisciplinary projects to improve public health Monitor efficiency, effectiveness and appropriateness Understand the attribution or contribution of observed results to a program; define new policies and programs that respond to these challenges

Program assessment
Design assessments so that they reflect a program's stage of development, define the purpose of the assessment, its uses, and the questions to be answered Good governance competencies in public health to train public health physicians 743 Table 3 continued Function Activities

Competency
Devising policies and goals in cooperation with the regional health department Legislation provides the general manager with substantial autonomy in managing human, financial and technological resources. This autonomy is expressed in: A three-year strategic plan in which the general manager defines the organization's mission and goals, which should be consistent with the regional health plan An annual strategic program in which the general manager defines annual projects that contribute to achieving the objective in the plan   (2014) Good governance competencies in public health to train public health physicians 745 Table 4 Governance of particular health services-Level I: Subjects: Structure Manager (Italy,2015), e.g. Managers of acute care and rehabilitation hospitals-Managers of health districts Function Activities

Competency
Negotiating goals for services Adopt general health objectives (based on regional and local planning) Propose health objectives, based on regional and local values and principles, for future planning in order to deal with unmet needs Use evidence-and research-based health policies and programs Defining and monitoring service programs Propose program objectives consistent with regional and local plans Give local managers feedback on the progress of the program (  Assessing production processes Give Department Director data for use in process assessments Discuss the achievement of objectives with personnel and identify areas needing improvement Assess an action or program Analyze information to identify appropriate implications, uses, gaps and limitations compared with the levels achieved in the US. Public health schools and departments need to increase their efforts to ensure continuing professional development by designing and delivering training courses tailored to the needs of public health professionals and employers (Vukovic et al. 2014). Our survey did not assess the ability of public health medical employees to do their jobs, but we did define a framework of competences needed for good governance, with a view to highlighting the skills that public health professionals in stewardship roles on various levels have to use to govern the services of a public health system. Each level of training, specialization, Masters, PhD courses or similar schemes, has to assure the acquisition of competencies suited to the roles and functions of the various public health professionals and employers.
The method of representing competences in tiers was also adopted by the Council on Linkages between Academia and Public Health Practice (2014) in a document that identifies three levels of public health professional: Front Line Staff/Entry Level, Program Management/Supervisory Level, and Senior Management/Executive Level. Only two of these levels have managerial roles, however, whereas our framework included some managerial skills even for the first level in the hierarchy.
Public health starts with a foundation of science but inevitably requires moving into the dynamic realms of social strategy, political will, and interpersonal skill (Koh et al. 2011). Public health schools and departments need to develop more progressive curricula (Czabanowska et al. 2014b). In order to gain knowledge and skills, both basic and specific training objectives in the academic setting and professional training activities in health services are required. New training strategies must also be considered such as team-based learning (Frenk et al. 2010) and blended learning (Czabanowska et al. 2014b). Finally, young professional networks could offer their members to develop competencies in a multidisciplinary and international contest (Boyle and Ribeiro 2014).
No previously published studies appear to have defined such a framework of competencies needed for good governance, though the concept of good governance has attracted a good deal of attention in the public administration sector. In 'New Public Management', good governance means working together coherently without relying on governments, but rather following a principle of subsidiarity. The concept of good governance is increasingly being discussed in the context of public health too (Boffin 2002). Good governance is both ethically essential and instrumental to public health (Mikkelsen-Lopez et al. 2011). Good governance is part of a national-scale effort to achieve well-being through a 'Health in all Policies' approach, for instance, focusing all stakeholders on the target of improving population health; but it should be a core concept for public health on a local level too (Brand 2007).
This study tried to overcome the lack of consensus on the dimensions of governance, their scope, and purpose, by identifying the governance functions related to the tasks and responsibilities of public health professionals in stewardship roles. These governance functions were divided into levels. On the higher level of health system governance (strategic and operational planning activities), we have the Regional Health Directorate and the ASL manager. There are two different levels involved in operational programming, i.e. structure managers (hospitals manager, health districts manager, health promotion manager) and managers of a particular health service (a head of an hospital, or district or prevention service). Our study suggests that the core competencies needed for good governance could be taught sequentially, progressing from the lower to the higher stewardship roles.
The competences described by the previously mentioned Council on Linkages Between Academia and Public Health Practice (2014) are organized into eight domains, not functions, and they form a consensus set of skills for the broad practice of public health in any health system.
Many other competency frameworks have been developed for the public health sector and there is a fairly strong consensus in the USA and Europe on what key competency areas should be included in academic public health curricula (Czabanowska et al. 2014a). As part of the Leaders for European Public Health (LEPHIE) Erasmus Multilateral Curriculum Development Project supported by the EU Lifelong Learning Programme, a public health leadership competency framework was recently outlined to support the development of a competency-based European public health leadership curriculum (Czabanowska et al. , 2014a. The framework described here was designed to respond to the need for clarity and consensus regarding a set of essential competencies reflected in the practice of stewardship. It could also be useful for planning professional training in both the academic and the health system settings (for postgraduate training and continuing professional development). Today's public health educational institutions and public health professionals are searching for an interface and synergies between science and practice. Our framework could also be useful for assessing the curricula of public health professionals wishing to be employed in stewardship roles.
This study is affected by several limitations. The questionnaire administered did not assess all areas of training; nevertheless, the results indicated that some fundamental areas were not covered suggesting the need for a better structured HSG framework of competence to accomplish during the training period.

Conclusion
Our survey among Italian public health residents revealed a significant gap between the training currently provided for public health professionals and what these trainees would have wished to receive, in view of their future role and functions in our public health system. We defined the competencies needed for good governance in the setting of public health professionals operating in stewardship roles. The framework of competencies proposed here is by no means intended as an end product. Instead, it is offered to public health system experts as a preliminary tool for them to assess, test, revise, and improve. Good governance in public health systems is the ultimate goal and action must be taken to work towards this ideal.