Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 1 | 13 ORIGINAL RESEARCH Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic Vesna Bjegovic-Mikanovic1,2, Sanja Matovic-Miljanovic2, Chinara Seitalieva3, Tatyana Makarova3, Gulgun Murzalieva3, Kanatbek Kozhokeev3 1 Faculty of Medicine, University of Belgrade, Belgrade, Serbia; 2 Euro Health Group, Denmark / Regional Office Belgrade, Serbia; 3 SDC Funded Project‚ Health Facilities Autonomy Project Phase II (exit phase), Kyrgyzstan. Corresponding author: Prof. Vesna Bjegovic-Mikanovic, MD, MSc, PhD; Address: Dr Subotica 15, 11000 Belgrade, Serbia; E-mail: vesna.bjegovic-mikanovic@med.bg.ac.rs Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 2 | 13 Abstract Aim: An assessment of the training needs and interests of health managers working in the health care facilities of the Kyrgyz Republic was conducted, aiming to tailor and shape future training interventions. Methods: A rapid assessment was organized among directors of health care services in the Kyrgyz Republic, using a web-based questionnaire. Due to the pandemic situation (COVID-19), it was impossible to involve all healthcare facilities as initially planned. Therefore, a convenient sample of 75 directors was drawn with a response rate of 77.3%, or 58 filled-in questionnaires. Results: Among respondents, 60.3% were female and 39.7% male managers, with an average age of 53.5 years. Most of the respondents (89.7%) came to a managerial position by direct appointment, while only 10.3% were appointed through competitive process. More than half of health managers (63.8%) do not have any managerial category, and only 25.7% indicated that they have membership in the Association of Health Administrators of Kyrgyzstan1. All respondents reported the need to develop computer skills. Discussion: There is a high demand in all aspects of the management of health organizations. The respondents are deciding about involvement in management training based on (a) the full range of training' topics, (b) the quality of the training content, and (c) the focus on developing practical skills. The most cited training needs are digital health (E-Health), financing management, planning, and quality control; the interest in distance learning courses is excellent. Almost two- thirds of managers reported that the Ministry of Health and Social Development (MOHSD KR) did not evaluate their work. Conclusion: The main implications derived from this assessment are related to the culture of lifelong learning among the population of Kyrgyz health managers. Keywords: health management, Kyrgyz Republic, lifelong learning, training needs. Authors’ contributions: All authors contributed equally. Conflict of interest: None declared. Source of funding: The project is financed by the Government of Switzerland. The opinions expressed in this publication are the views of the authors and do not necessarily reflect the opinion of the Government of Switzerland. 1 Ассоциация организаторов здравоохранения Кыргызстана Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 3 | 13 “Good leadership and management are about providing direction to, and gaining commitment from partners and staff, facilitating change and achieving better health services through efficient, creative and responsible deployment of people and other health resources.” WHO/EIP/health systems/2005 Introduction Modern management is creating and maintaining an environment in which people working together may accomplish predetermined objectives. It occurs in a formal organizational setting through the utilization of human and other resources. The provision of specific services fulfills health and medical care demands to individual consumers, organizations, and communities. As a universal and complex process, management in health care services, open towards its environment, consists of five essential components: planning, organizing, staffing, leadership, and controlling. An effective manager's activities imply basic and advanced skills that balance these interrelated components and competencies in evidence- based management (1,2). Besides basics in health services management, information and health legislation, performance, quality, and financial management are essential elements of a coherent strategy for health care management training. The multi- professionalism within health management teams and the corresponding inter- disciplinarity should provide an institutional environment where knowledge, skills, and experience are adequately implemented – in a participatory and supportive system representing a flat hierarchy. The Kyrgyz Republic recently approved a new State Health Program 2019-2030 - “Program of the Kyrgyz Republic Government on Public Health Protection and Health Care System Development for 2019-2030 - Healthy Person – Prosperous Country”. The Program aims to protect the health, ensure access to essential quality services, strengthen primary health care, and decrease financial hardship for all people and communities in pursuit of Universal Health Coverage and sustainable development by 2030. Also, the Program underlines the importance of qualified managers in health care services. Since 2013, the Kyrgyz Republic is implementing the legislation with a description of responsibilities for health facilities managers and their hiring on a contractual basis (3). The Den Sooluk Programme of health sector reform in the Kyrgyz Republic (lasting from 2011 to 2016 with extension up to 2018) opened direct opportunities through legislation and pilot initiatives for advancements in health care management to achieve better performance with existing resources. Today, the Ministry of Health and