A Needs Assessment for Postgraduate Training in Selected Public Health Disciplines at the University of Zambia: A Mixed Methods Study

Background: As most low and middle-income countries seek to achieve universal health coverage targets, there is an ever-increasing need to train human resources with the required core skills and competencies. This study reports on the needs assessment conducted to understand postgraduate training needs for three selected public health disciplines – Health Policy and Systems, Health Economics, and Healthcare Management and Planning – at the University of Zambia. Methods: The study adopted a cross sectional survey design. Data were collected through semi-structured interviews administered to 32 participants, identified through a comprehensive stakeholder mapping process, holding selected management positions in public and private health service organisations across Zambia. The organisations included regulatory authorities, research institutions, government ministries, insurance firms, multilateral and health services organisations. Results: Overall, more than 68% of the stakeholders reported that they had no employees that were formally trained in the three disciplines. More than 90% of the stakeholders opined that training in these disciplines would be beneficial in providing competencies to strengthen service provision. The horizontal skills mismatch for health economics, and health services management and planning were found to be 93% and 100%, respectively. Among the key public health training needs were: policy development and analysis, economic evaluation, and strategic management. Conclusions: This study confirms that introducing post graduate training in the proposed public health disciplines will not only benefit Zambian health services organisations, but also help strengthen the health systems in general. For other empirical contexts, the findings imply the need for the introduction of academic programmes which respond to ever-changing public health skills demanded; and should be matched with local priorities and service delivery. Key words: Health policy & systems, health services management & planning, health economics.


Background
Human resource for health is one of the six building blocks of a health system. Inadequately trained or unequally distributed health workers hampers the goal of providing access to quality health care to achieve Universal Health Coverage as espoused in the Sustainable Development Goals (SDGs). systems strengthening [13,14]. Indeed, it goes without mentioning that the current double burden of communicable and non-communicable diseases grappling most LMICs requires reorganisation and realignment of health systems, which can greatly benefit from the mentioned disciplines.
In Zambia, the need to expand public health training has seen the establishment of the first ever school of Public Health in Zambia at the University of Zambia -the leading public university in the country [15]. The School intends to introduce a number of postgraduate and undergraduate programs in various fields of public health. Before introducing new training programs, it is important to conduct a needs assessment so as to match public health training and service delivery needs, and more so, to gauge demand for the proposed training programs [16]. Various studies have conducted training needs across different public health domains [17][18][19][20]. These studies have been very critical in the development of appropriate public health training programs and core competencies. However, there is limited evidence particularly in sub-Saharan Africa around needs assessments for public health training programs. Thus, we conducted a needs assessment to understand postgraduate training needs and service gaps for selected public health disciplines; Health Policy and Systems, Health Economics, and Healthcare Management and Planning.

Methods 2.1 Research Design
The study adopted a cross sectional survey design, encompassing both open and closed ended questions. This enabled us to strengthen knowledge triangulation and ensure validity of findings [21] relating to the training needs and skills gaps of interest for health service organisations.

Sample and Sampling Techniques
Thirty-two semi-structured interviews with key health sector stakeholders in Zambia were conducted.
The stakeholders were purposefully sampled from local public and private health service organisations including; health insurance companies, relevant government departments, former and practising public health graduates, health professional association leaders, regulatory authorities, research institutes, and local and international organisations working in the health sector. The respondents were almost evenly split between public and private health service organisations (HSOs).
Seventeen (17) were public HSOs while fifteen (15) were private HSOs. The respondents were drawn from a number of regulatory authorities, line ministries, insurance providers, health service providers, international partners, and public health research organisations. Stakeholder mapping was used to identify key stakeholders to participate in the study. Stakeholder mapping is particularly useful when the aim is to produce a prioritised list of stakeholders for a given undertaking [22]. Using this technique, stakeholders who are more likely to be competent enough to comment on context specific training needs for each of the four disciplines. The breakdown of the final sample is summarised in

