Health workforce governance: Processes, tools and actors towards a competent workforce for integrated health services delivery.

A competent health workforce is a vital resource for health services delivery, dictating the extent to which services are capable of responding to health needs. In the context of the changing health landscape, an integrated approach to service provision has taken precedence. For this, strengthening health workforce competencies is an imperative, and doing so in practice hinges on the oversight and steering function of governance. To aid health system stewards in their governing role, this review seeks to provide an overview of processes, tools and actors for strengthening health workforce competencies. It draws from a purposive and multidisciplinary review of literature, expert opinion and country initiatives across the WHO European Region's 53 Member States. Through our analysis, we observe distinct yet complementary roles can be differentiated between health services delivery and the health system. This understanding is a necessary prerequisite to gain deeper insight into the specificities for strengthening health workforce competencies in order for governance to rightly create the institutional environment called for to foster alignment. Differentiating between the contribution of health services and the health system in the strengthening of health workforce competencies is an important distinction for achieving and sustaining health improvement goals.

Background

To accelerate gains in health outcomes, health systems must continuously adapt and evolve according to their changing contexts [1], [2]. In the WHO European Region, these shifts include population-ageing, increasing noncommunicable diseases, greater rates of chronicity and, in some countries, a rising incidence of communicable diseases, like multi-drug resistant forms of tuberculosis [1], [3], [4], [5].

In this context, health services delivery has proven its potential to react and adjust. While empirical evidence on impact remains to be realized [6], there has been nonetheless a substantive volume of activity in recent years to transform care towards more integrated models across countries in the WHO European Region [7], [8], [9], [10], [11].

The health workforce itself is, by-and-large, the engine behind these efforts. At the front-line of care, clinicians, health managers and other health professionals are intimately familiar with the needs and the realities of the system's operations [12], [13], [14]. Indeed, their ability to decode these demands and appropriately respond is at the crux of the performance of the health workforce and its measure of competence.

In effect, the link between health workforce competencies and improved health outcomes is looked to with increasing interest [15], [16]; a sharp shift from concerns which previously have emphasized rather the quantity of professionals or more narrowly, initial training and formal education [15], [17]. However, to adjust the competencies of the health workforce is not merely a workforce-enhancement exercise. It supposes major health workforce entry and exit changes that require investments and feedback on the part of the health system [15]. However, as documented health service delivery transformations signal, bottom-up health workforce-led efforts to improve services are hard-pressed to secure system-wide change, rendering many of these efforts small-scale, context-specific or ad-hoc solutions.

Critical to strengthen and sustain health workforce competencies is governance: the indisputably difficult assignment to bring better alignment between the day-to-day functioning of services delivery and the health system. This relationship is illustrated in Fig. 1. Although a simplification, the dynamic captured highlights a distinction between the system's initial contribution to competencies as part of the resourcing function of the health system's human resources for health, responsible for all aspects of workforce performance – its availability, competence, responsiveness and productivity [18] – and the continued investment overtime in health services delivery to enhance the performance of the health workforce, with feedback to optimally inform future generations [12]. The role of steward's to give direction and steer the system's actors is conveyed by the overarching boundary set by health workforce governance and it is these processes of governance and their minimum conditions that are further explored here.

Fig. 1

Key concepts visualized.

Purpose and rationale

This review aims to support health workforce governance by consolidating and aligning first hand experiences of countries with the literature and international expertise on advancing health workforce competencies. To do so, we ask the question: what processes and related tools apply for improving health workforce competencies? ‘Processes’ refer to those varied entry points in the cycle of health workforce competencies depicted above (Fig. 1).

From this, key actors engaged in improving health workforce competencies can be identified. This is seen here as a prerequisite for stewards to carry out the core processes of governance [19]. In the context of current health pressures described, a concerted effort to strengthen the governance function is vital for sustained, system-wide reforms, able to equip the health workforce with the competencies necessary for integrated health services delivery.

Methods

The authors used a three-pronged descriptive method to develop and validate a conceptual framework and findings: an adapted scoping study methodology [20], [21]; case studies documenting first-hand experiences from 53 countries in the WHO European Region; and survey responses from 10 international experts on human resource for health.

