Developing a competency-based curriculum for eye care managers in Sub-Saharan Africa

Introduction: There are insufficient healthcare providers to supply eye care services to the millions of people living with visual impairment in developing countries. Eye care providers may supply more efficient and effective services if supported by skilled managers. To help produce skilled managers, appropriate competencies for eye care managers in Sub-Saharan Africa were included in the curriculum for the Postgraduate Diploma in Community Eye Health course (PGDCEH) at the University of Cape Town. Methods: The competencies were developed from information from course-development consultations with Sub-Saharan ophthalmologists, and heads and managers of eye care programs; minutes of curriculum planning meetings; and the competencies and skills required by general, eye and public health managers. The competencies were mapped onto the PGDCEH curriculum. Results: The core expectations for eye care managers were in keeping with accepted generic management competencies and skills. Additional competencies (eg population/public health) were commensurate with those for medical and population-based clinical management, medical education and public health. Broader aspects of eye care (eg patient-centered care) were also incorporated. Conclusions: Competencies for eye care managers in Sub-Saharan Africa were developed using participatory and multidisciplinary approaches to enhance context-appropriateness. Identifying these ensures that the PGDCEH learning content reflects the actual skills required, provides clarity about learning outcomes, and forms the basis for student assessment. Further, job


Introduction
Of the estimated 314 million people who are visually impaired, more than 90% live in developing countries.Approximately one-fifth of these live in Africa 1 .More than three-quarters of visual impairment could be prevented or treated by an appropriately trained healthcare workforce with the relevant infrastructure to support them.However, Africa has insufficient healthcare providers.For example, it is estimated that 1 million extra health workers would have to be trained by 2010 to meet the targets of the UN Millennium Development Goals 2 .To help overcome this, the efficiency of the current healthcare workforce could be increased if human resources, materials, and financial management systems were well managed 3,4 .Well trained non-clinical managers could support the delivery of efficient and effective health care that is accessible to as many people possible.This would allow clinicians to concentrate on providing much needed health care 4 .In Sub-Saharan Africa, many eye care managers progress through clinical careerpathways and are ophthalmologists, ophthalmic clinical officers or optometrists.Many assume management roles in eye care programs without any formal management training.
Training courses should adequately prepare graduates for the tasks they need to undertake.Although the generic principles of management courses offered on different continents are similar, the context and setting are vastly different between, for example, India and Africa.Therefore, the direct appropriation of an Indian course for African eye care program managers would likely be inappropriate.Also, experience has shown that courses frequently do not permit adequate time for participants to learn and apply all that is required by the course and their employment.This is particularly so for 'short courses', but is not limited to these.
The result is that despite attending formal training, as with public sector hospital managers in South Africa 5 , many feel unprepared for the responsibilities of their job.Also, many program management courses do not result in a formally recognized qualification.This frequently leaves graduates without the prospect of career progression or the authority to implement plans 6 .
In response to the need for personnel with skills to manage eye care programs in Africa, and a desire for recognition of their training, a Postgraduate Diploma in Community Eye Health course (PGDCEH) was proposed at the University of Cape Town (UCT).
To avoid inappropriate and/or ineffective training, a competency-based approach for the PGDCEH course was adopted.Many other courses, including ophthalmology, have adopted this approach 7,8 .Using this approach, the learning content reflects the actual skills required after graduation, both faculty and students have clarity on learning outcomes expected, and student assessment can be based on and be appropriate to these learning outcomes.Consequently, the focus becomes the outcome of the education, rather than the education process (ie how knowledge, skills and attitudes are applied, rather than how knowledge is gained) 8,9 .In addition, concentrating on competencies helps differentiate the role of the eye care manager from those of other members of the eye care team, and provides a framework for the performance evaluation of graduates when they return to their workplace.The result is accountability in education and, ultimately, to the public 10 .This article reports on the assessment of the requirements for a human resource capacity development strategy, specific to Sub-Saharan Africa: the role and tasks expected of eye care managers in this region, competencies from related fields, and the corresponding competencies that would form the basis of a postgraduate education course.Comment is made about the curriculum development process, its outcome, and the next steps to ensuring the resultant course has a favorable impact on eye health.The objective of this undertaking was to develop a competency-based curriculum that could guide the course towards the application of knowledge and skills, with the expectation that this would enhance the workplace performance of the graduates.During the course, competencies, expressed as measurable behaviour, could also be used to evaluate competence independent of the performance of other learners.After the course, these competencies could be used for ongoing evaluation of the graduates' performance.
Furthermore  For the purposes of this article, competencies have been defined as the 'knowledge, skills, attitudes and personal qualities that an individual needs to effectively fulfill a particular set of functions, occurring across disparate job descriptions and employment situations' 9 .The generic competencies and skills required by managers 6 as well as the documented competencies for hospital-based managers 6 , medical managers 11 , population-based clinical managers 12 , public health 13 , and medical education 14 were explored.Fayol's classical management function framework (planning, organizing, leading/coordinating [implementing] and controlling [monitoring, evaluation and learning]) was used to organize these data 15 .
Albanese's five theory-based criteria were used to guide the development of competencies for this course 9 .Consequently the competencies are expressed as measurable behaviours, focusing on the expected performance of the graduates, to ensure the course content is aligned to the application of knowledge and skills.Furthermore, because the standards used for assessing competence are independent of the performance of other learners, this facilitates criterion-based assessment for this course.These also serve to inform learners and others about the outcomes expected after the course.

