Identifying core competencies for public health professionals in Uttar Pradesh, India: results from a Delphi exercise

Background Ensuring the public health to fulfill essential public health functions is a challenge in many low- and middle-income countries. The absence of an agreed set of core competencies to provide a basis for developing and assessing knowledge, skills, abilities, and attitudes contributes to this challenge. In Uttar Pradesh, India, where most staff are trained as clinicians, this study is aimed at identifying the requisite core competencies for health professionals in mid-level supervisory and program management roles to effectively perform their public health responsibilities. Methods We used a multi-step, interactive Delphi technique to develop an agreed set of public health competencies. A narrative review of core competency frameworks and key informant interviews with human resources for health experts in India were conducted to prepare an initial list of 40 competency statements in eight domains. We then organized a day-long workshop bringing together 22 public health experts and government officials from India, who added to and modified the initial list. After this, a revised list of 54 competency statements was rated on a 5-point Likert scale, with 1 as “not at all important” to 5 as “absolutely essential”. Aggregate statement scores were shared with the participants, who discussed the findings. Finally, the same list was returned to participants for an additional round of ratings. Stability between scores at different steps was identified using the Wilcoxon matched-pairs signed-rank test. Consensus was defined using the percent agreement criterion. 46 the 54 end reached on 48 across eight


Conclusions
This study produced a consensus set of core competencies and domains in public health that can be used to review current training practices, assess competencies of public health professionals, and revise or develop new training programs to address desired competencies in Uttar Pradesh. Findings from this study can also be used to support workforce development by informing competency-based job descriptions for recruitment and performance management and adapted for use elsewhere.

Background
A competent workforce is a prerequisite for a high performing public health system (1-4). However, many low-resource settings, including the state of Uttar Pradesh (UP) in India, struggle to ensure the health workforce has the appropriate public health competencies needed to perform public health functions effectively (5,6).
UP is the largest state in India, with almost 230 million people (7). As with many states in the country, UP continues to face several health workforce challenges. There are currently an estimated 9.1 health workers per 10,000 population compared to the WHO proposed Sustainable Development Goal index threshold of 44.5 health workers per 10,000 (8). There are no requirements for health workers to receive public health training, making it challenging to deliver essential public health functions for population health or professionally manage health services. In addition, there remain challenges related to improving the match between professional competencies and population health priorities, the mix of competencies among the health workforce, and the distribution of professionals across geographical areas-specifically rural and urban areas (9).
The identification of core competencies for public health professionals in UP provides a basis to address some of these challenges. Core competencies are key knowledge, skills, abilities, and attitudes that the health workforce should possess to effectively deliver essential public health functions like epidemiological surveillance, situation assessments, and health promotion (10,11). They draw on multiple public health disciplines and are not specific to a single program or topic. Core competencies should be defined for all employees in all positions throughout the public health system. However, competencies may be required at different proficiency levels for different cadres depending on the nature of their job responsibilities.
Around the world, efforts to develop core competencies for public health professionals have largely been made in High-Income Countries (HICs) and regions (12)(13)(14), and for the clinical health workforce (15)(16)(17), researchers working in low-resource settings (18), and public health academic programs (19)(20)(21). In India, the Public Health Foundation of India (PHFI), the Union Ministry of Health and Family Welfare (MOHFW), and others have developed core competencies frameworks for Master's in Public Health (MPH) programs and community medicine fellowships (22)(23)(24).
This study builds on these efforts and aims to identify the core competencies for public health professionals in supervisory or program management roles in UP. Currently, there is no public health cadre in the state, so these competencies are intended for professionals who have job responsibilities in public or population health. The identified core competencies are applicable to staff like Medical Officers (MOs), District Program Managers (DPMs), and Additional Chief Medical Officer (ACMO) who are senior to the frontline staff (i.e., ASHAs, Anganwadi workers) and junior to senior management and executive-level staff (i.e., Directors, Additional Directors, Chief Medical Officers) in the UP health system. Examples of responsibilities include developing operational plans to implement national programs, providing assistance in the formulation of village health and sanitation plans, undertaking financial and administrative duties, and organizing in-service training programs for staff in their facilities.
This study was undertaken as a part of broader efforts to strengthen public health worker performance, performance management, and training in the state. These efforts, particularly public health training, are timely given the national emphasis on health promotion and prevention through the creation of Health and Wellness Centers (HWCs) under the Ayushman Bharat program (25). The Indian national health policy (2017) has encouraged states to create a separate public health cadre (26). As UP contemplates developing its public health cadre, core competencies and subsequent training of current health officials can act as a stopgap measure to address current public health deficiencies. These can also inform the formal training that a public health cadre would need.

Methods
We employed the multi-step interactive Delphi technique called Estimate-Talk-Feedback-Estimate (EFTE), a widely-used consensus generating method that solicits opinions of experts through a series of carefully designed questionnaires and face-to-face discussions (27,28). We used the Delphi technique because of its various advantages including anonymity between participants-which minimizes group discussion biases; iteration with controlled feedback of group opinion-achieved through the use of successive questionnaires allowing participants to amend their views if they want; statistical aggregation of group response-which is shared with the participants, enabling them to see where their opinions lie relative to the group response; and expert input-ensuring that the participants are experts adequately informed in the topic (29).
We followed a total of eight steps in the Delphi technique, as outlined below and in Figure 1.

