A Review of Global Health Competencies for Postgraduate Public Health Education

During the last decade, the literature about global health has grown exponentially. Academic institutions are also exploring the scope of their public health educational programs to meet the demand for a global health professional. This has become more relevant in the context of the sustainable development goals. There have been attempts to describe global health competencies for specific professional groups. The focus of these competencies has been variable with a variety of different themes being described ranging from globalization and health care, analysis and program management, as well as equity and capacity strengthening. This review aims to describe global health competencies and attempts to distill common competency domains to assist in curriculum development and integration in postgraduate public health education programs. A literature search was conducted using relevant keywords with a focus on public health education. This resulted in identification of 13 articles that described global health competencies. All these articles were published between 2005 and 2015 with six from the USA, two each from Canada and Australia, and one each from UK, Europe, and Americas. A range of methods used to describe competency domains included literature review, interviews with experts and employers, surveys of staff and students, and description or review of an academic program. Eleven competency domains were distilled from the selected articles. These competency domains primarily referred to three main aspects, one that focuses on burden of disease and the determinants of health. A second set focuses on core public health skills including policy development, analysis, and program management. Another set of competency domains could be classified as “soft skills” and includes collaboration, partnering, communication, professionalism, capacity building, and political awareness. This review presents the landscape of defined global health competencies for postgraduate public health education. The discussion about use of “global health,” “international health,” and “global public health” will continue, and academic institutions need to explore ways to integrate these competencies in postgraduate public health programs. This is critical in the post-MDG era that we prepare global public health workforce for the challenges of improving health of the “global” population in the context of sustainable development goals.


iNTRODUCTiON
In the post-MDG era, there is increasing recognition that health and sustainable development are inseparable in an increasingly globalized and interconnected world (1,2). The complex interplay between humans, animals, and environment; dual burden of communicable and non-communicable diseases; emerging economies; and mobility of people are having profound political, social, and economic consequences (3). The concept of "global health" as the health of an interdependent global population is not only shaping our understanding of which and whose problems we tackle but also the way in which we educate students and design the global institutions that govern our collective efforts to protect and promote public health worldwide (3).
During the last decade, there has emerged a growing body of literature about global health. Based on MEDLINE searches, from 1996 to 2000, there were fewer than 50 publications with "global health" in either the title or abstract, which increased to more than 6,000 from 2011 to 2015. Global health has been defined in the context of various professional groupings such as medicine, nursing, oral health, pharmacy, allied health, and also medical subspecialties (4)(5)(6)(7)(8)(9)(10). Global health overlaps with international health and tropical medicine, and there are calls to explore similarities and differences between global health, international health, and public health (11,12). The global aspect of this term has been debated, and several meanings have been discussed. Global may imply worldwide or transcending national boundaries, or it could signal the interdisciplinary nature of public health in a globalized world (2).
The generation of knowledge and its optimal use and application, especially in the field of global health and development, has garnered significant attention in recent years. There has been a dramatic growth in the number of educational programs that offer global health programs at undergraduate and postgraduate levels. A consensus definition for global health remains elusive. Commonly used is that of Koplan and colleagues who defined global health as "an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care" (12).
Educational competencies are informed by the needs of professional workforce and include a combination of knowledge, skills, and attitudes required for acceptable level of practice. Educational competencies are critical to curriculum development and evaluation, coordination across education programs, faculty development, and scholarship. The Institute of Medicine's report "Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century" published in 2003 identified eight emerging areas significant to the future of public health education, which included global health, communication, cultural competence, and ethics (13). The report also recommended that competencies in these emerging content areas need to be identified and incorporated in graduate public health education (13). Calhoun and colleagues described the development of the Association of School of Public Health's Core competency model for Master of Public Health (MPH) degree and discussed that the aim of these competencies was to provide knowledge, skills, and expected attributes of emerging public health professional (14). Recently, several reports including the Lancet Report on Health Professional education and the WHO report on "Transforming and Scaling up Health Professionals Education and Training" guidelines have highlighted the centrality of competency-driven education for bringing in educational reforms (15,16). Calhoun and colleagues reviewed competency-based education program development in the context of global health workforce and discussed the status of competency model adoption across public health schools in the USA (17). This review analyzed the competency domains and outcomes using Blooms Taxonomy of educational outcomes showing that most competencies are in cognitive domain at a higher application level (17).
The recent literature in global health education has elicited several reviews that have sought to identify "core competencies" for various professional groups including medical, nursing, and public health education (5,(17)(18)(19)(20)(21). Academic institutions are also exploring the scope of their public health educational programs in the context of global health education to meet the demand for a global health professional in the context of the sustainable development goals. The American Association of Schools and Programs of Public Health Global Health Committee proposed a Global Health Competency Model, and the Consortium of Universities for Global Health (CUGH) global health subcommittee published four levels of interprofessional global health competencies (20,21). There have been other attempts to describe global health competencies in the context of specific education programs and perspectives from stakeholders (22)(23)(24)(25). The focus of these competencies has been variable with a range of different themes being described ranging from globalization and health care, analysis and program management, as well as equity and capacity strengthening. This review of the literature will provide a landscape of global health competencies and attempt to distill common competency domains to assist in curriculum development and integration in postgraduate public health education programs.

