Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 1 | 17 POLICY BRIEF Towards harmonisation of public health master education based on WHO- ASPHER Competency Framework for Public Health Workforce in the Euro- pean Region Sharmi Haque1, Inês Terêncio Marques1, Ieva Stankutė1, Inesa Bikniūtė1, Agnė Staišiūnaitė1, Katarzyna Czabanowska1 1 Department of International Health, Faculty of Health, Medicine, and Life Sciences, Maastricht University, The Netherlands Corresponding author: Name: Sharmi Haque Email: sharmi.haque@student.maastrichtuniversity.nl Address: Duboisdomain 30. 6229 GT, Maastricht, The Netherlands Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 2 | 17 Abstract The absence of harmonisation in public health curricula between Schools of Public Health is a possible root cause of the ability to effectively address future public health problems in the Euro- pean Region. Increased cross-border mobility enables public health higher education institutions to become transnational actors in the direction of competency-based education. Four Public Health Master’s programmes were compared: Management of Public Health in Lithuanian University of Health Sciences (LUHS), Governance and Leadership in European Public Health in Maastricht University (UM), Public Health in National (Portuguese) School of Public Health (ENSP) and Public Health in The University of Sheffield (SH). The WHO-ASPHER Competency Framework was used to compare the four public health master programmes. Inconsistencies were found among these masters. Content and Context which includes core public health disciplines appears to be the most consistent element. Relations and Interactions focus appeared diminished in the four schools examined. Performance and Achievement varied within the evaluated curricula. (1) The WHO-ASPHER Competency Framework served as a reference to assess the core programme elements for the partial harmonisation of public health masters in relation to the competency, val- ues covered and inter-professional orientation. Recommendations: • Increase competency-based education • Introduce leadership and communication skills in the public health curricula; • Increase the network of Schools of Public Health in the European Region; • Use a competency framework towards partial harmonisation of public health programmes. Keywords: curriculum, competency framework, harmonisation, master programme, public health, workforce Acknowledgments: We would like to thank Prof. Kasia Czabanowska for the considerate feed- back. Likewise, we thank Julien Goodman, Director of the Agency for Public Health Education Accreditation (APHEA) Secretariat, Dr. Richard Cooper, Deputy Director of Public Health Sec- tion of The University of Sheffield, John Middleton, ASPHER President and Robert Otok, Director of ASPHER Secretariat for insightful expert comments. Authors’ contributions: All authors contributed equally to this work. Conflicts of interest: None declared Funding: None declared Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 3 | 17 Context Population health demands public health pro- fessionals (PHP) to respond to increasingly imminent and global communicable disease outbreaks in the future. (2) The COVID-19 pandemic has presented an unprecedented challenge to both the public health field and its professionals. (3) The evolving public health problems require a prepared PHP for a future that is both variable and unknown. Public health education needs to adapt to pre- pare these professionals for these demands. Congruency between public health curricu- lum and practice is pivotal in allowing PHP to execute the public health activities they need to undertake. The absence of harmoni- sation in public health curricula between Schools of Public Health is a possible root cause of the ability of PHP to effectively ad- dress future public health challenges. (4) In addition, PHP are not regulated health profes- sionals when compared to their counterparts such as medical professional counterparts in the 2005/36/EC Directive amended by 2013/55/EU Directive, which substantiates the recognition of professional qualifications. (5) The notion of public health differs be- tween the various Member States (MS) in Eu- rope and the definition is incoherent and poses limitations in translating and ascertain- ing into the various European languages. (6) Its contemporary term is defined as “the art and science of preventing disease, prolonging life and promoting health through the orga- nized efforts of society”. (7) There is a grow- ing consensus in Europe – on the key compe- tence areas in academic public health curric- ula (8) and a demand for an equally compe- tent public health workforce (PHW) across the MS. (1) To better prepare the PHW, edu- cation, and performance, workforce planning and investment in capacity-building must be improved. (9) Close partnerships between ed- ucational institutions and employers are es- sential to ensure the future employment of PHP. (10) Educational institutions should in- vest in training to cope with the demands of the public health challenges that their gradu- ates must face. Hence public health compe- tencies and values need to be promoted through the harmonisation of the curricula. (10) A comprehensive and integrative ap- proach to competency development is re- quired in order to