Process and sources of evidence

The sources of evidence and process for collection are described as follows:

Scientific and grey literature. A purposive literature search was conducted using PubMed, Health Systems Evidence and Google Scholar between February and April 2014. This was complemented with hand searching of key organizations and conference abstracts to identify open access scientific and grey literature available in English on governance and competencies of the health workforce. Online searches included various combinations of the following keywords: ‘health’; ‘governance’; ‘competencies’; ‘health systems’; ‘health workforce’; ‘health professionals’; ‘health services delivery’ and ‘integrated care’. The reference lists of literature deemed relevant for analysis were additionally consulted. This literature search has not intended to be systematic.

Field evidence. Between late-2013 to mid-2015, descriptive case studies on initiatives to transform health services delivery from all 53 Member States of the WHO European Region were developed. Cases triangulate evidence from an electronic 21-item questionnaire, 60-min key informant interviews with a representative from each of the 53 countries and topic-specific reporting. The initiatives captured vary widely in their approach to transform services delivery, differing also by their specific aim, scale of implementation and stage of reforms. Through a horizontal analysis across cases, those processes and tools most commonly activated to strengthen the performance and competencies of the health workforce have been extracted.

Technical experts. In the fall of 2014, through a snowballing of recommendations, 10 experts, including WHO national counterparts or appointed in-country focal points, international experts and WHO country office staff, participated in semi-structured 30 to 60-min phone interviews according to questions in Annex 1.

This work has been prepared in the context of the forthcoming Framework for Action towards Coordinated/Integrated Health Services Delivery in the WHO European Region [22].

The sources of evidence and process for collection are described as follows:

Scientific and grey literature. A purposive literature search was conducted using PubMed, Health Systems Evidence and Google Scholar between February and April 2014. This was complemented with hand searching of key organizations and conference abstracts to identify open access scientific and grey literature available in English on governance and competencies of the health workforce. Online searches included various combinations of the following keywords: ‘health’; ‘governance’; ‘competencies’; ‘health systems’; ‘health workforce’; ‘health professionals’; ‘health services delivery’ and ‘integrated care’. The reference lists of literature deemed relevant for analysis were additionally consulted. This literature search has not intended to be systematic.

Field evidence. Between late-2013 to mid-2015, descriptive case studies on initiatives to transform health services delivery from all 53 Member States of the WHO European Region were developed. Cases triangulate evidence from an electronic 21-item questionnaire, 60-min key informant interviews with a representative from each of the 53 countries and topic-specific reporting. The initiatives captured vary widely in their approach to transform services delivery, differing also by their specific aim, scale of implementation and stage of reforms. Through a horizontal analysis across cases, those processes and tools most commonly activated to strengthen the performance and competencies of the health workforce have been extracted.

Technical experts. In the fall of 2014, through a snowballing of recommendations, 10 experts, including WHO national counterparts or appointed in-country focal points, international experts and WHO country office staff, participated in semi-structured 30 to 60-min phone interviews according to questions in Annex 1.

Analytical framework

We rely on system thinking to assemble the dynamics between ‘human resources for health’ and the ‘health workforce’ [18], [23], [24], [25]. We have adopted WHO's broad characterization of human resources for health as the varied strategies for preparing the workforce, its enhancement and exit management for optimal availability, competence, responsiveness and productivity [12]. The ‘health workforce’ is then subsumed within the purview of the broader human resources for health sphere and is limited here to concern those front-line health professionals working directly for patients and populations such as, but not limited to, service managers and executives, doctors, nurses, midwives, pharmacists, lay health workers, community health workers and allied health professionals. This definition relies on how the health workforce has previously been defined by WHO [12], [17], [26].

For the purpose of this paper we define competencies as the essential, complex knowledge-based acts that combine and mobilize knowledge, skills and attitudes with existing and available resources to ensure quality outcomes for patients and populations [27]. In defining governance, we recall the work of previous reviews on the topic in the health sector [19], [28], [29], adapting the findings from these to focus specifically on a description of governance processes or areas for action, rather than values or outcomes of governance. As a minimum, we consider these processes to include setting priorities for the system's direction, organizing for action across actors, and measuring and feeding-back on performance.

