Results of the systematic review and meta-synthesis phase
These 12 studies were published over 12 years from 2005 to 2017. These studies have been conducted in 6 developed countries (including the United States, Australia, Canada, Ireland, Spain, and the United Kingdom) (17-27) and 1 developing country (Iran) (28). The focus of this study was on health headquarters working in the health sector. All 12 studies used qualitative methods (including focus group, call, semi-structured, and structured interviews, Delphi, and expert panel).
Based on the results of this stage of the study, a total of seven main themes were obtained, which are: 1) Leadership and management (14 sub-themes), 2) analysis, interpretation, and reporting (6 sub-themes), 3) public health knowledge (7 sub-themes), 4) Interpersonal relationships (5 sub-themes), 5) individual competencies (8 sub-themes), 6) Cultural and community competencies (8 sub-themes), and (7) global health competencies (3 sub-themes). Also, based on the results of this stage of the research, about 42% of the obtained codes were related to management and leadership competencies and its sub-themes. For more information, see the published article from this stage of the study. Table 1 shows a summary of the information obtained from this stage (see the published article for more information)(12).
Descriptive results (interview) - Competencies of health headquarters
To find the competencies of the health headquarters from the experts' point of view, the data were saturated by interviewing a total of twenty-six participants among the experts. Three people refused to participate because of their responsibility in health organization during covid-19 pandemic. All of participants was PhD with experience in field of HRH. Finally, six main themes (as competency categories) and thirty-four sub-themes were extracted from this stage. Most of the duplicate codes were related to leadership and management competencies, analysis, interpretation and reporting competencies, and individual competencies, each of which is described below.
- Leadership and management competencies
Leadership competencies in an organization are the effective abilities by which a person can create an inspiring picture of the future, motivate people to follow the organization's vision, and ultimately effectively guide people toward the organization's goals. Leadership competencies are leadership skills and behaviors that contribute to optimal performance in organizations.
- Leadership and related skills
Leadership is important for all organizations to achieve their goals. Since leadership is a key factor in improving organizational performance, the success or failure of the organization depends on the effectiveness of leadership at all levels. One of the key points about leadership is the ability to motivate other experts. Regarding the need to have the ability to motivate, one expert said:
"The ability of a health headquarter to motivate and persuade subordinate units, that is, to lead and manage them, is very important" (P4).
- Policymaking and related skills
Policy-making in the health system is a combination of economics, sociology, anthropology, political science, public health, and epidemiology that provides a comprehensive picture of how health systems comply with health policies and seek to understand and improve the achievement of collective health goals. One of the interviewees said in this regard:
"What is certain is that we all have no doubt that policy-making is necessarily a headquarter task, so we need to see what skills are needed for policy-making and supervising" (P23).
- Planning and related skills
Planning skills are the best solution for sharing critical and limited resources. If this method is used correctly and scientifically, it will lead to significant results in achieving the goals. Experts emphasized the ability to plan at all levels, as one of the interviewees said about the importance of planning skills for health headquarters:
"An expert who plans at the macro level should be able to plan based on international and upstream policies" (P10).
- Organizing and related skills
The organizing is defined as identifying and categorizing required activities, grouping essential activities into achievable goals, assigning a group of activities to a manager and delegating authority to supervise them, and providing horizontal and vertical coordination in the organizational structure.
Regarding the importance of organizing skills for the health headquarters, one of the experts said:
"These experts should be familiar with the skill of labor division in a department to avoid interfering and overlapping responsibilities. Also, every task should be left to people who are capable of it. Also, all people should work coherently and as a whole, so that each work is complementary to the other" (P11).
- Financial management and related skills
Financial management includes the method of financing and the type of allocation. This applies not only to long-term resource budgeting but also to short-term resources such as current assets. the lack of financial skills in the health headquarters of the Ministry of Health will lead to decisions that affect the entire health system. In this regard, one of the experts said:
"Since many of the decisions that are made in healthcare organizations have important outcomes, especially in the field of finance, the health headquarters should have financial management skills in addition to policy-making and planning" (P7).
