Building a picture of core competencies to improve the performance of public health managers

Effective leadership and governance is a core pillar of a resilient health system, and yet remains inadequately monitored. Public health systems in many low to middle-income countries face poor allocation of resources, ineffective oversight, coalition building, quality control and accountability, which are symptomatic of poor leadership and governance, contributing to a sub-optimally performing health system. A technically sound solution to a health system problem may be evident on paper, but without the right set of managers and leaders to provide strategic direction, the intended outcomes are seldom achieved.

Managers, at all levels in the health system, are expected to display certain competencies (skills and behaviours) that drive performance within the health system. A key challenge health systems across the world grapple with is how to assess whether managers are performing their roles competently in the pursuit of delivering health system objectives. In our recent work, we have found that one way of answering this question is to create a framework that breaks competency into knowledge, skills and attitudes that enable a manager to perform a particular function effectively. Competency frameworks have been extensively used by organisations to manage aspects of the workforce but in some of our recent projects, we’ve adapted it to development programme contexts, to tackle issues around public sector capacity development.

A competency framework has multiple end uses for a government entity. It can serve as a reference point to clarify the roles of individuals within organisations by realigning the terms of reference for managers and clarify the functions the managers are expected to perform. Alternatively, it can be used as a capacity development tool to understand the current capacity levels of managers, identify gaps and take corrective measures for improvement. Once the expected competencies are internalised and understood, the framework can be developed into a performance measurement tool by using measurable methods for demarcating poor, better, and ideal performance across key competency areas to appraise the performance of the health managers. In some of our previous work, we have similarly used competency frameworks for multiple purposes including planning, developing and monitoring capacity.

In a recent public health project, we were faced with the challenge of developing a competency framework when there was limited availability of formal job descriptions for different cadre of managers. Furthermore, there was a stark discrepancy between what the managers did on the ground and some of the more generic terms of reference available as part of national government programmes. Developing a relevant competency framework in a context in which these functions are not clearly laid out, presented an interesting challenge.

The starting point was to consider the organisation’s stated objectives, and using that as a guiding light to identify the core functions managers were expected to perform. This was achieved through extensive fieldwork, which included interviewing not just the primary jobholders but a range of other stakeholders that work closely with the jobholder, such as the immediate subordinates, the supervisor and a few close peers. A grounded approach helped to embed our competency framework in the context in which individuals operate, which a theoretical job-description or a set of documents review alone would not have accomplished. This exercise enabled us to identify appropriate and contextually relevant behaviours and the levels of knowledge and skills managers need to display to perform their functions effectively.

These competencies were then clubbed into broader competency ‘buckets’ and further classified into essential competencies – or the minimum levels of competencies that a manager needed to have – and ‘good to have’ competencies. At this stage, it is essential to stress test the framework externally for validity and relevance. This was achieved through a round of validation interviews with experts who had not just a thorough understanding of the technical work undertaken by health system managers, but also the institutional constraints faced by managers in the system. We presented our competency framework to a wide range of stakeholders to understand what they felt the immediate utility of the framework could be in health systems.

We offer the following lessons for those interested in using this approach:

1. Strong and continuous stakeholder engagement: To make the framework useful for government counterparts, it is essential to actively engage and communicate with stakeholders that influence policy-making, right from the design phase to get their buy-in and understand the utility of the framework from their perspective. This includes stakeholders such as the ministry officials, key development partners, and local research organizations. This has a two-fold benefit – it ensures that the competency framework is designed in a way that is fit for purpose, and also that it is grounded in the contextual challenges that the health managers face on a daily basis.

2. Follow an adaptive and iterative approach: Be adaptable and open to discarding competency indicators that look crucial in theory but do not hold true to the context. This was especially relevant to our public health work in what was a severely capacity constrained environment, where even a basic competency framework was starting to look like a theoretical wish list! The field and expert interviews are a good source of information to make an informed decision on what is relevant and what can be discarded, and what are some of the “good to have indicators”; it is important to maintain a balance between “critical” and “good to have” indicators.

3. Lose the subjectivity: To the extent possible, remove the subjectivity from the competency indicators so they are easy to apply and use. Ensure the competency indicators are tangible and can clearly be observed. If a particular government agency decides to use the competency framework as a performance management tool, each of the competencies will need to be further broken down into either measurable indicators, or observable behaviours.

This approach is a first step in addressing the problem of performance measurement and management, which is central to a performant health system. Government agencies and other technical assistance partners can follow a similar approach to develop a bespoke competency framework to track the performance of managers and providers, steps to build capacity over time.

By Alok Rajan and Silky Agrawal