Limitations

Adopting a results-oriented approach, we have looked here exclusively to improving health workforce competencies. This is to the exclusion of other performance measures, i.e. availability, responsiveness and productivity, also linked with health outcomes [12]. This focus on competencies has directed the scope to which health workforce governance has been considered here. This is ultimately a subset of health workforce considerations including, planning and forecasting, professional migration and cross-board regulations and professional health and safety. Moreover, the findings are a descriptive account of processes and tools for strengthening health workforce competencies. Neither the literature nor experiences from countries have been analyzed to infer an association with outcomes and impact; an assessment of this sort would have implied different methods.

Findings

In this section, we summarize key findings across all sources of evidence, triangulating theory, opinion and practice, based on the evidence from literature, technical key informants and country experiences, respectively. The literature reviewed constituted the main source of evidence, drawing from the field evidence and technical key informant interviews to further refine and validate the findings. Illustrative country case examples are referenced in brackets and refer to specific initiatives that demonstrate the processes identified. The specific evidence reviewed in the context of this work can be found in the online version at Web Appendix 1. Case study results are reported in full elsewhere as a compendium of initiatives towards the integration of health services delivery in the WHO European Region.

Health services processes and tools

Strengthening health workforce competencies is found a consistent priority across case studies and has been a long-standing focus of the literature [30], [31], [32], [33], [34], with a renewed commitment to health and development goals in recent [15]. Reviewing the processes taken in order to strengthen health workforce competencies, the following entry points – individually or in a series of actions – are found regularly the focus of interventions. These processes and tools are summarized in Table 1.

Table 1

Health services processes and tools for health workforce competencies.

Recruiting and orientation
• Job descriptions that include requisite competencies.
• Multi-profile interview panels.
• Interviews with role-playing or scenario descriptions.
• Multi-disciplinary orientation.
• Training across staff for an inclusive professional culture.
Supporting practice environments
• Multi-disciplinary teams, care plans and registries.
• Shared-care protocols for health providers.
• Common referral and/or transition documents.
• Co-location of services.
• Electronic platforms and applications for virtual meetings.
• Information resources (e.g. videos, checklists; notice boards).
Continuing professional development
• Ad-hoc trainings spanning a few days, weeks or months.
• Online quizzes or certification courses.
• Learning plans designed between managers/clinical leaders and staff themselves.
• In-service trainings and seminars.
• International exchanges, study abroad or study tours.
• Conferences.
• Temporary placements for observational learning.
Improving performance
• Periodic performance audits with feedback.
• Self-assessments.
• Patient satisfaction surveys.
• Patient reported outcomes.
• Adverse reaction or anonymous malpractice reporting.
• Interviews and case-based oral exams.
• Peer reviews.
• Operations meetings and quality circles.
Mentoring
• Coaching and mentorship.
• Champion system/role model system.
• Training of trainers.

Recruiting and orientation

The literature recognizes competency-based recruitment and orientation as a means to guide the selection of candidates with optimal potential to attain sought-after competencies [34], [35]. The process involves first identifying those competencies expected from a posting, which can in turn inform recruitment and initial training. Key informants signal applicable tools for this process may include multi-profile interview panels, multi-disciplinary orientation to facilities and initial trainings across staff for an inclusive professional culture.

Supporting practice environments

Enabling a supportive practice environment can be characterized as the activation of a built-in physical and social infrastructure that safeguards the time and resources for strengthening competencies. Strategies to do so are well documented in the literature [36], [37], [38], [39], [40], [41], [42]. In case studies, this included the introduction of multi-disciplinary care teams within and between levels of care (Cyprus; Belgium), joint care plans (Ireland) and/or shared patient registries (France). In a similar way, shared-care protocols (Andorra), standardized referral and/or transition documents and the co-location of services, are regularly applied. The use of electronic platforms, such as applications for professionals to liaise remotely in virtual meeting rooms (Croatia; Estonia; Lithuania; Denmark) or using new technologies like tablets in the community (Ireland) has enabled a means to overcome challenges of distance and time constraints. Information resources, such as videos in Scotland and checklists for non-specialists in Uzbekistan, share a similar intent to provide user-friendly, practical supports.