- Control management and related skills
Control is an ongoing process to ensure that actual results are in line with planned schedules. about the health headquarters should be familiar with this skill. In this regard, one of the experts said:
"What is certain is that control and supervising activities are necessarily the duties of health headquarters, so we should see what skills are needed to monitor and control" (P25).
Another issue that one of the experts mentioned was paying attention to process control instead of controlling people. He said:
"These experts should also be familiar with the issue of control and supervising. What a health headquarter should control is not the people but the projects, resources, events, and activities that people are involved with (P17).
- Change management and process improvement skills
Change management is a skill used for preparing, equipping, and supporting individuals to successfully adapt to change. Change management is done by providing guidelines to create the ground for organizational success and achieve the desired goals. Regarding the need to familiarize the health headquarters with change management skills, one of the experts said:
"One of the most important skills that a health headquarter should have is the ability to manage change, especially in health organizations that face a variety of issues and challenges, and to be able to make the changes made at the system level completely transparent to the members of his/her subset, and reduce their resistance” (P19).
Time management skill is one of the acquired skills that lead to improving people's working life. Regarding the importance and position of this skill in the health headquarters, one of the experts said:
"These experts should be able to manage all their work programs using time management skills. Sometimes the small tasks assigned to the experts are so delayed that it becomes a problem" (P4).
- Empowerment and counseling and related skills
In personal productivity, the organization uses the set of potential talents and abilities of the individual to advance the organization. Also, the organization by activating the potential forces and talents of the individuals aligns them with the goals of the organization. Therefore, effective management of these valuable resources is necessary to achieve the goals of the organization. Regarding the need for empowerment skills in the health headquarters, one of the experts said:
"The issue of empowering others to be able to transfer their competencies to other people is very important" (P5).
- Competencies related to analysis, interpretation, and reporting
The set of skills of this category to collect, process, analyze, interpret, and reporting data provides significant assistance to health headquarters. Information analysis deals with the process of predicting events and probabilities, based on current data, which will happen in the future. Based on the interviews with their experts, these skills are classified into the following six themes:
The analysis is the breaking of a set into smaller pieces to better understand it. A basic acquaintance with statistics is essential for health headquarters. in this regard, one of the experts said:
"Health headquarters should be familiar with the statistics to some extent (basic for lower levels and advanced for higher levels). They should know statistics to give statistical analysis" (P22).
In the field of research, familiarity with the methods of conducting quantitative and qualitative research was another important issue for experts. One of the experts, while considering the ability to conduct qualitative research more important, said:
"The policymaker must be able to conduct qualitative studies and be fully acquainted with them. The discussion of ability in qualitative studies is important because many studies cannot be estimated quantitatively" (P9).
- Topic or subject recognition skills
Problem-solving, as a scientific concept, has key elements with specific definitions and concepts that while being aware of them, one can understand the problem and separate it from other similar concepts, as well as analyze different types of problems from different points of view. Regarding the importance of this skill in the health headquarters, one of the experts said:
"health headquarters who feed the policymakers and can identify issues in-depth, have a very important status especially in the service sector" (P20).
- The skills of collecting, analyzing, and interpreting data
Gathering information is one of the most important parts of any scientific process. If this is done regularly and correctly, the work of analyzing and concluding the data will be done with good speed and accuracy. One of the experts said about this skill and related abilities:
"The health headquarters should be able to collect and process information" (P16).
Another skill in this area is the ability to analyze. The analysis is the analyst's mental effort to simplify complex concepts, to understand the components of a phenomenon, to examine the relationship between the analyzed phenomenon and other phenomena, and to predict future developments. Regarding the importance of this skill in health headquarters, one of the experts said:
"A very important characteristic that both executive experts and health headquarters should have is analytical skills, that is, to be able to analyze issues well" (P24).
Interpretation is expressed by taking a critical position on a particular event or incident. The interpreter, by in-depth examination, presents various and relatively invisible aspects of the event to the audience. Also, depending on the expertise and ability of the interpreter to understand and respond to the needs of the audience, the roots of the event are identified and its possible consequences are anticipated. One of the experts said in this regard:
"Having the ability to interpret at this level is essential for the health headquarters. This skill is the ability to reveal hidden layers that are vaguely formed in analyzes and topics and require further explanation” (P13).