better understand the needs of MS to build a PHW capacity. The Associ- ation of Schools of Public Health in the Eu- ropean Region (ASPHER) together with the World Health Organization (WHO) Regional Office for Europe Coalition of Partners to Strengthen Public Health Services in the Eu- ropean Region developed the WHO-AS- PHER Competency Framework for the Pub- lic Health Workforce in the European Re- gion. (1) The framework focuses on three core categories: Content and context includ- ing science and practice of public health, pro- moting health, law, policies, and ethics, and one health and health security. Relations and Interactions including leadership and systems thinking, collaboration partnerships, and communication, culture and advocacy, and Performance and Achievement including governance and resource management, pro- fessional development and reflective ethical practice, and organizational literacy and adaptability. Under these categories, ten do- mains are explored, given a total of 84 rele- vant public health competencies. Annex 1. We evaluated four public health schools in different European countries in order to make recommendations. As a result, we took a sample of some programmes and selected the interviewees who were the best in the field. Purpose Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 4 | 17 The aim of this policy brief is to propose rec- ommendations that can contribute to the par- tial harmonisation of public health master programmes using the WHO-ASPHER Framework. More specifically, we assessed four public health masters from Lithuanian University of Health Sciences (LUHS), Maastricht University, National (Portuguese) School of Public Health (ENSP), and The University of Sheffield in relation to the com- petency areas included in the WHO-AS- PHER Framework. Approaches A narrative literature review and expert con- sultations were conducted concerning the core areas of public health masters. PubMed and Web of Science databases were em- ployed in the search for publications related to competencies underlying public health ed- ucation. Keywords such as “Public Health” “Public Health Education” and “Harmonisa- tion” were used as search entries. The narra- tive literature review permits the examination of emerging evidence and facilitates suffi- cient literature to be assessed given the focus of the topic (11) The WHO-ASPHER Com- petency Framework was used as a reference point to establish convergence and diver- gence between four public health masters. We assessed how the given modules of each School of Public Health have been aligned to the competency in the framework using both the summary of modules and learning objec- tives of the curricular unit. Tables and graphs were formulated in order to display the com- parative results on the public health core competencies of each School of Public Health. Expert consultations were held to provide further perspective into the key com- petency areas covered by public health edu- cation and provide their opinion on the poten- tial need for the harmonisation of public health programmes. The Director of the Agency for Public Health Education Accred- itation Secretariat, Deputy Director of Public Health Section of The University of Sheffield, the President of Association of the Schools of Public Health in the European Re- gion (ASPHER), and the Director of AS- PHER Secretariat were consulted for a better insight into the public health programmes in the EU. Policy recommendations were de- veloped in favour of partial harmonisation of public health master programmes in the Eu- ropean Region, particularly with respect to the core public health competencies. Limitations The findings were based solely on four dif- ferent public health programmes and may not be applicable to all academic programmes in Europe Region. Studies that explore a larger number of public health programmes will be profitable in understanding disparities. Fur- ther analysis would need to be conducted and to get a better overview of the effectiveness of theoretical and practical learning delivery. The assessment of the competencies was per- formed objectively in alignment with the syl- labus information. In order to avoid re- searcher bias, the further revision would be needed from the course director in order to validate the results. The access to module in- formation was limited at the university’s website. Direct communication with the uni- versity staff was needed to obtain the neces- sary information on modules that were inac- cessible. Findings Our findings (Figure 1) demonstrate that Maastricht University programme in Govern- ance and Leadership in European Public Health has 38% of content and context, 33% Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 5 | 17 relations and interaction, and 28% of perfor- mance and achievement. The curriculum ap pears balanced with anincreased focus on content and context. In contrast, the Na- tional(Portuguese) School of Public Health constitutes a largely content and context- based course (53%) with a much lesser focus on relations and interaction. However, it has a significant portion of the course within per- formance and achievement. Similarly, The University of Sheffield harnesses a content and context-based course (45%) that still highlights the importance of both perfor- mance and achievement. In