Continuing professional development

Continuous professional development refers to those efforts that promote a culture of continuous, life-long learning and career development. Life-long learning ensures that basic standards of care are maintained and that opportunities are available to complement previous learning with a practical focus [15], [43], [44], [45], [46]. Continuous professional development aims to ensure patient safety and ultimately improve health outcomes. In this way, it is a responsibility of all health professionals. Its effective implementation relies on the principles of collegiality, practice-based learning and a common transformative culture [47]. In effect, learning opportunities are frequently cited to take shape as practice-based, self-reflection, problem-solving and self-directed learning [32].

A number of flexible ways to promote continuous professional development are identified, varying from ad-hoc trainings, spanning from a few days to weeks or months, and at varied intervals of repetition. Such trainings are found to promote new or the advancement most commonly for new clinical skills in a number of case examples, as well as new communication and teamwork competencies (Norway; Italy; Belgium), leadership and management (Israel; Cyprus; Romania), and/or the use of new equipment (Ireland; Denmark; Croatia; Estonia; Belarus; Macedonia). Other approaches include in-service trainings or seminars (Switzerland; Latvia), international exchanges, study abroad or study tours (Russia; Lithuania), conferences (Turkmenistan) and temporary placements for observational learning (Sweden).

Improving performance.

Performance improvement is an integral process for the regular strengthening of competencies. It requires a non-punitive environment that promotes systematic reflection overtime [48]. This is in direct contrast to a professional culture that places blame for medical errors or instances of compromised patient safety [12], [47], [49]. Regular monitoring and evaluation is a valuable opportunity for the health workforce to self-reflect and prompts modifications to their practice as called for [50]. Generating and applying performance information in this way has been described as a tool for change, promoting innovation in practice [51], [52], [53], [54], [55], [56], [57].

Audits and feedback on the performance of health professionals is the most frequently applied approach to map clinical processes, identify gaps or variations and their causes [50], [58]. Other tools to assess competencies include: self-assessment [59], multi-source feedback [60], [61] patient satisfaction questionnaires, patient reported outcome measures (Greece; Austria), and/or adverse reaction or anonymous malpractice reporting [62], interviews, case-based oral examinations, record reviews and peer-ratings (Turkey). Regular meetings for the review of operations are applied with the intent to reflect and improve upon performance, such as in Ireland, whereby providers are convened every 6-weeks for discussion. Similarly, working groups for proposals, discussion and feedback on Israel and Romania or ‘quality circles’ in Switzerland held by the leadership team every three months, share in their bottom-up orientation for problem-solving performance improvements.

Mentoring

Research shows peer role models, clinical leaders and tutors have transformative power in demonstrating how care can produce needed improvements by spearheading the development of new service models, building exceptional levels of trust and collaborative relationships with their peers and patients [63], [64], [65]. In Spain, for example, a network of ‘champion’ nurses was established to promote new practices and support the training of other health professionals. Similarly, a supportive coaching system was established for newly trained managers in Romania as an aid in the implementation of new projects. The ‘training of trainers’ technique was also applied in the cases from Kazakhstan and Kyrgyzstan.

Health system processes and tools

Beyond the processes in health services lies the contribution of the health system as an enabler for the scale and long-term sustainability of efforts for strengthening health workforce competencies. Importantly, while country case studies demonstrate significant, almost immediate, changes following health services strategies to strengthen workforce competencies, activating complementary health system-level solutions takes time. Nonetheless, these changes prove a unique promise to legitimize enhancements of the workforce by formally instating such changes and, in doing so, feed into future generations of the workforce.

In reviewing the evidence, processes and tools undertaken to promote robust, competency-based health systems for the entry, enhancement and exit of the workforce, include the following (Table 2).

Table 2

Health system processes and tools for health workforce competencies.

Planning and forecasting
• Information systems and observatories for planning, forecasting and monitoring.
Selecting applicants to initial education
• Admission quotas.
• Specialized programmes for under-represented students.
• Multi-disciplinary candidate selection process.
• Educating
• New undergraduate, post-graduate degrees and residencies.
• Expansion of taught skills.
• Modernization of curriculum.
• International study credits and scholarships for study abroad.
• Accreditation of training schools.
Evaluating (novice-level)
• Objective Structured Clinical Examinations.
• Interviews.
• Written and multiple choice testing.
• Periodic evaluations based on peer and external observations.
Certification and registration
• New professional certifications.
• Examinations for graduating health professionals.
• Accreditation of certifying bodies.
Clinical decision supports
• Clinical protocols updated and aligned with core competencies.
Re-certification of health professionals
• Periodic re-certification examinations for health professionals.

