SPECIAL COLLECTION: CAPACITY BUILDING FOR GLOBAL HEALTH LEADERSHIP TRAINING EXPERT Gaps, Challenges, and Opportunities for Global Health Leadership Training

Background: Global Health Leadership (GHL) programs are essential for training emerging health care professionals to be effective leaders. Synthesizing knowledge acquired through experience implementing GHL programs can inform future recommendations for GHL. Objective: To describe the lessons learned, highlighting gaps, challenges and opportunities, during implementation of two GHL capacity building programs, namely the Afya Bora Consortium Fellowship in Global Health Leadership and the Sustaining Technical and Analytic Resources (STAR) fellowship and internship program for global health professionals. Methods: A mixed methods case-comparison study was conducted, using qualitative data (expert opinion) collected from the Program Directors in order to understand the experiences of the two GHL programs. A structured response guide was used to assess the overall experience in GHL program implementation, operational challenges and reported gaps. Afya Bora and STAR have been implemented for 8 and 2.5 years respectively. Thus, the analysis reflects a snapshot of the two programs at different stages. Findings: The results reflect knowledge gained through extensive experience in implementing the two GHL programs. Afya Bora has trained 188 multi-disciplinary fellows, and 100% of the African fellows are engaged in leadership positions in government departments and non-governmental organizations (NGOs) in their countries. STAR has placed 147 participants (89 fellows and 58 interns) in more than 25 countries globally. Both programs were successful in strengthening south-south and north-south collaborations for a common goal of improving global health. Implementation of both fellowships identified room for improvement in operational procedures and financing of the programs, and highlighted knowledge and skills gaps, as well as challenges in sustainability of the training programs. Conclusions: Afya Bora and STAR have had significant impact and have contributed to changing the leadership landscape in global health. Future GHL programs should address sustainability in terms of financing, delivery modalities and domestic integration of knowledge.


INTRODUCTION
Over the last two decades there has been greater local control and ownership of health programs, and public health efforts are increasingly being led by professionals in their own countries from medical, public health, and related fields [1]. Global health is an area for study, research, and practice that, 1) places a priority on improving quality of, and access to, health services, and on achieving equity in health for all people worldwide; 2) emphasizes transnational health issues, determinants, and solutions; 3) involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and 4) is a synthesis of population-based prevention with individual-level clinical care [2,3].
With poverty, porous borders and pandemics, there is now increasing urgency to strengthen global health programs, and yet this has remained a challenge [4,5]. In many countries, health care professionals in fields such as medicine, dentistry, and nursing have become increasingly involved in global health initiatives to strengthen the response [6,7]. While pharmacists and laboratory specialists also play a critical role in the detection, prevention and control of diseases, there has been less focus on the important contributions made by pharmacists in global health, and strong leadership by laboratory personnel continues to be limited in many low-and middle-income countries [8,9]. In addition, professional fields such as communications, journalism, law, management (e.g., human resources, business, finance), and others, all have and continue to play important roles in improving global health. To sustainably collaborate in an inter-professional, multi-sectorial environment, global health professionals need to have the crucial leadership training required to build local capacity. Unfortunately, few programs have been able to incorporate leadership and situational analysis skills needed to bring evidence-based interventions and programs to scale [5,6,[10][11][12].
Strong leadership requires an essential set of competencies in order to strengthen global health programs, especially during and following epidemics like Ebola and pandemics like COVID-19 [13,14]. Evidence indicates that health leadership is centred on the ability to identify priorities, provide strategic direction to multiple actors within the health system, and create commitment across the health sector to address those priorities for improved delivery of health services [13,14]. These skills are rarely included as part of research or clinical training and represent an addressable hurdle toward closing the "know-do gap" in low-and middle-income countries (LMIC) and in sub Saharan Africa (SSA) in particular.
Global Health Leadership (GHL) programs were developed in part to respond to the skills gaps identified as vital for emerging public health leaders and professionals to have sustained impact on the programs they champion. Since many of these individuals were in public health practice, not academics, programs needed to expand their content and the context of delivery beyond academic institutions in order to meet the needs of specific cohorts and local and national health systems [15][16][17][18]. In our review of available GHL programs, training content varied from simple leadership skills (such as effective communication) to more advanced training on cross-cutting leadership management skills [5,[16][17][18]. While formative program evaluation data on the impact of emerging GHL programs exist, literature gaps persist in several major areas: 1) who should be trained? 2) what needs to be implemented? 2) how are programs most successfully implemented? [7,14,15]. This paper documents the lessons learned during the implementation of two GHL and capacity building programs: the Afya Bora Consortium Fellowship in Global Health Leadership (Afya Bora) and the Sustaining Technical and Analytic Resources (STAR) project [16][17][18][19]. These two programs were selected purposefully, with the aim of understanding the similarities, differences and lessons learned in implementing GHL programs under different contexts. This paper describes successes and challenges, and provides future recommendations.