Generation of an initial list of relevant core competencies
We prepared an initial list of 40 competency statements across eight public health domains after undergoing a narrative review and synthesis of core competency frameworks globally and rapid qualitative interviews with Indian public health experts (see Supplementary  (22,23).
Rapid qualitative interviews were conducted with six Indian experts to identify context-specific core competencies to consider. Interviewees with knowledge and expertise in the competency identification of health workers and familiar with the UP context were purposively selected. We used a semi-structured interview guide to extract themes related to participants' understanding of public health and essential public health functions, their comprehension about public health competencies, core competencies required of mid-level public health workers to deliver these essential public health functions, and current challenges as well as opportunities to integrate core competencies in workforce development efforts. After this, we reviewed the transcripts of the interviews, determined sections relevant to the research question, inductively developed a coding system, and identified the material in the transcript related to each topic. We then reworked the competency statements to integrate the findings of the interviews.

Organization of a consensus workshop
We sought to arrive at a set of public health competencies through a consensus-building process that included a wide range of stakeholders, as this would likely increase the prospects of the results being used in workforce development (34). A one-day consensus generation workshop was held in Lucknow, Uttar Pradesh, on 26 July 2019. A diverse group of 22 participants with backgrounds in public health, professional education, and human resources for health representing the Government of UP (GoUP), academia, and public health Non-Governmental Organizations (NGOs) in India participated in the meeting. Table 1 provides the demographic characteristics of the participants. At the beginning of the Delphi process in the workshop, the lead author provided detailed background information to the participants about core competencies and the Delphi process to be used in making opinion judgments, and resolved any questions that participants had.

Revision and addition to the initial list
The 22 participants were divided into four separate groups, with approximately 6 participants per group. These groups were determined before the workshop to ensure heterogeneity of backgrounds among participants in each group.
A list of the initial 40 draft competencies (prepared in step 1) was given to each participant, who then modified and added to the list individually. Participants were asked to focus on amending the list in light of the critical competencies that they thought were necessary to work successfully as a public health program manager or supervisor in UP. In their groups, participants then discussed major changes and additions to the competency list. However, discussion regarding weights or importance of competency statements was discouraged to avoid groupthink and interfere with the goals of the process.

Compilation of amendments, and development of a modified list
The Delphi facilitators in each group (each with graduate training in public health, who were provided training specific to Delphi facilitation) consolidated the written amendments from the participants to decrease duplication and sought clarifications on competency phrasing if required. The facilitators then worked across groups to compile the list of additions and modifications to develop an updated competency list, which included 54 competency statements.

First Delphi scoring
This modified list of competency statements was presented to all 22 participants. They individually rated each of the 54 competency statements in terms of their importance on a five-point Likert scale, from 1 as "not at all important" to 5 as "absolutely essential." Participants then scored each statement on its own merit instead of comparing it against the other proposed competencies. They were encouraged to score based on how important they thought the competency is to provide public health services as a mid-level public health manager in UP currently.

Score compilation, analysis, and summarization
The questionnaire results from step 5 were compiled, analyzed, and summarized. Results were shared with individual groups and displayed to the panel. Competency statements were ranked from high (absolutely essential) to low (not at all important). Averages, median, and quartiles were shared with the participants to facilitate the discussion.

Discussion of results
Participants discussed the results of at least two domains pre-assigned to their groups. Delphi facilitators guided the discussions, and participants were allowed to question findings and suggest alternatives. Each group then reported back to the plenary on the main points from their discussions.

Second Delphi scoring
The same competency list was returned to the 19 remaining participants who were asked to rate these statements again.

Data analysis
After the workshop, the stability between Delphi scoring steps (steps 5 and 8 listed above) was assessed using Wilcoxon matched-pairs signed-rank test. Previous research shows that it is necessary to ensure that there is enough stability between Delphi scoring rounds to establish that the results are stable and reliable (35). A statement was considered stable if there was no statistically significant change in responses between the scoring steps for each statement (p≥0.05).
Consensus was identified using the percent agreement criterion. A statement was deemed to have reached consensus when over 80% of the participants ranked it as "very important=4" or "absolutely essential=5" in the second Delphi scoring step (step 8).
Data from the two Delphi scoring steps were entered into STATA 14.2 and analyzed (36). For both the scoring steps, the measures of central tendency (mean, median, and mode) and measures of dispersion (range, interquartile range, and standard deviation) were also calculated.

Results
Findings from the narrative review: International scenario of core competencies for public health professionals Based on the narrative review, we found similarities in domains and competencies across various core competency frameworks, as well as differences in their emphasis (see Supplementary Table 1 In reviewing the similarities and differences across the frameworks, we merged domains and competencies that were similar, and selected dissimilar ones that we deemed valuable in the UP context to be considered by the Delphi participants. We also reviewed Indian MPH core competency frameworks that have been proposed by PHFI and MOHFW, which identify 86 and 20 core competencies, respectively.