- Problem-solving, solution-providing, and decision-making skills
Problem-solving skills and abilities help people to solve problems that have occurred in their career path. One of the elites said about the importance and necessity of this skill in the health headquarters:
"He/she must be able to identify solutions to those problems. He/she must also know how to achieve these solutions, for example, he/she should be able to ask elite people for advice on the problem-solving or use other facilities" (P14).
Another skill that was considered by experts in this sub-theme was decision-making skills. Decision-making skills are the process of choosing a course of action from a variety of actions. The process involves using what you have (or can provide) to achieve what you want. In this regard, one expert said:
"Sometimes managers do not allow this skill to be strengthened in experts. That is, managers, think that an expert should only have the power to support decisions, but in my opinion, an expert should also have the ability to make decisions. That is, he should have the power to decide at the moment" (P3).
- Follow-up analysis and getting feedback on implemented solutions
Feedback is information that people receive based on their performance. This information includes messages sent by the sender of the message to the recipient of the message. Regarding the importance of using feedback skills (receiving and presenting), one expert said:
"Another ability is the issue of receiving and providing feedback after each decision. Receiving feedback from the manager, colleagues, and people who are influenced by the decisions, especially in the subordinate units, is very effective in improving an individual's performance" (P11).
- Reporting and related skills
Reporting is the writing of news, information, facts, causes of problems, and their logical and sequential analysis to achieve the correct solution. The report should be concise and clear. Regarding the importance of reporting skills of health headquarters, one of the experts said:
"In many cases, managers do not know what they want. If the headquarter is a creative one, he/she can create a decision feed for his/her managers. He must be able to manage crises. Many things that are done by the headquarters must be reported and completed quickly" (P8).
- Competencies related to interpersonal relationships
Carrying out any activity, including planning, organizing, coordinating, leading, and supervising, requires the establishment of these relationships. By strengthening flat organizational structures and transformational leadership styles, organizations' need for experts with interpersonal competencies also increases.
Communication skills refer to the ability to communicate information to others effectively and efficiently, which can improve a person's personal and professional communication. It is communication skills that determine the effectiveness of communication.
Regarding the importance of this skill in establishing effective communication with the subordinate units, one expert said:
"If a headquarter is unable to communicate with the subordinate units he/she cannot convey his/her messages and instructions to them" (P1).
Teamwork is one of the skills used to meet the challenges of today's competitive environment, as a way to increase organizational flexibility and achieve other benefits such as cost reduction, faster processes, innovation, effective decision making, higher work conscience, and better service. Regarding the importance of this skill at all levels of health headquarters, one expert said:
"Teamwork is not related to levels and status. Thus, all members should have this ability" (P3).
The skill of building effective and constructive relationships is called networking. In networking, you connect with people with whom you want to share information, gain support, enter into deeper relationships, share your ideas and interests, or show a sense of belonging. Regarding the need for the experts who are familiar with networking, one of the experts said:
"High-level health headquarters must know networking and should be able to identify and use different networks because, at these levels, works cannot be done without networking" (P21).
- Establish effective international communication and related skills
Given that the issue of health is one of the topics for which no boundaries can be imagined, it is necessary to have skills related to communication at the international level. One of the experts said in this regard:
"Diseases exist all over the world. Therefore, we should be in constant interaction with the whole world and have the ability to communicate to exchange information. For example, given the nature of today's world, health headquarters should learn other languages and gain knowledge of other countries' systems through research" (P26).
The ability of each person to do different things is called individual skill. Individual skill is learnable and teachable and is acquired and improved through experience. So it can be said that skill is the ability to do a job or activity. Of course, sometimes this ability is related to the thoughts and vision of an individual and is not physical.
Creative thinking means the power to develop new solutions to problems, and this is another expression outside the framework of thinking.
Explaining the importance of this skill in the health headquarters, one of the experts said:
"The characteristic of this skill is that it helps other skills as well, meaning that the person is not content with just his own experiences and his thoughts are flexible so that he can try to create new things" (P12).