Social Development (MOHSD KR), in close collaboration with international and national partners, considers the changing context of the Kyrgyz Republic becoming a lower- middle-income country with the necessity to increase performance in the health sector. An example of the recent positive development is an orientation towards continuous quality improvement in health care, which requests better health services management (4). Also, positive initiatives were in pilots aiming to improve the health services management Health Facilities Autonomy Project and Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 4 | 13 Health Results-based Financing initiative. Nevertheless, the need for strategic management improvement in the health sector is still visible. A brief overview of the literature has pointed to the recent history of health management strengthening in the Kyrgyz Republic, but the lack of information on their effectiveness, training focus, with emphasis on individual managers not on team development, except rare practices and country-wide efforts to develop planning, monitoring, and reporting system together with financial management. These efforts jointed with multiple initiatives through several projects, often not coordinated, poorly institutionalized, and therefore not sustained. As a particular challenge, the recent reviews stressed the weaknesses of "formal management training, lack of incentives for performance improvement and lack of overall accountability of managers." One of the main problems noticed through the literature in the Kyrgyz Republic was typical for all transitional countries. With health sector decentralization, doctors and nurses are often asked to take up new responsibilities, i.e., to fulfill leadership and managerial functions for which they have not been well prepared and trained (5). At the same time, they are usually not aware that their professions (doctors and nurses) do not qualify them to hold management positions. Besides, managers' incentives are not present at a small scale, bringing low motivation for improvements. Financial incentives are weak, salaries and allowances compared broadly with similar posts in the public sector (no significant financial incentives for excellent performance). Non-financial incentives are not recognized: status of managers within their community, degree of autonomy (very little control of resources under limited funds), learning and sharing opportunities – few; lack of a "managers' forum" (despite of the existence of Health Managers Association), opportunities for career progression – limited, recognition – mainly through the appraisal system and monitoring and supervision by the central authority within the Ministry of Health and Social Development. Challenges for leadership and management development include defining what it is and why it is necessary, measuring the difference that better leadership and management makes, integrating into traditional health and health care models and frameworks, institutionalization—where and how, and the need for long-term partnerships and commitments. Within the inception phase of the Health Facilities Autonomy (HFA) Phase II project, financed by the Government of Switzerland, an assessment of the training needs and interests of health managers working in the health care facilities of the Kyrgyz Republic was conducted, aiming to tailor and shape future training interventions. Methods The rapid assessment was organized among directors of health care services in the Kyrgyz Republic utilizing a web-based questionnaire. Due to the epidemiological situation regarding COVID-19 in the Kyrgyz Republic and the additional work burden imposed on managers with the organization of health services under emergency conditions, it was not possible to involve all health care facilities, as initially planned. Therefore, a convenient (6) sample of 75 directors replaced the whole population of health services managers (354 directors). The response rate was 77.3%, or 58 respondents (23 male and 35 female health managers). By the level of the managed health organization, five respondents were from the tertiary health care institutions situated in Bishkek city, 17 from secondary and 36 from primary health Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 5 | 13 care facilities (Family Medicine Centres and General Medicine Centres with beds). The distribution of responders by the administrative level of health organizations and regions is presented in Table 1. Table 1. Distribution of Respondents by the level of Health Organizations and by Regions Region No. of respondents Tertiary level Secondary level Primary level / (Family Medicine Centers) Primary level (General Practice Сenters with beds) Total in the KR* No. of surveyed Total in the KR* No. of surveyed Total in the KR* No. of surveyed Total in the KR* No. of surveyed Batken 2 7 4 6 2 Chui 12 11 4 8 4 4 4 Issyk-Kul 18 7 4 6 11† 2 3† Jalalabad 4 17 3 10 9 1 Naryn 1 6 1 6 1 Osh 1 23‡ 8‡ 1 4 Talas 12 6 5 3 5 2 2 Bishkek city 8 11 5 10 19 3 Total 58 5 17 24 12 * Data for 2016. † Respondents are Directors and their Deputies. ‡ Data include Osh Oblast and Osh city. The questionnaire (in Russian) developed for data collection comprises three parts: 7 questions to collect general information about health organizations, ten inquiries related to the characteristics of health managers, and 26 questions about their needs and interests. Results Profile of the responding health services managers in the Kyrgyz Republic Among respondents, 60.3% were female and 39.7% male managers, with an average age of 53.5 years. The youngest manager was 29 years old, while the oldest one had 65 years (SD=7.786). All of the surveyed health managers have a medical background, and all use computer software for their work on an everyday basis. On average, they belong to experienced staff with 39.5 years of overall working experience (SD=8.595). However, their managerial experience is not short, being 12.3 years (including positions of deputy directors), with significant variations among respondents (SD=9.364). For example, the youngest manager has only eight months of managerial experience and only four years of overall working experience, which is the minimum legal request in the Kyrgyz Republic. On the other hand, the most extensive managerial experience in different executive positions has one of the directors – in total 38 years, assuming that he started to work in an administrative role immediately after completing medical studies. At the time of this assessment, the average appointment duration was 7.3 (SD=6.665), with the minimum being two months and the maximum 22 years (see figure 1 for details). Most of the respondents (89.7%) came to a Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 6 | 13 managerial position by direct appointment, while only 10.3% were appointed through competitive process. Almost two-thirds of health managers who responded (63.8%) do not possess any specific managerial category. Concerning the participation in health management training, more than half of the respondents completed some training after their appointments (53.4%), while 29.3% took this opportunity before their appointments. Ten managers avoided answering this question . Figure 1. Duration of the managerial experience 39.7 15.5 10.3 19 15.5 54.4 19.3 7 14 5.3 0 10 20 30 40 50 60 up to 5 years 6 to 10 11 to 15 16 to 20 21 and above Overall experience Experience at this position Percent Years Belonging to a professional association is an essential feature of each health care manager; however, only 25.7% indicated that they hold a membership in the Association of Health Administrators in the Kyrgyz Republic 2 . Even fewer of them take an active role in the events of the Association – only 21.2% responded positively to this question. Key barriers faced by health managers in their performance This rapid assessment aimed to explore the key barriers that health managers face in their performance (Table 2). Based on the respondents' opinion, the most challenging 2 The new Association of Health Managers of Kyrgyz Republic (Ассоциация руководителей организаций здравоохранения Кыргызской managerial activity is to perform quality management. However, in the reviewed literature, it was evident that the highest priority during recent years in the Kyrgyz Republic was to improve different aspects of management for continuous quality improvement in health care. Two-thirds of assessed managers found that they have barriers to perform quality management. The subsequent prominent difficulties are coming in two fields: health organization performance and remuneration optimization and staff incentives. In both areas, more than half of the managers experience barriers or difficulties. Through optimization of the Республики) was founded only after this study was conducted. Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 7 | 13 health organization performance is directly interconnected, the manager found fewer problems with this activity. In essence, only one-third think that there are some barriers in this area of their work. Remuneration and staff incentives are difficult to achieve in an environment of fiscal constraints. A similar finding is with human resource management – only 13.8% of respondents indicated barriers in this critical area of their work. As expected, in the fourth place are obstacles related to financial planning, accounting, analysis, and control with 62.1% of managers indicated those barriers and difficulties. Taking into account the above mentioned problems with the optimization of health organizations, remuneration, and staff incentives, we found interesting that the least problematic areas of work for the respondents are human resources management and analysis of staff performance (13.8% and 12.1% respectively). Table 2. Key barriers faced by health managers in their performance No Barriers / Difficulties Number of respondents Percent 1 Optimization of health organization performance 38 65.5 2 Financial planning, accounting, analysis and control 36 62.1 3 Human resource management 8 13.8 4 Remuneration and staff incentives 38 65.5 5 Information system and reporting (internal/external) 25 43.1 6 Analysis of health organization performance 17 29.3 7 Analysis of staff performance 7 12.1 8 Quality management 41 70.7 9 Procurement, supply and management of materials (stocks) 32 55.2 10 Other (please, specify)* 4 6.9 * Respondents specified two other barriers related to their specific health facilities: (a) revision of salaries in psychiatric services; (b) equipment and their technical assistance. Though answers could be subjective, almost two-thirds of managers reported that the Ministry of Health did not evaluate their work individually following Order No 724 of June 25, 2019. Nevertheless, most managers (75.0%) agreed with the overall results of the latest assessment by the Ministry of Health and Social Development. Besides, 62.5% considered that a regular individual evaluation of the leader's activity is necessary. Training needs and interests The respondents confirmed their need for advanced training in health management. The most requested topics for skills improvement are E-health (79.6%), finance management (70.4%), planning (66.7%), the basics of management and quality management (64.8%), while office work, public