Findings from the Key Informant Interviews
Respondents underscored the importance of a variety of competencies, including those related to management. They discussed the significance of financial and human resource management, including the active supervision of teams. Given its highlighted importance, we separated management as two domains in the initial competency list-one that focused on policy and program management and the other on financial management and budgeting.
Assessment and analysis skills were also highlighted as important competency areas. Respondents

Findings from the Delphi workshop
Several changes were proposed in step 3-revision and addition to the initial list. Fourteen new competencies were added. See Table 2 for these additions and amendments, which formed the subsequent competency list that participants rated in the Delphi scoring rounds.
Public  [1] Bolded statements compose the final list of competencies. [2] Step 8 (second round of Delphi scoring) had three fewer participants compared to Step 5 (first round of scoring). All three participants who left were male, two of whom were government human resource planner, and one was an academic. Note: participants are the same people in each step, as no new participants were added between steps.
[3] Consensus was identified using percent agreement criterion. A statement was deemed to have reached consensus when over 80% of the participants ranked it as "very important=4" or "absolutely essential=5" in the second Delphi scoring step. The statements where no consensus was reached have been identified in the table above with a red text in the corresponding p-value.
[4] Stability between Delphi scoring steps was assessed using Wilcoxon matched-pairs signed-rank test. We considered a statement to be stable if there was no statistically significant change in responses between the scoring steps for each statement (p≥0.05). Statements where stability was not reached (p<0.05) have also been identified in red text in the table above. Given the importance of these competencies, we left them on our final list. We recognize that subsequent Delphi steps to generate stability in these statements would have been ideal.
* Competency statement was added in step 3-revision and addition of the list.

Discussion
We generated expert consensus on core competencies for public health professionals assuming midlevel management roles in Uttar Pradesh, India, using an interactive Delphi technique. Consensus was achieved on 48 competencies across eight domains in public health. These competencies represent the current requirements of health professionals to fulfill their job roles and to address the public health needs of UP.
To our knowledge, this is the first attempt to develop core competencies for practicing public health professionals in UP or elsewhere in India. There have been previous efforts in India to generate core competencies in public health education. However, an attempt to identify practice competencies in UP, and India more broadly, is novel. It is helpful to recognize the distinction between core competencies for public health professionals and those for students in educational programs.
Educational competencies tend to delineate the skills, knowledge, abilities, and attitudes that students are expected to achieve at the end of their academic programs. They may be organized around traditional academic disciplines like biostatistics, epidemiology, health policy and management, environmental health, and social and behavioral sciences. Professional competencies, on the other hand, reflect the current needs of the workforce, and these are considered to be at the foundation of individual and team success in the workplace (37).
The core competency framework developed in this study covers many of the competencies and domains identified in HICs. However, it also differs in its emphasis on policy and program This distinction may also reflect the weaknesses of health systems in resource-poor settings, and the need to train public health professionals in management-a vital lever to strengthening health systems (38).
There were six competencies-which belonged to public health sciences, assessment and analysis, policy and program management, partnerships and collaboration, and leadership domains-that did not achieve consensus in the second Delphi round and were removed from the final list.  (39,40). For this study, the cutoff point of 80%, stability criteria, and the composition of the expert panel were particularly relevant. In terms of the cutoff point, 80% or higher was chosen a priori because this threshold is common in many Delphi studies (41). However, the theoretical basis for such cutoff is unexplored (39). In terms of analysis, there were a few statements that did not meet the stability criteria, as indicated in Table 2. It would have been ideal to conduct subsequent Delphi scoring steps to attempt to generate stability in these statements as well.
However, given the time limitation, we were unable to do so.
Regarding the composition of the expert panel, panelists for this study were chosen after extensive consultations and online searches. However, some potential participants declined the invitation due to a lack of availability. These non-participants were similar in their backgrounds from the participants in the Delphi process. However, a different composition of Delphi participants may have resulted in a different final set of competency statements, as experts panels largely dictate the nature and content of the results in Delphi studies (29).

Conclusions
The core competencies identified with this research provide a unique starting point in UP to understand and meet health workforce development needs, manage performance, and advance the health of the communities they serve.
Specifically, the results can be used in the following ways. First, core competencies can be codified through a Government Order (GO), which will formalize the findings for government officials and help link future GoUP efforts in performance management to these competencies. Second, the results of this study can be used to develop a competency assessment instrument. Future research can assess the reliability and validity of that instrument, which can then be used to evaluate levels of competencies of health professionals working in management and supervisory roles in UP (42). The results of the assessment can inform appropriate training programs to address gaps in competencies.
Third, these results can be used to evaluate training programs offered through the State Institute of

Consent for publication
Not applicable.
Reliability and Validity of a New Survey to Assess Global Health Competencies of Health Professionals. Global Journal of Health Science. 2012;5(1):13-27. Figure 1 Step diagram of the process and results of identifying core competencies for public health professionals