Search Strategy
A literature review was conducted in April 2016 using six electronic databases using the keywords: TITLE-ABS (Global Adj3 health OR international Adj3 health) AND (education* or training* or universit* or curriculum* or college*) AND (competenc* or skill* or outcome* or objective*). The search was limited to English language only, and all document types were searched with a focus on primary research studies, evaluation reports, conference abstracts, and all types of review articles.
Two reviewers (Shailendra Sawleshwarkar and Joel Negin) initially reviewed the titles and selected articles that discussed global health from an educational aspect for the abstract review. All shortlisted titles were directly imported into Endnote© version 7 (Thomson Reuters, Philadelphia, PA, USA). Duplicate results were then removed. During abstract review stage, studies related to specific medical, nursing, and medical subspecialties professions that were related to global health but not dealing with public health were excluded. After limiting abstracts to those related to global health from educational point of view, a full text review was conducted to identify those dealing with global public health education. At this stage, a detailed analysis was done of all those articles, and specific articles addressing global health competencies in the context of graduate public health education were identified. After going through the bibliographies of these articles a cross search was undertaken to identify any additional relevant articles.
Articles were discussed by two authors (Shailendra Sawleshwarkar and Joel Negin), and full review of the selected articles was undertaken. Information was extracted on global health competencies, year of publication, type of programglobal health/international public health/public health/other, location of the review, method used for developing or describing competencies (if relevant), competency domains/themes, and list of competencies in each domain/theme.
Core competency articles were read in detail, and a list was generated with all competencies mentioned in these articles. A note was made if the article identified the competency domain directly in their article, and this was noted as "Yes, " and if this was not identified, then "No" was recorded. If the article described the competency domains in the context of learning outcomes but competency domain was not explicitly stated then this was recorded as "Implied. " Figure 1 presents a flow chart of the search strategy. The titles of 6,242 references were screened by 1 independent reviewer, and 510 unique references were selected for abstract review. After limiting abstracts to those that dealt with global health education from public health aspect and after excluding duplicates, this reduced the number of abstracts to 126. Additional search with and cross references yielded 10 additional abstracts that were added and resulted in a total of 136 for a review. Fifteen articles described competencies either as a focus of the article or in the context of a program. Two of these were not included in the final set as one of them described the same program and as another article focused on global health research competencies. Thirteen articles described competencies in the context of public health education and are summarized in the Table 1.