comparison to the other three Schools of Public Health, it pre- sented a broader range of elective modules and fewer core modules when compared to the other three Schools of Public Health. It contributes to the variability of the pro- gramme and allows further specialization of the professionals into their topics of interest. However, this poses limitations when the ra- tio of the core modules and elective modules is fairly equal. Lithuanian University of Health Sciences characterizes a balanced course with a slightly higher focus on performance and achievement. However, the proportion of re- lations and interactions was only 20%. Con- tent and context which is related to more tra- ditional, core public health disciplines appear to be the most consistent element when con- sidering public health programmes. It under- pins the concepts of science, knowledge, and theory that explain public health practice. It is essential to further deepen the knowledge for public health graduates as it provides the foundations of understanding public health issues and problems. However, there is an in- creasing concern as to what extent these pub- lic health schools are adequately preparing graduates to contribute towards population health. Figure 1 - Core competencies distribution among the Schools of Public Health evaluated. Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 6 | 17 The focus on relations and interactions ap- pears diminished in all four schools of public health and further work needs to be done. In- creased collaboration across stakeholders needs to be addressed to ensure that today’s public health curriculum is relevant. COVID- 19 has shown that a shift in focus in reinforc- ing intersectoral, interdisciplinary, and coor- dinated international collaboration needs to be implemented and facilitated to ensure an effective response to future possible out- breaks. Furthermore, the role of leadership and system thinking does not appear to be fully covered in all four Schools of Public Health. In fact, Maastricht University is the only one having a strand that directly ap- proaches leadership. Conversely, the Na- tional (Portuguese) School of Public Health revealed no incorporation of these competen- cies within its curricula. Leadership revolves around vision, mission, strategy, and inspira- tion; it establishes direction and leads to change. Its integration under public health programmes contributes to the development of a strong and competent PHW that is pre- pared to overcome the constant changes and challenges that characterize the public health sector. (10, 12) Identifying strategies to en- gage with government leaders in integrating community interests and concerns with gov- ernment priorities during the emergency re- sponse is needed. (12) In times of crisis, the emphasis on developing the communication and interactions competency can harbor an effective response to future public health is- sues. Clear communication channels are im- portant to ensure public health compliance and increase trustworthiness. In light of the COVID-19 crisis, this would prove invaluable for future pandemic prepar- edness and should not be exempt from PHP’s education and training. Within the evaluated Maastricht University National (Portuguese) School of Public Health The University of Sheffield Lithuanian University of Health Sciences Content and Context Relations and Interactions Performance and Achievement Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 7 | 17 curricula, performance and achievement is presented between 28 % to 41 % Competen- cies provide a framework for workforce de- velopment planning and actions. Compe- tency-based education facilitates what gradu- ates are able to demonstrate learning for a workforce-related need. It is apparent that the Schools of Public Health did not successfully integrate the role of professional develop- ment and reflective ethical practice in the ed- ucation process. According to the experts, ethics and code of conduct were some of the competencies that, although briefly men- tioned on the curricula, need more attention. Both ethical aspects of individual versus so- cietal and national versus international rules for data protection and data storage should be clearly discriminated in the syllabus. (13) Moreover, the ability to self-assess profes- sional development based on the required competency and the willingness to pursue lifelong learning in public health needs should be a part of the education process. (1) Overall, the experts agreed on the benefits of a partial harmonisation of public health pro- grammes. It was mentioned that some frame- works were already developed by some coun- tries, such as the UK, and the ASPHER list of European Public Health Competencies and WHO-ASPHER Competency Framework at a European level. Experts stated that funding, cultural backgrounds, and lack of resources are major barriers to achieving harmonisa- tion. Moreover, the needs of different health systems can determine the different outcomes of public health master programmes. Recommendations 1. Increase competency-based educa- tion. Competency-based education is the present and future of public health education. (14) Such education would form the basis of the public health leaders’ professional develop- ment, which would enable the workforce to meet the