METHODS
Study type: This is a mixed method case-comparison study, where the qualitative data (expert opinion) was collected from the Program Directors to understand their lived experiences of the Afya Bora and STAR leadership training programs.

IMPETUS TO THE GLOBAL HEALTH LEADERSHIP PROGRAM IMPLEMENTATION
Afya Bora: "We were motivated to improve the health of populations and individuals in Africa and believed that one way to do this would be by filling a gap in training. Before designing the fellowship, a meeting with more than 100 African and US health professionals was held in Nairobi to discuss what to do. Many of our African colleagues saw the need for better training of those leading public health and healthcare programs in Africa. People in health-related leadership positions had formal training in their clinical area of expertise and then were thrust into leading/managing programs without ever being taught and acquiring skills specific to effective leadership and management." STAR: "STAR was conceived by the Public Health Institute (PHI) and its partners (Johns Hopkins University, the University of California San Francisco, and the Consortium of Universities for Global Health) in response to a request from USAID. The ideas were built upon the experience and lessons learned from previous USAID-funded fellowship programs in Global Health, which had been implemented by PHI over the previous 23 years. The focus of this new fellowship program was influenced by USAID's Journey to Self-Reliance (see: https://www.usaid.gov/selfreliance). The desire was for STAR fellows and interns to support host country governments and partners to achieve locally sustained results and to strengthen local capacities, while at the same time building their own skills to work more effectively both locally and globally."

OPERATIONAL ISSUES AND CHALLENGES DURING THE IMPLEMENTATION OF SUCH GH LEADERSHIP PROGRAM What went well?
Afya Bora: "The majority of the fellowship's working group members were extremely engaged, and we had excellent representation from all countries and from both nurses and physicians. Working group members had extensive knowledge of topics and a strong commitment to capacity building. There were enough funds to bring people together and create a sense of community, trust and collaboration. This held the program together even when times were difficult from a funding standpoint." STAR: "Having highly skilled recruitment, global operations, and performance management staff has enabled STAR to operate smoothly. We are able to recruit and match Fellows and Interns to placements and onboard them quickly. We provide supportive services to the Fellows and Interns, as well as their onsite managers in host organizations throughout their fellowship and internship periods. As demonstrated during the COVID19 pandemic crisis, STAR's global operations team has been able to pivot with rapid responses, such as repatriation when necessary, to ensure the safety of our Fellows to the greatest extent possible." STAR: "STAR staff from our performance management team, our learning team, along with our monitoring, evaluation, and learning advisor monitor and continually evaluate the fellowship and internship program at the individual and program levels. Staff check in with each Fellow on a quarterly basis to monitor progress against their learning and work objectives, and to track growth against the core competencies and milestones framework. Staff also check in with onsite managers to gain perspectives in order to intervene early in case there are any performance issues with the Fellows. The Monitoring, Evaluation and Learning (MEL) advisor conducts semi-annual and annual surveys to measure satisfaction of the Fellows, the host organization hiring managers, and the onsite managers, to ensure we are meeting the needs of everyone involved in our program. The MEL advisor is responsible for data collection, analysis, and report writing." What were the challenges before the program implementation?
Afya Bora: "The development of the curriculum and the development of the competencies took tremendous time and required constant attention and improvement." STAR: "Since our program is demand-driven and requires interest to be generated amongst both the host organizations and the donor in order to create fellowship opportunities, the biggest challenge initially was creating the demand that would bring funds with opportunities for fellow recruitment and placement. Additionally, developing the framework which included the GH competencies and milestones for learning and the structural foundation which included establishing HR systems (i.e. compensation packages, performance management procedures) and the global operations processes that support hiring local and third country national Fellows in LMICs took considerable time and resources." What challenges did you experience during the program implementation?
Afya Bora: "Funding lapses were stressful and created tensions between fellows and program leads. In some instances, fellows would apply for the fellowship through their supervisors and when the reality came for them to now enrol for the program, they would not be released. The program implementation was supposed to be rotational. However, in some instances this was not possible to rotate in the countries, which participated in the program." STAR: "The on-demand nature of STAR fellowships means we don't have a cohort of Fellows to whom we can provide consistent training. In addition, the STAR fellowship model puts the decision-making for recruitment of the Fellows in the hands of the hosting organization and donors. This leads to a lack of internal consistency for the selection of Fellows because the final recruitment decisions are made by different people. As a result, our Fellows are very diverse in terms of their levels of experience and skill sets, their countries of origin and placements, and the subject matter focus of job descriptions. This type of program necessitates an individual learning approach. There are benefits to such an individually tailored approach for meeting the needs of the Fellows, however, there are 5 Voss et al. Annals of Global Health DOI: 10.5334/aogh.3219 also challenges. First, it makes it harder to foster a connection, either personal or professional, among the fellows. Second, the amount of effort it takes to determine and build out the individual learning plans, monitor the progress, follow up on problems, and foster networking opportunities is considerable and has cost implications that make demand generation for the fellowships more difficult with host organizations and donors." Were there challenges within the organization and outside the organization? Afya Bora: "No major challenges. At times working group members have dropped out and we had to replace them. However, funds did not always come in a timely manner and for a fellowship that needs to recruit and pay stipends on time; this made it difficult for us. We were backed up by the University of Washington a few times with bridge funding as we awaited funds to be delivered; we would have had to stop the program without the backing." What are you most proud of with regards to your GHL program? How would you strengthen existing programs?
Afya Bora: "Adequate funds that are granted for an extended period of time (e.g. 3-5 years) rather than year to year funding." STAR: "Establish a solid funding from an independent source. If the funding comes from the host organization there will be competing interests. The program has more control towards its objectives if they have independent funding." DISCUSSION COVID-19 experience highlighted global weaknesses in human resources for health, financing, effective communication and leadership. This has raised awareness that there is need to strengthen training of health and allied professionals on leadership for global health programs. By exploring the motivation for creation, key elements in program design, and implementation challenges and successes of two leading GHL programs, we identify insights that can serve to inform ways to bridge the current gaps in leadership development for global health professionals.