Data Analysis
The data collected were entered and organised in Microsoft Excel 2013. Quantitative data was analysed using proportions and tables. The analysis of quantitative data was conducted in the following manner. Firstly, we analysed the proportion of organisations who reported to have had people formally trained and the level of training in the three public health disciplines: Health Policy and Systems, Health Economics, and Healthcare Services Management and Planning. Secondly, we examined the skill gaps by examining the proportion of organisations who would find training across the three disciplines beneficial. In particular, we present the proportion of respondents who thought that training in each of the three disciplines would be beneficial to their organisations as well as their rating of the skills gap for each discipline. Relatedly, for each discipline, the specific skills required in order of importance were also identified.
Lastly, we assessed the skills mismatches relating to health economics, and health services management and planning. The concept of 'skill mismatch' is multidimensional. It is commonly defined in two ways: vertical or horizontal mismatch. Vertical skills mismatch refers to a situation where the level of education or skills is either less or more than is required to perform a given job. On the other hand, horizontal skills mismatch exits whenever an employee's level of education or skills is not appropriate to perform a given job [23]. In this study, we defined the skills mismatch from a horizontal perspective. In particular, a skills mismatch is said to exist whenever we have employees performing roles relating to Health Policy and Systems, Health Economics, and Healthcare Management and Planning, for which they are not formally trained.
Data from the open-ended questions was analysed using thematic analysis. The text across the three predetermined themes; health policy and systems training, health economics training and health services management and planning was read and re-read. The data was then summarised by theme, across the different stakeholders included in the study. The open text format allowed for the capture of training needs in the words of the participants.

Ethical Considerations
This study was grated ethical exemption by the University of Zambia Biomedical Research Ethics Committee (UNZABREC) as it was deemed to fall under non-human subject research (attached as a supplementary file). Administrative permission to conduct the study was obtained from the National Health Research Authority (NHRA) as provided by the Zambian law. We ensured confidentiality by deidentifying all the data and only respondents who verbally consented were interviewed. This approach to obtaining informed consent was approved by UNZABREC. The approach was appropriate since the study was broadly classified within the realm of non-human subject research.

Results
All 32 potential respondents who were identified in the stakeholder mapping also responded to the questionnaire. This represents a response rate of 100%. Key results from the study are summarised in the sections below.

Level of Training
We first report on the levels of training in the specified public health disciplines, skills gaps and need for training. In particular, the respondents indicated whether their organisation had anyone with some training in each of the three public health disciplines (see Table 2). For health policy and systems, 56% of the respondents indicated that no one had been formally trained in their organisation. For those who reported having had some form of training in the health policy and systems, 19% were trained at masters' level, 13% had received in-service training, 9% had been trained at the bachelor's degree level, and 3% at the PhD level. However, it is important to note that in almost all instances the health policy and systems training was received as a part of training in other public health disciplines and not as a specialist field of study.
Only 34% of the respondents reported having someone with some training in health economics in their organisation. Among those trained, 3% received in-service training, 3% were trained at the bachelor's degree level, and 28% at the master's degree level. In terms of full or specialized training, only one respondent reported having had someone in the organisation specially trained in health economics; at the master's level. The rest received health economics training either in-service or as part of other public health related training.
For health services management and planning training, only 22% of the respondents reported having had some training in health services management and planning. Of these, 3% had received in-service training, 3% at the bachelor's degree level, and 16% at the master's degree level. Strikingly, none of the people trained had a full or specialized training in health services management and planning.

Stakeholder Perspectives on Training Needs and Skills Gap
Almost all organizations indicated that training in the proposed public health disciplines would be beneficial to their organizations (see Table 3). We found that 94% of the respondents felt that specialized postgraduate programs in health policy and systems as well as health economics would be very beneficial to their organisations. In addition, 91% of the respondents were of the view that formal training in health services management and planning would benefit their organisations. In terms of the extent of benefit, we asked respondents to indicate, on a Likert scale (High, Medium, and Low), how important specialized training for each discipline would be for their organization. Most respondents indicated that the need is high (see Table 4). In particular, across all three disciplines, at least two-thirds of the respondents were of the view that formal training in these fields was a matter of agency; while at least a quarter of the respondents were of the view that skills gap across the three fields was moderate. report some of these views using the exact text as provided by the respondents. These views illustrate participants' perspectives on why training in the three discipline is critical, and more so, what kind of competencies they expected and how they would benefit their organisations.

Health Policy and Systems Training
Most of the participants agreed that health policy and systems training was important across the entire health sector. They thought having many professionals trained in health policy and systems would provide competencies to improve the running of the health sector. It would help change paradigm shift from mostly focusing on clinical challenges within the health system, but also focus on supporting functions and how the interact with broader structural factors within which services are provided. Furthermore, health policy and systems was said to be critical in providing skills to people to handle systems issues like managing change within health systems and being able to set achieve strategic goals for population health improvement. It was also stated that health policy and systems training at postgraduate level had a greater role to with regards facilitating innovative research to strengthen health systems.