diverse and evolving expectations to improve population health. (15) More tradi- tional educational frameworks often focus on what the student should know, whereas com- petency-based education focuses on the stu- dents’ performance after he graduates and en- ters the job market. (16) As some pro- grammes of public health have already adopted competency-based education, many have struggled and continue to struggle with the actual implementation and curricular re- design. (14) Competency-based education needs to be introduced in public health train- ing to achieve harmonisation among public health curricula and close the gap between public health educational content and the competencies required in practice. (15) 2. Introduce leadership and communica- tion skills in the PH curricula. Currently, the role of PHP is constantly changing. Leadership skills must be har- nessed including the ability to connect with various stakeholders in different sectors and deal with issues in the health system. (17) Based on our research, there is a deficiency of leadership and communication skills inte- gration in PH curricula. Integration of these skills in the PH curricula will harmonise the professional development of all PHP in dif- ferent universities and increase their ability to tackle health problems equally. (18) Awareness of how to interact with various parties such as doctors, policymakers or soci- Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 8 | 17 ety is critical for PHP. The knowledge deliv- ery to individuals with various levels of un- derstanding and education, also comprehen- sion and applying cultural awareness and sensitivity in communication with diverse populations is very important. (19) Improved communication and leadership skills in pub- lic health programmes will harbor new per- spectives and opinion exchange in order to facilitate project collaboration and imple- mentation of policy change in the vital public health areas. 3. Increase the network of Schools of Public Health in the EU. The advancement of partnerships joining forces in public health preparation has proved useful at the European level. (8) Networking between schools of public health is pivotal in strengthening the basis for comprehensive, interdisciplinary, dynamic, and coherent pub- lic health education. (20) It would demon- strate a shift towards achieving excellence, knowledge brokering, and the exchange of experience concerning best practices in pub- lic health. (20) Information exchange among public health schools can contribute to better public health and achieve harmonisation of public health in all European countries. 4. Use a competency framework to- wards partial harmonisation of public health programmes. Core competency frameworks for public health education exist in different structures across national and European regions. (1) Ac- cording to our expert consultations, it would be beneficial for one framework to be agreed upon and move towards harmonisation of public health curricula. Through this com- mon framework, the public health graduates can work towards the same core competen- cies creating an affinity amongst the future European PHW, addressing academic gaps, redundancies, and misalignment. The WHO- ASPHER Competency Framework for the Public Health Workforce in the European Re- gion can be a starting point to strengthen the education and performance of future PHW. (1) Conclusions There are disparities between the four Euro- pean public health masters, which suggest that partial harmonisation based on core com- petency assessment can prove to be benefi- cial in educating and preparing PHW to com- bat current and future public health problems such as COVID19 pandemic. The WHO-AS- PHER Competency Framework is a starting point for competency-based education devel- opment. Furthermore, the establishment of a comprehensive network among the schools of public health has shown to be useful in achieving partial harmonisation of public health in European countries. References 1. World Health Organization. WHO- ASPHER Competency Framework for the Public Health Workforce in the European Region 2020. 2020;1– 73. Available from: http://www.euro.who.int/pubrequest 2. 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DOI: 10.11576/seejph- 4684 P a g e 12 | 17 Appendices Table 1 - Core categories and respective domains. Content and Context Relations and Interactions Performance and Achievement Science and Practice Leadership and systems thinking Governance and resource management Promoting Health Collaboration partnerships Professional development and reflective ethical prac- tice Law, policies and ethics Communication, culture and advocacy Organizational literacy and adaptability One Health and Health security Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 13 | 17 Table 2 - Maastricht University. Content and Context Relations and Interactions Performance and Achievement Science and prac- tice Promot- ing Health Law, poli- cies and ethics One Health and Health security Leader- ship and systems thinking Collabora- tion part- nerships Communica- tion, culture and advocacy Govern- ance and resource manage- ment Professional development and reflec- tive ethical practice Organizational liter- acy and adaptability Introduction to Governance and Leadership in European Public Health X X X X X