Planning and forecasting

Health workforce planning is integral for anticipating a workforce capable of preforming tasks that meet future health demands. This hinges on a thorough understanding of those driving forces and challenges that shape the population's need [12]. Strengthening information systems and observatories have been targeted in the European Region as levers for planning, forecasting and monitoring workforce competencies [43]. For example, in Italy, the case profiled demonstrated the regional government's strategic application of adjusted clinical groups in planning the competencies for the future health workforce.

Selecting applicants to initial education

The principle of recruiting from a pool of eligible candidates those applicants with greatest potential in line with performance objectives is a key criterion for admission to initial education [15], [66], [67]. The importance of this is highlighted in the literature, drawing attention to also promote diversity in applicants that mirrors the patient population [12]. Relevant tools may include admission quotas to increase diversity [68] and specialized programmes for under-represented students [69]. The literature also recognizes the specification of criteria for candidates through collaborations spanning service executives, patient associations, professional associations and colleges as a relevant tool for promoting competency-based selection [15], [40].

Educating

The sustainability of new competencies for the health workforce is accelerated by the introduction of new or adapted educational programmes [15]. The purpose of accrediting or recognizing an educational programme is to ensure that it is able to produce the graduates intended, meeting commonly agreed standards. In the cases review, this included the development of new undergraduate degrees (Azerbaijan) and medical residencies (Belgium; Lithuania) as well as post-graduate masters programmes (Finland) for newly trained medical students to continue their studies. Revisions to existing curricula, strengthening or formally broadening trainings for the inclusion of additional competencies have also been activated (Luxembourg; Slovakia; Turkmenistan). The modernization of the curriculum to absorb emerging fields into formal education has served to uptake services delivery initiatives, such as degree programmes in telemedicine in Denmark. International partnerships, grants and scholarships during education have extended opportunities to new modules and credits during studies with proven success (Cyprus). The challenge of breaking down barriers between academic institutions and professional groups can be addressed by developing competencies in collaboration.

Evaluating (novice-level)

Initial education ensures students can consolidate knowledge and skills, and while these will only be mastered when they are assigned the direct responsibility of a patient, exposure to and basic understanding of competencies can nevertheless be evaluated in initial education settings. Instating a diverse set of evaluation tools to capture novice-level knowledge, skill and judgement is thus, integral in the development of competencies. This can be activated by a range of evaluation tools including Objective Structured Clinical Examinations (OSCEs), interviews, written and multiple choice testing, periodic evaluations based on peer and external observations [31], [45], [70].

Certifying and registering health professional

The certification and registration of health professionals is a standard process in the initial development of the health workforce. Certification marks the successful completion of evaluations to become a professional. In some cases, this is followed by registration with regulatory bodies representing the public or the profession's interests.

Country case studies describe certification as an essential means to secure the formal introduction of new competencies. In a number of cases, through continuous professional development and the advancement of curricula it becomes possible for new certifications to eventually be untaken and officiated by the health system. For example, community-nursing certifications in Malta or palliative care nurses in Serbia. In Bulgaria, an initiative to introduce home care services was formalized by the approval of ‘home helps’ by the Ministry of Health. Accreditation of certifying bodies is an important mechanism for instating a standard of competence in this process to be upheld [15].

Clinical decision supports

Updating clinical guidelines with best available evidence and aligning them with the education and continuous development of health professionals [47], [71], [72] is a task reserved for the health system stewards and informed by research and professional associations. Across nearly all cases, formally adjusting or updating care protocols for the consistent provision of services according to a common set of standards was a fundamental health system-level intervention. In the case of the Republic of Moldova, for example, unifying clinical decision supports was a core component for streamlining child health services across newly trained family medicine physicians.

Re-certification of health professionals

The re-certification of health professionals at regular intervals is standard practice in the regulation of health professionals and is applied across the European Region. In case studies, primarily those from Former Soviet Union Countries sharing relatively more recent reforms in the certification and accreditation of health professionals, efforts to strengthen continuous medical education targeted recertification processes. This included, for example, establishing new training centres based on international standards for a phased introduction to re-certification and complementary enhancement training after initial diploma (Kazakhstan; Belarus).