- Having systemic thinking skills
Systems thinking helps people examine the relation between structures, patterns, and events, and not just pay attention to the observations. Systems thinking is based on a kind of holistic approach that cannot be understood by analysis. Systems thinking focuses on how the subject interacts with other components of the system. One of the experts said in this regard:
"They must have a holistic and systematic view, that is, look at the issue through the entire health system and see their place in the health system, which requires knowledge about the health system" (P8).
Critical thinking means correct thinking in the pursuit of relevant and reliable knowledge about the world. Regarding the importance of this skill in the health headquarters, one of the experts said:
"One of the most important things is to have the ability to think critically. When we monitor, we give it credit, which means that our goal is to improve the process. Whatever our goal is, we must have critical thinking" (P3).
- Skills related to ethics and moral values
The issue of ethics has always been considered because of its scientific place in the culture of societies. One of the interviewees believed that the issue of professional ethics is a common skill that should be acquired by all those who work at every level of the health system. He said in this regard:
"Some competencies, such as ethics, seem to be common to all people working in the health system" (P2).
Another expert addressed the issue of responsibility and accountability and the importance of their existence as a skill related to ethics and said:
"responsibility and accountability are needed at all levels, but accountability is more needed at higher levels. It is something that many people do not have, of course” (P3).
- Skills to develop individual capabilities
Personal development is an effort and investment to develop individual skills. One of the experts said about the reasons for the need for this skill in health headquarters:
"Science is constantly changing. As a result, the health headquarters must be able to use the new sciences "(P9).
- Individual management and related skills
These skills help a person to manage and control himself/herself in a variety of situations. One of these skills is anger management, that is, learning to control anger and the skill of maintaining calm and composure. Another skill is stress management. This skill refers to a wide range of techniques and methods that are designed to control the level of individual stress, especially chronic stress, and improve a person's daily functioning. One of the experts said in this regard:
"It is very important for professionals working at this level to be familiar with stress management skills because they constantly face various pressures” (P11).
Conflict is inevitable in the organization and is not necessarily "unnecessary" for the organization. Conflict can increase creativity and promote innovation and change or may waste energy and resources of the organization. Therefore, the ability to lead and control the phenomenon of conflict in organizations is one of the most important skills. Another related skill is self-motivation skill. Self-motivation means the ability to motivate oneself to move forward. This issue was also of interest to the experts (P8) (P10).
- Cultural and community competencies
Culture is defined as a complex set of knowledge, beliefs, arts, laws, ethics, habits, and whatever one learns as a member of the community. Social culture is also composed of systematic subsets and elements such as values, beliefs, customs, and norms. There are different cultural systems in different societies. Also, there are subcultures within a large and wide cultural system.
- Familiarity with community health culture
A health culture is a coherent and systematic set of goals, values, beliefs, customs, and norms of a people belonging to a large community, ethnicity, or nation that leads to effective unhealthy and healthy behaviors. One of the experts said in this regard:
"Familiarity with the overall health culture program, which is a set of values, beliefs, and norms that meet the needs of everyday life, is very important for someone who works as a member in this organizational set" (P7).
- knowledge about the health system
The health system consists of all organizations, institutions, and resources that provide services to maintain and promote the health of individuals. The need to get acquainted with this system is important for the health headquarters. One of the experts stated in this regard:
"The health headquarters should be familiar with the structure of the health system. When a person works in the Ministry of Health, he must know what components the health system consists of and what its pillars are and be familiar with the process” (P9).
- Advocacy and related skills
Many health programs designed to change behavior are not possible without reforming the minds of decision-makers and changing public policy. One of the experts said in this regard:
"Another skill needed by health headquarters is to know the situation and structures outside the health system. They should seek support and advocacy from and interact with other existing social organizations so that they move them in the direction of health goals” (P6).
- Familiarity with the structure of international health
The health systems of each country are affected by international organizations involved in the field of health. According to one of the experts, familiarity with international organizations involved in the field of health is one of the competencies required by health headquarters. He said in this regard:
"Experts should be familiar with various international and domestic issues in their field. For example, they should follow the news of the World Health Organization and be aware of the information and news inside the country so that they can update their information. They must acquire these skills at the level of macro-politics" (P10).