Public Health Leadership Strand X X X X Measuring and Comparing Health in Europe - Quantita- tive and Qualitative Ap- proaches X X X Identifying and Assessing Good and Best Practices in Health X X X X Europe as one Zone- Euro- pean Health Law and Poli- cies X X X X X Diffusion, Implementation and Quality Assurance of Health Innovations in Europe X X X X X Public Health Law and Gov- ernance X X X X X The EU, Enlargement and Public Health X X X X Research Methods X X X X Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 14 | 17 Table 3 - National (Portuguese) School of Public Health. Content and Context Relations and Interactions Performance and Achievement Sci- ence and prac- tice Promot- ing Health Law, policies and ethics One Health and Health security Leadership and sys- tems thinking Collabora- tion partner- ships Communica- tion, culture and advocacy Governance and resource management Professional development and reflective ethical prac- tice Organiza- tional literacy and adaptabil- ity Fundamentals of Public Health X X X X X Statistics X X Health Action and Planning Strategies X X X Health Economics X X X Health Promotion Princi- ples and Strategies X X X X Evidence-Based Health Programs X X X X X Epidemiology X X X Health Law and Ethics X X Social Research Methods in Health X X X Occupational and Environ- mental Health X X X Health Policy and Manage- ment X X X X Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 15 | 17 Table 4 - The University of Sheffield. Content and Context Relations and Interactions Performance and Achievement Science and prac- tice Promot- ing Health Law, policies and ethics One Health and Health security Leadership and sys- tems think- ing Collabora- tion partner- ships Communica- tion, culture and advocacy Governance and resource management Professional development and reflective ethical prac- tice Organizational literacy and adaptability Epidemiology X X X Health needs Assessment, Planning and Evaluation X X X X X Introduction to Research Methods X X X X Introduction to Statistics and Critical Appraisal X X Key Issues in Global Public Health X X X X X X X Table 5 - Lithuania University of Health Sciences. Content and Context Relations and interactions Performance and Achievement Science and practice Promoting Health Law, policies and ethics One Health and Health security Leadership and sys- tems thinking Collabora- tion partner- ships Communication, culture and ad- vocacy Governance and resource management Professional development and reflective ethical prac- tice Organiza- tional literacy and adaptabil- ity Public Health and Health Care X X X X X X Management and Organi- sational and Governance X X X Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 16 | 17 Health Ethics and Hu- man Relations X X X X Health Policy and Strat- egy X X X X X Research Work X X X Health Impact Assess- ment X X X Leadership and Manage- ment of Changes X X X X Applied Epidemiology Biostatistics and Qualita- tive Research X X X Research Work X X X X Health Information Man- agement X X X X Heath Economics and Applied Finances X X X Health Law X X Health Care Organisation and Practice X X X X X X Haque S., Terêncio I., Stankutė I., Bikniūtė I., Staišiūnaitė A. Towards harmonisation of public health master education based on WHO-ASPHER Competency Framework for Public Health Workforce in the European Region (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph- 4684 P a g e 17 | 17 Expert consultations interview guide 1- What is your opinion on the harmonisation of public health master programmes in European Union countries? • What can be possible barriers? 2- According to you, what are the most important competencies or competency areas that should be cov- ered by public health master programmes? 3- Is harmonisation of public health programmes needed? Why and how can we move towards the har- monisation of public health education? 4- Drawing from the results of our research in which we compared PH master curricula in Lithuania Uni- versity of Health Sciences (LUHS), Maastricht University (UM), National (Portuguese) School of Pub- lic Health (ENSP) and The University of Sheffield (SH) it is evident that leadership is not incorporated in most of the available public health programmes. • Why do you think it is the case? • How and to what extent can both leadership and collaboration be further integrated into the public health programmes? 5- Some public health programmes include elective modules. On one hand these seem to contribute to the variability to the programme, on the other they allow further specialization of the professionals into their topics of interest. Until what point can this choice benefit the programmes or be a barrier to har- monisation? 6- Finally, are you familiar with the WHO-ASPHER Competency Framework for Public Health Work- force in the European Region? Yes/No • If yes: What do you think, which are the competency areas included in the framework that are mostly reflected in public health programmes. Can you give some examples? • If no: Explain WHO-ASPHER tool and vision and where to find it. 7- Do you think there is a need for a standard competency framework to support the structure and content of public health master curriculum? If so, are you familiar with other framework © 2021 Haque et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.