Actors

Multiple, relatively autonomous, actors influence health workforce competencies; where actors are differentiated from other stakeholders, as the individuals, organizations, groups or coalitions within and outside government, locally, nationally and internationally, with both the interest and power to influence reforms [73], [74]. Reviewing the evidence, those actors commonly identified are listed in Table 3. The table additionally accounts for the focus of their influence.

Table 3

Key actors for health workforce competencies.

Health services delivery processes for health workforce competencies	Health system processes for health workforce competencies	Both processes in health services delivery and health system
• Health managers• Health workforce• Clinical leaders• In-service educators• Quality improvement teams• Patients, families and care giver advocates; ombudspersons	• Ministry of Health• Ministry of Education• Regulatory bodies (accreditation of education, health institutions, curricula, technologies, training centres; licensing of health professionals)• Health workforce observatories• Health state institutes/republican centres	• Colleges, universities and other training institutions• Regional (oblast), district and municipal authorities• Health insurance funds• Health professional associations• Patient associations• International development partners• Non-state actors

In health services, actors share a common concern for strengthening the health workforce competencies, matched by the potential to influence this by activating the above-mentioned tools. For health system processes, key actors with leverage over human resources for health have the capacity to influence policy and regulate competencies across the health system. Interestingly, boundary-spanning actors are also identified. These actors have direct leverage to influence both health services and the health system.

Discussion

Previously, strengthening the health workforce has predominately targeted system-wide reforms for initial professional education [15], [17]. As a consequence, other processes have been eclipsed in the conceptual debate, undervaluing the importance of continuing the development of competencies in day-to-day practice as a factor of performance of the health workforce. However, as has been shown here, competencies are the product of a cycle extending from initial taught knowledge and skills to their application, with repeated reflection and feedback for continued maintenance and further advancement overtime.

In this cycle, it is the stewards, in their oversight to govern, which catalyze the alignment of processes and respective actors. This task, as the World Health Report 2000 [18] described, calls on stewards to define the ‘rules of the game’ – the formal and informal rules that determine the boundaries within which the system's actors operate [75]. In doing so, the governance function ‘enables the conditions’ for aligned action, setting an institutional framework and explicit boundaries in which actors interact and are expected to perform [76], [77].

Steering the system for improved health workforce competencies is made easier by differentiating between health services and the health system. Applying the findings on the specificities of the processes, tools and actors for strengthening competencies identified, we consider key lessons learned from the evidence of particular pertinence for stewards to carry out their role. These lessons apply across the core governance processes of setting priorities, organizing for action and measuring and feedback.

Setting priorities

Build partnerships

Governance plays a critical role in creating an environment that facilitates productive partnerships for strengthening competencies within the health system and also across sectors [78]. Inter-ministerial and interdepartmental committees [78], [79], [80], public-private task forces [80], integrated budgets and accounting or co-funding arrangements [78], are examples of those mechanisms well documented in the literature to foster multi-actor interactions. In cases, like Kyrgyzstan, linking Development Partners and community-based structures or in Luxembourg, working across Ministries, building partnerships was essential to mobilize interest, power and resources in a coordinated fashion.

Recalling Table 3 and its distinction noted between actors in health services or the health system, country cases demonstrate the significance of partnering across these spheres. Cases from Norway and Ireland for example, were well positioned to leverage scale and sustain efforts credited to the partnerships established from the health workforce to the Ministry of Health.

Formulate a strategic direction

Sequencing activities strategically is the foresight and direction uniquely offered by system stewards. This often leans on tools or mechanisms including strategic plans [81], [82], policy changes, operational guidelines, training manuals, protocols [83] and targets, goals and performance measures [81], [83] that set clear priorities and actions. In case examples, having clarity on the number of trainings, new certifications, and other processes for strengthening competencies ensured the timely achievement of goals, while also minimizing duplication. In the case of Israel, a well structured and documented approach for locally planned and implemented trainings and workshops for district management ensured consistency while also promoting local autonomy and ownership in the process.