Results
There was considerable overlap and agreement between the perceptions of ophthalmologists and eye care program managers as to the role and tasks of the managers.However, there was difference in emphasis.The heads of eye care programs (non-government organization representatives and national blindness prevention coordinators) focused on the knowledge and understanding that an eye care manager should possess (Tables 1,2).The key differences in emphasis are indicated in the tables in italicized font.
The core expectations of what is required of eye care managers (Tables 1,2) were in keeping with what are regarded as generic management competencies and skills (Table 3) 6 .However, there was an expectation (Tables 1,2) of a wide range of additional competencies (eg population/public health, including eye health promotion; clinical/medical eye care) because these would be necessary in the provision of comprehensive eye care services.These were commensurate with the competencies specified for medical and population-based clinical management, medical education and public health (Table 3) 6 .
Research focused, and more analytical skills such as epidemiology and biostatistics were considered less relevant to the tasks of an eye care manager and were therefore excluded.Public health biology and environmental health sciences were also excluded.
Program heads, eye care managers and ophthalmologists made little reference (Tables 1,2) to the broader aspects of eye care (eg patient-based care or considering care from a patient point of view; how eye care interacts with the larger health context; system and ethical/legal aspects of eye care provision).However, the consultation process that involved ophthalmic, population public health and education expertise ensured that a consensus of broader competencies was ultimately incorporated into the PGDCEH (Fig1; Appendix I).
The curriculum is composed of a combination of on-campus and remote study blocks to optimize the opportunities for

Conclusions
A systematic process, informed by best available evidence from the literature and stakeholders from a wide experience base, was used to develop a competency-based curriculum (Appendix I) anchored in the realities of providing eye care in Sub-Saharan Africa.This ensured that the curriculum was in concordance with the expected combination of generic competencies and skills required by eye care managers and those needed for medical and population-based clinical management, medical education and public health (Table 3).
It is anticipated that this curriculum will enhance the effectiveness of training eye care program managers and the resultant management-related performance after training.
The process of developing competencies to be taught in the PGDCEH was participatory.In the first instance, a range of workers in the field (clinicians, program directors and eye care managers) were used to define the role, tasks and generic competencies required of an eye care manager.Each group gave emphasis to different functions and skills, depending on their own work experience and perspective.This enriched the quality of the raw material on which the final competencies were based.Also importantly, this process garnered ownership and buy-in by those who in the future may be recommending or selecting candidates to attend this course.

Plan the delivery of eye health care:
Use the principles of project cycles to plan, in collaboration with other stakeholders, comprehensive, patientcentered eye health services that are based on the best evidence available and local needs, priorities and resources, to improve the eye health of the population in the program area.

Organize the delivery of eye health care:
Arrange, coordinate and administer human, material and information resources to implement the eye care strategies for health promotion, disease prevention, and control/management for eye care priority areas: cataract, refractive error, childhood blindness, trachoma, glaucoma and diabetic retinopathy.The process was further strengthened by the use of a multidisciplinary group of experts who, with a wider public health and education perspective, finalized the competencies.This ensured that essential aspects such as the provision of patient-centered care, ethical/legal issues and systems thinking, which had been ignored by the primary informants, were included.These are necessary for the provision of good quality comprehensive eye care services, integrated with general health care, and to ensure continued utilization of services and service sustainability.