relations, and presentation skills (the art of performance) are considered by respondents as areas with the least need for improvement in their work (see Figure 2). The respondents believe that health management training will help them to improve their theoretical knowledge (77.6%) and practical skills (70.7%). All respondents reported the need to develop computer skills. Only 33 out of 48 respondents reported that Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 8 | 13 they received certificates that prove their participation in health management training, while 20 out of 33 respondents used those certificates to confirm their managerial category. According to the assessment results, only 20.8% of health managers expressed satisfaction with the quality of the existing programmes/modules on health management in the Kyrgyz State Medical Institute on Retraining and Continuous Medical Education (KSMIRCE), while 60.4% were only partially satisfied. The majority of respondents took training in the KMIRSCE (87.2%). The most frequent topic of the training was "Actual issues of modern management in health care," followed by "Basics in health care management." Other issues of attended pieces of training included "Medical Legislation," "Human resources management," "Rights and obligations," "Modern issues of management and marketing.” Even though they expressed the highest need for improvement in digital health technologies, only one respondent mentioned participation in a course with the topic "Innovative technologies. "In most cases, the received courses were full-time in the classroom of the educational institution (72.9%). The usual duration of the sessions varied from 2 to 4 weeks. Seventeen respondents (29.3%) participated in health management training during 2018- 2019; others participated before 2018, or not at all. The respondents indicated the average number of hours allocated annually to their continuous skills development. For 21.6% of respondents, this education lasted 50 hours and more, 45.1% dedicated 25-50 hours, 27.4% reserved less than 25 hours, while other indicated that they did not have continuing education. Figure 2. Needs for improvement of managerial knowledge and practical skills 0 10 20 30 40 50 60 70 80 90 100 Basics of management Healthcare management Organization management Planning Monitoring and evaluation Analysis of the institution Human resources management Quality control Financial management Materials and medicines management, incl. procurement Health care reform in the Kyrgyz Republic E-health Health legal Issues Office work Public relations Art of performance - presentation skills Practical skills Knowledge Note: The rays in the spider web indicate the percentage. The majority of respondents (86.5%) are planning to participate in programmes of Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 9 | 13 continuing education, particularly skills development; 70.6% can initiate alone the entrance to the advanced training for managers. The respondents also mentioned the request of the Ministry of Health and Social Development (19.6%) as the initiating factor for involvement in the management training, followed by the submission of Oblast Coordinators (7.8%). As the most important factors to choose the particular program/module the respondents indicated (Figure 3): • the possibility to improve their practical skills; • the format of training (equally preferable formats are daytime and distance learning); and • topics and quality of the training program. Among two-thirds of respondents, participation in programmes of continuing education is self-initiated. As a source of funding for paying courses fees, 25,0% of respondents cite state budget, 65.4% budget of health organization, while 17.3% cite external sources such as international donors/sponsors/projects. A considerable number of respondents reported their investment in training, especially for travel expenses (38.5%). Figure 3. Factors in the selection of management training 13.46 23.08 23.08 26.92 48.08 51.92 57.69 73.08 78.85 82.69 0 10 20 30 40 50 60 70 80 90 The ability to teach after this training Cost of education Class time (daytime, evening time, weekends) Expenses in addition to training (transport, accommodation) Training location Opportunities for professional growth, promotion Training duration Training program (topics, content, modules) Form of study (full-time, distance learning) The opportunity to gain practical skills Percent More than half of assessed health managers (57.7%) expressed interest in being part of the trainers' team, participating in the Training of Trainers (TOT), and contributing to the process of continuing skills development for other health managers. Worthwhile to mention is that 35% of respondents reported that they have innovations to share with others, and 11.8% of health managers already had some teaching experience. Discussion and conclusions The conducted assessment showed that the Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 10 | 13 surveyed health managers at all levels of the health care system are usually appointed to their managerial positions directly (not on a competitive basis). All of them are specialists with a medical background. Only one-third of respondents had some form of training in health management before taking their managerial responsibilities. The rest of them have received training after their appointments or didn't receive it at all.The majority of those who participated in the existing health management training offered by the KSMIRCE expressed partial satisfaction. Usually, participation in the health management training is self-initiated (despite official