Organizing for action

Regulate

Formalizing changes in regulatory frameworks can be key predictor of scale and sustainability [84], [85], [86], [87]. Without clear and aligned policies, bottom-up, workforce-led changes, have previously faced real constraints in their ability to manoeuvre and expand within the system. Efforts to renew regulatory frameworks such as the renewal of procedures and decrees [76], codes of conduct [77], [88], [89], new performance standards for accreditation and licensing [82], [89] or the introduction of statutory bodies as national regulatory agency have proven there importance for matching the institutional conditions with sought changes. In Bulgaria, for example, the introduction of home care workers was formalized by a change in policy allowing health professionals in the home.

Establish organizational adequacy

Increasingly decentralized systems demand concerted efforts on the part of governance match this context with the corresponding organizational arrangements [90], [91]. In cases, including Andorra, Lithuania, Ireland and the United Kingdom, piloting new processes was often a relied upon technique to test new organizational structures and refine arrangements prior to full-scale reforms. Tools including implementation or annual operational plan [92], monitoring and evaluation plan [82], [88], organizational charts [82], [92], [93] are among those well-cited options in organizing for action.

Foster participation

The literature is clear in conveying that governance requires well-articulated structures and processes for continuous engagement [94], [95]. Strong links have been found between the degree of participation of all actors and the success of implementation [96], with previous reviews noting in particular the importance of the public's participation to promote responsiveness to their needs, transparency and trust [79], [95], [97].

Open meetings, public workshops, national forums, citizen advisory committees or citizen juries [78], [92], public satisfaction surveys [98] and consensus conferences [77], [99] have been found effective for encouraging the participation of actors. From country cases, the time and resources needed for fostering participation of actors was often underestimated. In cases from Denmark and Lithuania, for example, over a year was spent at the outset of a new initiative to engage actors in dialogue on the topic, exchange ideas, drive coalitions and build a sense of ownership.

Measuring and feedback

Ensure accountability

Making explicit the ways in which actors are expected to perform by mandating clear roles and responsibilities [100] is a requisite for accountability [19]. As the advancement of competencies spans multiple actors, strengthening accountability is of particular pertinence. Accountability is ultimately predicated by conditions including also the allocation of necessary resources (technical, time, human, financial), performance measurement, regulation and feedback [100], [101]. For example, in Romania, the devolution of authority to organize and deliver community-based solutions was followed by an investment to build local managerial capacity to then carryout this mandate. Performance-based contracts [102] or pay-for-performance techniques [77] are frequently cited in the literature as means to measure and react to performance.

Generate information

The collection, analysis and use of information hold a number of important applications for governance. Information is found an integral part of the change process, closing the feedback loop between health services and the health system. Nevertheless, in nearly all cases, monitoring and evaluation activities necessary for system-level operations were a residual activity, with little investment of human resources or time. Thus, it is of clear importance for stewards to activate relevant mechanisms such as commissioned reports, audits and performance reviews [76], [93], health impact assessments or health needs assessments [77], [99] to generate necessary information for future decision-making.

Promote transparency

Transparency is a central tenet of governance, building trust, awareness and support for accountability [102], [103]. Watch-dog committees such as facility boards, parliamentary committees [76], [77], [78], the release of performance information to providers and the public [76], inspectorates and fact finding commissions are well-referenced tools for promoting transparency. In the case of the Netherlands, publically reporting of performance aimed to promote informed choice from patients in selecting providers, fuelling continued performance improvement. The case of Estonia to introduce a national electronic health record has also demonstrated an important role in systematizing transparency.

Conclusion

This work has aligned the growing body of literature, experience and expertise related to the health workforce with a specific focus on strengthening competencies. In doing so, the specific processes for strengthening competencies have been reviewed. Challenging traditional, more linear notions for developing health workforce competencies, a multi-layered, multi-actor and cyclical process has been identified.

Stewards, in their governing role, face the certainly difficult assignment to set the necessary conditions for aligned action. This task, however, can benefit in knowing the processes underpinning the strengthening health workforce competencies and the possible tools to be applied; differentiating between the contribution of health services and that of the health system. In the context of current health needs and its demand for integrated health services delivery, a concerted effort across core processes of governance to strategically engage tools and mechanism conducive to strengthening health workforce competencies is an imperative.