Article Characteristics
All the 13 shortlisted articles that described global public health competencies were published between 2005 and 2015 with 6 from the USA, 2 each from Canada and Australia, and 1 each from UK, Europe, and Americas (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30). A range of methods were utilized to describe competencies and included literature review, interviews with experts and employers, surveys of staff and students, and description or review of an academic program.
Jogerst and colleagues described the work of Global Health Competency Subcommittee of CUGH to identify interprofessional global health competencies and proposed 2 competency levels with 13 competencies across 8 domains for the Global Citizen Level and 39 competencies across 11 domains for the Basic Operational Program-Oriented Level (21). Ablah and colleagues described a Global Health Competency Model developed through a multistage modified-Delphi process and described 7 domains and 36 competencies that complement the foundational public health competencies (20). Pfeiffer and colleagues conducted 26 semi-structured interviews with global health practitioners and leaders about the competencies and curriculum for global health professionals of the future and identified key knowledge (health systems and determinants of health) and skills (analytical, leadership and management, and policy development) areas (30).
The six main competencies stressed by the Program are 1. Situational analysis: the ability to analyze a situation in-depth so as to intervene successfully. 2. Policy formulation and decision-making: the capacity to develop and influence policies and strategies conducive to life and human health. 3. Negotiation and advocacy: the ability to understand and direct change processes in relation to a given problem or challenge that is shared by different groups or institutions. 4. Project management and cooperation: the ability to develop and establish relationships and reach collaborative agreements that are mutually beneficial in order to achieve specific objectives. 5. Production and dissemination of information: the ability to develop and communicate innovative information about international health. 6. Communication: the ability to formulate an argument and communicate it effectively to key stakeholders in order to achieve a desired outcome  A few articles described global health competencies in the context of either a master's program in international health or tropical medicine or global health component of a program and included those at the course review at the Emory University (24), alumni survey at the University of Toronto (28), program review of international health program at the Pan American Health Organization (26), alumni survey of program run by the tropEd network (25), and curriculum development through review and survey at the University of Washington (22).

Global Health Competency Domains
The 13 articles listed various competency domains and described them-these are summarized in Table 1. These competency domains primarily refer to three main aspects, one that focuses on knowledge aspects of health and disease with inclusion of burden of disease and the determinants of health.
A second set focuses on core public health skills including policy development, analysis, and program management. Another set of competency domains could be classified as "soft skills" with a combination of knowledge, skill, and attitude and include collaboration, partnering, communication, professionalism, capacity building, and political awareness. These 3 aspects of the 11 competency domain grouped as predominantly knowledge based, skill based, or a combination of knowledge, skill, and attitude are depicted in Figure 2. The list of competencies was reviewed, and similarly defined competencies were included under the same domain. There were some differences between articles regarding how these competencies were described and how they were grouped. This was more pronounced in the competency domains that discussed soft skills. Competency domains that were described by at least 6 of the 13 articles selected for review were included in the final list of 11 core competency domains along with a summary of the key elements of the identified competency domains distilled from selected articles ( Table 2). Table 2 also lists the category (knowledge, skill, or attitude) of each competency domain as per the Bloom's Taxonomy for educational objectives (31).
Analysis of the frequency of competency domains identified by the selected articles is shown in Figure 3 with domains 2, 8, and 10 being the most commonly identified domains. The competency domains that were mainly categorized as knowledge according to Bloom's Taxonomy included Global burden of Disease, Globalization of Health and Health care, and Social, Economic, and Environmental Determinants of Health. Those that could be categorized as both skill and attitude included mainly "soft skills" such as communication, collaboration and partnering, ethics and professionalism, capacity strengthening, and sociocultural and political awareness.
Although this list captures the most of the competencies described in the selected articles, there were few competencies that were not included as separate domains in the 11 core competencies. These included those with specific focus on disease conditions or groups such as maternal and child health or travel medicine or some components of health systems or broader themes such as primary health care, health promotion, or global governance.