rules/requirements reflected in the regulatory documents of the MOHSD KR). Health managers use different financial sources to cover training fees and travel expenses (state/organization budgets, international donors/projects, personal resources).According to the assessment results, there is a high demand in all aspects of the management of health organizations. The respondents are deciding about involvement in management training based on (a) the full range of training' topics, (b) the quality of the training content, and (c) the focus on developing practical skills. The most cited training needs are digital health (E_Health), financing management, planning, and quality control. More than half of the respondents expressed their interest in distance learning courses. One-third of health managers in this assessment reported innovations implemented in their health organizations to share with others. Therefore, there is a possibility to identify potential candidates for a pool of trainers among the surveyed health managers. The main implications derived from this assessment are related to the culture of lifelong learning among the population of Kyrgyz health managers, which have broad state support expressed in several strategic documents (7). Following the actual trends in health management education, the competence- based training development and the application of instructional innovation through applied management learning have to inspire training teams in each country. This participatory approach allows follow-up of the training impact in real life – on organizational behavior and performance improvement, both in quality and efficiency. Based on the results of this assessment, the advantage of a step-wise approach for capacity development of Kyrgyz health managers is the following: i. After discussion of the training needs assessment with a broader population of health managers and stakeholders from the MOHSD, Centre of Health System Development and Medical Technologies (CHSD&MT), educational institutions (particularly KSMIRCE), and other relevant partners, the process of renewal of competences' list becomes crucial. During the assessment, we find it necessary for highly qualified performance within health care management. The importance of managerial competencies in monitoring and improving the performance of organizational leaders and managers are well accepted. Different processes have been used to identify and develop competency frameworks or models for healthcare managers worldwide to meet different contextual needs (8)."Today's healthcare executives and leaders must have management talent sophisticated enough to match the increased complexity of the healthcare environment. Executives are expected to demonstrate measurable outcomes and Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 11 | 13 effectiveness and to practice evidence-based management. At the same time, academic and professional programs emphasize the attainment of competencies related to workplace effectiveness. The shift to evidence- based management has led to numerous efforts to define the competencies most appropriate for healthcare" (9). The basis for the intended Delphi process (10) in achieving consensus about the Kyrgyz list of managerial competencies, besides the results of this assessment, will be the international list "Leadership Competencies for Healthcare Services Managers." ii. The training strategy should rely on modular training of trainers, applied management improvement projects, and recognition of the best performers of pilot projects (11,12). A training strategy should be developed to cover the recommended competencies through several coherent modules. Modules should have clearly defined learning objectives, expected outcomes and competencies, module prerequisites, content, recommended readings, teaching methods, means of evaluating participants' performance, and training schedule. In cooperation with Kyrgyz partners (designated to health management education), the curricula development should involve a combination of management training in different areas including process improvement, project management, and program management. The new curricula could combine courses to address the skills needed to work with and supervise people effectively. The initial focus has to be on the capacity building of Kyrgyz trainers after the selection of the national trainers' team. Also, the proposal of educational events has to request national and international accreditation (either within the European Union of Medical Specialists – UEMS and its European Accreditation Council for CME - EACCME® (13) or preferably to Agency for Public Health Education Accreditation – APHEA and its Board for CE) (14). iii. As several previous reviews pointed to the necessity of better strategic and operational (business) planning in the Kyrgyz health care institutions, particular attention has to to be given to training related to strategic management in health care. Using the advantage of instructional innovations and applied management learning, empowered Kyrgyz trainers in health management should follow up training (managerial teams) participants in the application of gained competencies. Each managerial team could be responsible for developing the strategic plan and business plan for their health organization using the logic of strategic planning (defining mission, vision, and the SMART objectives of the health care organization, précising activities and indicators for monitoring and evaluation, and assigning responsibilities with WBS- work breakdown structure and budget). iv. Under the health programme (2019- 2030), the Kyrgyz Republic continues