Skills Training Needs
We also identified the particular skills training needed in order of importance. These are summarized in Table 5. For health policy and systems training, the top skills desired were policy analysis and planning, monitoring and evaluation of health programs, and health systems research capacity; followed by implementation and management of health programs, change management, and training relating to policy, politics and power; in that order. For health economics training, the most pressing skills needs are health care financing, economic evaluation of health programs; followed by decision analytic modelling, and health economics research capacity. There is also a demand for training in the operations of the health insurance market and measuring health system efficiency. For health services management and training, the most sought out skill was strategic management in health programs, followed by leadership and management in health programs, and program implementation.

Skills Mismatch
An alternative way of looking at the skills gap is to look at the skills mismatch -the misplacement of skills for a given job description. In this study, this is taken to imply a situation where a person not formally trained (as part of a specialist programme) to perform roles related to a given public health field is performing those roles. We found significant horizontal skills mismatch in both health economics and health services management and planning (see Table 6). All people performing roles relating to health services management and planning were not formally trained to perform them. For health economics related roles, 93% of people performing them were not formally trained.

Discussion
Achieving universal health coverage (UHC) requires a well-trained health workforce. This study has highlighted the significant skills gap which exists across selected public health disciplines. For example, the study found that almost two-thirds of stakeholders indicated a lack of capacity in health policy and systems training. They also indicated the need to introduce formal programme training in this public health discipline. The skills gaps in health systems and training is not unique to Zambia.
Uzochukwu and colleagues highlight the inadequacy in health policy and systems capacity in Nigeria, and the subsequent reliance on the developed world for training (19).
With respect to health economics, the study finds that almost 70% of the stakeholders report that no staff members were formally trained in relevant health economics components. The most sought after competencies were in health care financing and economic evaluation. The latter competency was also found to have the most significant knowledge gap in a recent study on health economics knowledge needs assessment for Latin America (20). For organisations with a staff member performing health economics-related roles, we found a horizontal skills mis-match of 93%; a further reflection of the health economics knowledge gap.
An important finding of this study was that health services management and planning had the highest skills gap across the three disciplines. It also had a horizontal skills mis-match of 100%. The depth of the skills gap in health services management and planning is also pronounced in other sub-Saharan African contexts. For example, a self-assessed assessment of relevant health services management skills among healthcare managers in South Africa find significant skills gaps in strategic planning, health delivery and people management (21).
Overall, the study has identified significant skills gaps across the selected disciplines. The study also uncovers evidence that similar skills gaps are present in other sub-Saharan African contexts such as Nigeria and South Africa as well as other developing contexts such as Latin America. An important implication of this observation for closing relevant public health skills gaps in other empirical contexts is the need to introduce academic programmes which respond to ever-changing local public health training needs. Relatedly, curricula for these programmes should be regularly reviewed to make them relevant to public health skills demanded, which are often dynamic. These reviews should be guided by formal needs assessments.

Limitations
This study is ground breaking in the sense that no published study has assessed the skills needs relating to health policy and systems, health economics, and health services management training in Zambia. However, it has a number of limitations. Firstly, the study is 'static' in nature in the sense that it has been unable to track the changing skills needs in a dynamic healthcare sector. Future studies should analyse the dynamic nature of the market for public health professionals. These studies will help to inform curricula modifications in order to respond to changing needs.
Secondly, the study takes a demand-side perspective. It has analysed the skills gap from the perspective of the demanders of the various public health competencies. Future studies should also incorporate a supply-side perspective. For example, there is need to assess the various institutional factors that impede training in selected public health disciplines. Despite these limitations, the study has provided important evidence to support the case for introducing structured programmes in health policy and systems, health economics, and health services management and planning in Zambia's public health training institutions.

Conclusions
Inadequate and/or poorly trained human resources for health remain a major constraint to achieving UHC -a key policy objective of many countries around the world. This study assessed the skills gaps and mismatches in health policy and systems, health services management and planning, and health economics.
This study found significant skills gaps across all the three disciplines. For example, over two-thirds of all interviewed stakeholders reported that they had no staff members in their organisations who had formal training in relevant competencies across the disciplines of interest. Additionally, a significant skills mismatches were identified in health economics, and health services management and planning.
Our findings provide support for the introduction of structured training programmes in the three public health disciplines. However, there is need for more research on the ever-changing training needs of the health sector. This will help academics to tailor public health training to local context needs.