Control
However, the pursuit of a quality education experience delivering competent graduates able to implement workplace activities and produce favorable impact on eye health does not conclude here.Teaching faculty require information, training and support to facilitate the implementation of this competency-based curriculum.It is this information and the emphases placed within it that will further differentiate an African course from those from other parts of the world.
Also, appropriate assessment of student learning must be organized 7,16,17 .
Table 3: Competency areas for generic, medical and population-based clinical management, and medical education and public health 6,[11][12][13][14] Generic management [6]  Medical management [11]   Population-based clinical management [12]   Medical education [14]   Public health [ This assessment of required eye care manager competencies further provides the basis for future evaluation of the appropriateness of the curriculum, and the impact of the eye care managers' training program on eye care service delivery in Sub-Saharan Africa.A widely available, but indirect measure of the effectiveness of the course is assessing the cataract surgical rates of the districts with formally trained eye care managers.However other more direct indictors and qualitative information will be collected for ongoing evaluation and modification of the course to enhance the learning experience and increase its effectiveness.In a continuing process of refinement, the competencies will be evaluated for relevance and relative importance to the everyday work of eye care managers.Existing eye care managers, graduates of the course, employers and other stakeholders will be asked to rate these and provide an assessment of their perception of the proficiency required for each.This information may then be used to modify the competencies, improve course teaching (including appropriation of increased time to competencies deemed more important or difficult to acquire) and assessment, and/or plan continuing or refresher education 18,19 .
Organize the delivery of eye health care Arrange, coordinate and administer human, material and information resources to implement the eye care strategies for health promotion, disease prevention, and control/management for eye care priority areas: cataract, refractive error, childhood blindness, trachoma, glaucoma and diabetic retinopathy.Plan advocacy strategies based on an advocacy project cycle, including problem and stakeholder analysis to construct a strategy map and a communication plan.
• Plan and implement an advocacy strategy using a project cycle, marketing strategies, lobbying and networking skills to: o develop, improve or promote the profile of the organization o promote appropriate participation in a population-based health service o alter patient, provider, or organizational behavior in order to improve health, the utilization and the delivery of eye health services o support the development of eye health care services.Participate in the design of a curriculum for training a cadre of primary eye care workers, using effective teaching and learning methods to facilitate the acquisition of knowledge, skills and attitudes.Organize the training for primary level workers and the assessment and evaluation of the training.Apply appropriate administration, financial and business management, and resource mobilization techniques to eye care programs to ensure efficient delivery of cost-effective health services.
Cost and prepare a comprehensive budget for an eye care project.Write, present and appraise proposals, business plans and agreements for eye care programs and projects, taking into consideration the factors that influence feasibility.Interpret financial and management reports relating to eye care programs.Identify and mobilize the most likely sources for resources for different requirements and situations.Coordinate the administration of programs: including efficient resource allocation, and management of resources using stock and inventory control systems.
Lead / coordinate the delivery of eye health care Demonstrate effective leadership capabilities, including creation of a vision, development of a shared strategy, coordination of stakeholders and resources, change management and communication strategies to implement the eye care services.Employ leadership strategies and skills to motivate and enable people and organizations to work together to effectively implement eye health services and promote sustainability.
Promote working in eye care and interdisciplinary teams to achieve a shared vision: cooperate, collaborate, communicate, and integrate care, to ensure care is effective and efficient.Build partnerships with other organisations and the community, using effective written and oral communication skills and strategies for collaboration.Appraise collaborative agreements and identify the key deliverables of each stakeholder.Develop strategies to enable and motivate the eye care team to achieve organizational goals: collaborative problem solving, decision-making, evaluation and managing change.Appropriately use management principles and leadership styles in conflict resolution, negotiation, consensus building, problem solving, team building, and change management.Value commitment to lifelong learning, challenging the status quo and making changes when required, and engage in dialogue and learning from others.Act as a role model: demonstrate transparency, accountability, integrity, and honesty in all actions and apply social justice and human rights principles when addressing community needs.
meeting included a workshop component to encourage interaction.A highly regarded academic with international expertise in eye health development, especially in Sub-Saharan African programs, facilitated the discussions.The UCT team presented the proposed draft curriculum, and the different groups negotiated the merits of including or excluding certain components from the course.The meeting reached consensus on job descriptions and the knowledge that eye care managers would require.This information formed the basis of the PGDCEH curriculum.A faculty member from an external training institution (the first author) collected information from focus group discussions about the perceived role and tasks of eye care managers from ophthalmologists and eye care managers from the same geographical area and also from the literature.The minutes of curriculum planning meetings and the PGDCEH curriculum were examined to identify content areas and the required knowledge for associated practical application.
knowledge assimilation and experiential learning in the workplace.Much deliberation was required to finalize the logistics and feasibility of these components.Once these components were finalized, the curriculum was submitted to the stringent approval processes of the Higher Education Qualifications Authority of South Africa (HEQA).Guided by the rules and standards of HEQA, the UCT-based faculty modified the curriculum content and structure, and as requested.In particular, HEQA required more details about the activities and outcomes envisaged for the remote component of the course curriculum.After submission of the revised curriculum, the program was accepted and entered into the University's academic program for implementation in 2009.

Figure 1 :
Figure 1: Competency areas for eye care managers as presented in the University of Cape Town Postgraduate Diploma in Community Eye Health curriculum.

•
Plan systems for information collection and sharing.Determine management information needs and how appropriate technology, along with health management information systems, can be used for: o communication of health policy and management issues o management of knowledge/data o mitigation of error o support for decision-making o monitoring and evaluation o reporting and communication.Manage and support human resources.Determine human resources needs for different cadres and plan selection for training accordingly; recruit and deploy appropriately skilled personnel.• Provide support to the eye care team to perform effectively, ensuring that job descriptions, work schedules, communication processes, performance appraisals and supervision are in place.• Identify ethical and professional standards for eye care personnel and ensure services comply with pertinent legal and regulatory requirements.Implement a training program for primary eye care providers.

13]
For eye care managers, limited to knowledge of the priority eye conditions in their areas.