to invest in the programme for continuous quality improvement, requiring competent managers. Managerial teams will also pay Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 12 | 13 attention to capacity building to apply useful managerial tools, such as Total Quality Management (TQM). Training in TQM tools will allow health care managers to use a systematic data-based method for improving the quality of specific work processes and therefore contribute to the overall improvement of performance. Health care managers will be competent to go through a fantastic Seven-Step improvement process and experience progress in their healthcare organizations within 5 to 6 months. Educated trainers of the KMIRSCE and CHSD&MT has to follow up (monitor and evaluate) the whole applied management learning. v. In evaluating and monitoring, educated trainers can use the Kirkpatrick method (15). vi. In the end, applied leadership and management skills, not just theoretical knowledge, has to be overall objective. Applied management improvement projects will reinforce classroom learning, empower local groups to identify and manage their improvement opportunities, multiply training benefits, and generate products that have a measurable impact on health care organization goals and stakeholders. Health care managers will be capable of including others from the organization in transferring managerial skills. Strengthening the management skills of health managers in the Kyrgyz Republic involved in the integrated interventions can be accomplished by combining management training on technical management areas in project management and process improvement, combined with training directed at addressing the skills needed to work with and supervise people adequately. The Health Facilities Autonomy Phase II project, financed by the Government of Switzerland is seen as a platform for improvement of health management training in the Kyrgyz Republic that applies the above described step-wise approach for capacity development of the Kyrgyz health managers. “Remember, training is not what is ultimately important…performance is.” Marc Rosenberg President of the Society for Performance and Instruction References 1. Bjegovic-Mikanovic V. Governance and management of health care institutions in Serbia: An overview of recent developments. Review article. SEEJPH 2016. DOI:10.4119/UNIBI/SEEJPH-2016- 94. 2. Bjegović V. Health Management: Theory and Practice. In: Bjegović V, Donev D, ed. Health Systems and Their Evidence-Based Development. A handbook for Teachers, Researchers and Health Professionals. Lage, Germany: Hans Jacobs Publishing Company; 2004:241-62. 3. Jakab M, Smith B, Sautenkova N, Abdraimova A, Temirov A, Kadyralieva R, et al. Better non- communicable disease outcomes: challenges and opportunities for health systems. Kyrgyzstan country assessment: focus on cardiovascular disease. Copenhagen: WHO Bjegovic-Mikanovic V, Matovic-Miljanovic S, Seitalieva C, Makarova T, Murzalieva G, Kozhokeev K. Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic. (Original research). SEEJPH 2021, posted: 05 September 2021. DOI: 10.11576/seejph- 4728 P a g e 13 | 13 Regional Office for Europe; 2014. Available from: http://www.who.int/iris/handle/1066 5/153905 (accessed: April 11, 2021). 4. WHO Europe. Quality of Care Review in Kyrgyzstan. Copenhagen: WHO Regional Office for Europe; 2018. Available from: http://www.euro.who.int/__data/asse ts/pdf_file/0004/383890/kgz-qoc- eng.pdf (accessed: April 11, 2021). 5. GIZ. Developing Capacity for Health Services Management in Kyrgyzstan. Policy Brief. Bishkek: GIZ; 2019. 6. Saunders M, Lewis P, Thornhill A. Research Methods for Business Students. 6th edition. New York: Pearson Education Limited; 2012. 7. Ministry of Education, Science and Youth. Education Development Strategy of the Kyrgyz Republic for 2012-2020. Bishkek; 2014. Available from: https://planipolis.iiep.unesco.org/en/ 2014/education-development- strategy-kyrgyz-republic-2012-2020- 6620 (accessed: April 11, 2021). 8. Liang Z, Howard PF, Leggat S, Bartram T. Development and validation of health service management competencies. J Health Organ Manag 2018. DOI:10.1108/JHOM-06-2017-0120. 9. Stefl ME. Common Competencies for All Healthcare Managers: The Healthcare Leadership Alliance Model. J Health Manag 2008;53:360-74. 10. Brill TM, Bishop MJ, Walker AE. The Competencies and Characteristics Required of an Effective Project Manager: A Web- Based Delphi Study. Educational Technology Research and Development 2006;54:115-40. 11. Centers for Disease Control and Prevention. Sustainable Management Development Program. The Health of People is directly related to Effective Health Systems. Atlanta: CDC; 2012. 12. Parviainen HM, Halava H, Leinonen EV, Kosunen E, Rannisto PH. Successful Curriculum Change in Health Management and Leadership Studies for the Specialist Training Programs in Medicine in Finland. Front Public Health 2018;6:271. DOI: 10.3389/fpubh.2018.00271. 13. European Accreditation Council for CME - EACCME®. Available from: https://www.uems.eu/areas-of- expertise/cme-cpd/eaccme (accessed: April 11, 2021). 14. Agency for Public Health Education Accreditation – APHEA. Available from: https://www.aphea.be/Pages/A1a.CT EE/CTEE_Accreditation.html (accessed: April 11, 2021). 15. Heydari MR, Taghva F, Amini M, Delavari S. Using Kirkpatrick's model to measure the effect of a new teaching and learning methods workshop for health care staff. BMC Res Notes 2019;12:388. DOI: 10.1186/s13104-019-4421-y. _____________________________________________________________________________________________ © 2021 Bjegovic-Mikanovic 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.