- Competencies related to administrative activities in the health sector
Working in the public health environment requires a set of skills, abilities, and knowledge that the lack of any of them can lead to dysfunction of experts.
- Familiarity with the related rules, regulations, and guidelines
Familiarity with the related rules, regulations, and guidelines provides a clear picture of duties and responsibilities. Familiarity with the rules is considered a relative and general requirement for experts in the current situation, and the lack of initial knowledge will cause huge losses and unpleasant events. One of the experts said in this regard:
"Since health headquarters prepare regulations in the organization, so they must be familiar with the legal basis of the creation of these documents, otherwise the organization will faces problems" (P6).
Familiarity with the related rules, regulations, and guidelines was also considered as an undeniable necessity from the perspective of experts (P8), (P2) and (P4).
- Familiarity with administrative correspondence
Administrative correspondence is the official language of the organization and will lead to the success and development of the organization. Therefore, administrative correspondence plays an important role in the administrative structure. It also indicates the level of knowledge and expertise of experts and managers of the organization. One of the experts said in this regard:
"The skill of doing administrative correspondence is very important for someone who works in the headquarters. There are problems at all levels. Familiarity with administrative correspondence and knowing the hierarchy of correspondence are of the most important skills" (P4).
- Familiarity with computer science and related software
Every employee, regardless of his/her position, should be familiar with a series of specific skills to use technology practically. One of the experts said in this regard:
"Another important issue is the familiarity of health headquarters with different software" (P10).
- The skill of honoring the customer
Proper communication of experts of public and private organizations with the client and providing services to them through desirable and appropriate methods, plays an effective role in improving the quality of services and customer satisfaction and correction of their view toward the relevant organization. One of the experts said about having this skill in the health headquarters:
"Being customer-oriented, the customer of here can be experts in other areas, and not just outsiders, so this is also important. The relationship with other clients is also very important. Being customer-centered and customer-oriented are important capabilities " (P10).
Descriptive results of the third stage: designing a proposed model of competence of health headquarters
According to the results obtained from the analysis of the results of the previous steps, the competencies extracted for each level of health headquarters were determined. The summary of the results obtained from this stage of the research can be seen in Table 2
Descriptive results of the fourth stage: Validation of the proposed model of general competencies of health headquarters by Delphi method
After analyzing the data obtained from the Mini-Delphi stage, interviews and meta-analyses of six themes and thirty-eight sub-themes were obtained to design a model of general competencies to recruit health headquarters. By merging the elements and components obtained from the previous steps, duplicate cases were removed and similar cases, which were mostly cited in the obtained evidence, were extracted. Finally, a questionnaire was designed to conduct Delphi based on the criterion of the need for competency at each level. After sending the questionnaire, 15 questionnaires were completed and collected. About 60% of the participants in this stage were women. Most of the participants had a Ph.D. degree (73%).
After analyzing the results obtained from the first Delphi stage regarding the competencies required by the experts of the third level of the headquarters, all (100%) of the competencies were approved (average agreement scores above 75%). Regarding the competencies required by the second level of health headquarters, 29 competencies out of 38 items were approved in the first stage of Delphi (65.8% of the competencies). 9 competencies entered the second Delphi stage (average agreement scores below 75%) in which seven items were approved. Also, the two items "Planning and related skills" and "Problem-solving, solution-providing, and decision-making skills" were removed from the set of competencies required for this category (average agreement scores less than 75%). Also, regarding the competencies required by the first group of health headquarters, all 13 categories of competencies were agreed upon by the respondents in the first Delphi stage.
Finally, in the third stage of Delphi, to determine the level of competencies required by each group of experts, three-level questionnaires (high level, medium level, low level) were designed and sent. 15 answers were obtained at this stage. Then, based on the method mentioned in the third chapter, the required level of each competency in each group of experts was determined.
Finally, after applying the opinions of respondents in the Delphi stage, the final competency model of the health headquarters was redesigned. Fig. ... shows the final model of the general competencies of the health headquarters.