DiSCUSSiON
Health is central to the discussions about achieving sustainable development, and there are calls to review the role of public health in this era of globalization through the recently proposed Global Charter for the Public's Health by the World Federation of Public Health Associations (32). Jenkins and colleagues argued for new conceptualization, review, and evaluation of "global public health" and also argued for curriculum change in public health education for the global public health workforce (33). Global health education has attracted increasing interest from academic institutions in the last decade. Current discussion about global health also presents an opportunity to explore integration of globalization, equity, political awareness, and interconnectedness in the public health curriculum in both high-income and low-income settings.
In this review, we identified 11 core competencies that may be relevant to postgraduate public health education. These competencies comprised those mainly dealing with knowledge such as global aspects of burden of disease and health care and mainly skill-based domains such as core public health skills of strategic analysis, and program management. The competencies also included those dealing with attitude and skill with key underlying themes of equity, ethics, professionalism, and human rights along with a set of "soft skills" such as communication, collaboration, partnering, and capacity strengthening and leadership were also identified. The competencies belonged to lower cognitive domains of 'understand' and 'apply' and also included a number of competencies with higher order cognitive domains of 'analysis' and 'evaluation.' The articles described mainly the knowledge aspects of health and disease and core public health skills of management and analysis  (19,22,29)]. Those articles that put more emphasis on "soft skills" typically did not include global burden of disease, but this may be due to assumption that it is a part of core public health knowledge (24,26). The interprofessional competencies described by Jogerst et al. described two levels of competencies-global citizen level and basic programoriented competencies (21). Global citizen level competencies  include those that focus on health and disease along with communication skills and sociopolitical and cultural awareness at the global citizen level. At the program level these include program management, capacity strengthening, and strategic analysis, which include core public health competencies but also add a set of skills that also described by Ablah et al. in the global health competency model (20,21). The Global Health Competency Model described by Ablah et al. specifically mentioned that the global health competency domains should be constructed upon the foundational MPH core competencies (20). Global health competencies have been described for many professional groups-medical (4, 7, 34), nursing (5), and allied health (6). There seem to be some differences in the core competency domains for clinical health professionals and public health professionals: those for medical professionals focus more on the global burden of disease and health-care services. In a large-scale consultation on global health competencies for UK postgraduate doctors in the United Kingdom, involving over 250 diverse stakeholders identified 5 key competencies, which focused on global epidemiology, determinants of health and health systems along with global governance and ethics/human rights (4). There is significant overlap in the competency domains with the MPH core competencies (version 2.3) by the United States Association of Schools of Public Health in 2006 (14), but additional "soft skills" can be seen as building on the core public health competencies (20). The new soft skills such as political awareness, communication, and collaboration are an important tool in today's globalized and politicized field of health.
The development of competencies allows for deeper thought on the definition and practice of global health. The similarities and differences in competencies are a good opportunity for academic public health institutions to engage in reviewing curriculum regarding knowledge, skill, and attitude required to prepare the global health professional. In their effort to define the field, Wernli and colleagues used a term "academic global health (AGH)" and suggested that it integrates the three traditional areas of health care, international health, and public health (35). They defined AGH as "within the normative framework of human rights, global health is a system-based, ecological and transdisciplinary approach to research, education, and practice which seeks to provide innovative, integrated, and sustainable solutions to address complex health problems across national boundaries and improve health for all" (35). The key dimensions described in this paper broadly deal with set of competency domains we have described in our paper including core knowledge areas in health care, core skills in public health, and set of "soft skills". These "new public health professional skills" have been highlighted in a recent paper describing the collaborative consultation by the World Federation of Public Health Association about how to adapt public health to a future role in global health (36). Global health education in public health programs needs to explore ways to incorporate the soft skills in the curriculum in addition to the technical focus on knowledge and skills to prepare the public health professional to face challenges of global health in the context of sustainable development.
Our review has a few limitations. There are a relatively few articles published about global health competencies, and hence we have also included articles that described competencies in the context of postgraduate programs in international health. We also recognize that global health competencies in individual programs in school of public health may not be published but are important, and we are planning to review this information in future. This review only focused on literature published in English and so may have overlooked information that was published in other languages. In this review we mainly focused on domains of global health competencies and not detailed sub competencies and learning outcomes for each domain and learning outcomes and more detailed analysis of the identified competency domains. We plan to conduct the detailed analysis in the context of postgraduate public health educational program in the Asian region.
Most of our articles discussed competencies based on programs or discussions in developed countries with some limited representation from the Asia. While the concept of global health originated in the developed world, due to the nature of global health, the long-term relevance and success of education in global public health education depends on the adaptation of the curriculum in both high-income countries and low-and middleincome countries (LMIC) (35,37). In a recent review, Rabbani and colleagues have argued that schools of public health in LMIC can contribute to overcoming several public health challenges faced by LMIC by building the capacity of cadres of competent and well-motivated public health workforce including educators, practitioners, and researchers (38).

CONCLUSiON
This review presents the landscape of defined global health competency domains for postgraduate public health education. The discussion about use of "global health, " "international health, " and "global public health" will continue, and academic institutions need to explore ways to integrate these competencies in postgraduate public health programs. This is critical in the post-MDG era that we prepare global public health workforce for the challenges of improving health of the "global" population in the context of sustainable development goals.

AUTHOR CONTRiBUTiONS
SS and JN were involved in conception and design of the review; involved in the interpretation of the data; approved the final submitted version. SS worked on the first draft with review by JN.