SUCCESSES
Both programs have indicated successes in several areas including program development, identification of partner/host countries and institutions, employing competent and experienced faculty and being able to smoothly recruit and deploy fellows to the host organizations or training sites. Over the past eight years, Afya Bora has trained 188 fellows and the survey in 2018 indicated that 100% of the African fellows have returned to their countries where they are engaged in leadership positions in government departments and non-governmental organizations (NGOs) (Afya Bora program Overview 2019). STAR, as a newer Global Health fellowship program operating for 2.5 years, has placed 147 participants (89 fellows and 58 interns) in more than 25 countries globally as well as in Washington, DC-many of whom are host country nationals. STAR host sites include Ministries of Health, non-governmental organizations, UN Agencies, USAID Missions and USAID Washington Headquarters. As both programs continue to have an impact on various disciplines and multiple sectors within an interdependent health system, they underscore the importance and opportunity of making GHL programs multi-disciplinary and inter-professional in nature [14][15].
(1) Foundation of Core GH Competencies Foundations of core GH competencies are presented in Table 1. From their inception both Afya Bora and STAR prioritized developing a core set of distinct and multi-disciplinary competencies Table 1 Summarized findings of the case-comparison of GHL programs.

5.
Major issue identified was that while many clinicians were highly skilled professionals, most lacked leadership skills and experiences to manage regional or national health programs. 6. Formation of working group to develop curriculum with equal representation of African and US members.

7.
Identification of attachment sites with capacity to mentor fellows in Botswana, Kenya Uganda and Tanzania was carried out by the working group.
8. Development of a selection (matching) process of fellows from initially Uganda, Kenya, Tanzania and Botswana through the local national universities.

9.
A six months project pilot in 2010 was conducted to understand and improve the implementation processes, test the learning content, and shape the outcomes expectations. 1. Evolved from a 23-year legacy of global health fellowship programs funded by USAID, which aimed to provide opportunities for Americans and US permanent residents to work in technical positions within USAID. Established as five-year cooperative agreements that begun with the Population Leadership Program (PLP), which then evolved to Global Health Fellows Program I and then Global Health Fellows II. Each subsequent program continued to refine approaches and track records to recruiting and supporting diverse fellows and interns, while expanding its strategies to include a wider range of highly qualified talent across the global health pipeline as well as and placement sites.

2.
In 2018, under the USAID Forward initiative during a period that focused heavily on the journey to self-reliance, USAID's vision, reflected in the STAR Program emphasized two major themes: (1) preparing diverse US (United States) and developing country GH professionals to innovate lasting solutions, based on deep mastery of program implementation, research and analytic skills that are honed during field experience and; (2) fostering effective, empowered, sustainable collaborations among US and LMIC academia, and other relevant groups.
3. STAR aims to strengthen the capacity of global health professionals, organizations, and companies to implement stronger programs, achieve better results, and make a bigger impact in the global health field. Position based opportunities are available on a rolling basis to qualified candidates globally. Due to the diversity of participants, their technical skills and geographic placements and the unique reality of rolling admissions, a cohort model was not feasible thus, the fellowship developed tailored individual learning opportunities for both the participants and the host organizations.

4.
Developed STAR competencies and milestones framework and associated tools to standardize the core skills required of GH professionals and help individuals identify their need, leverage resources to address learning gaps, and track milestones using a common approach.
Target Population Nurses, physicians, public health professionals, pharmacists, ethicists, and lawyers. STAR targets diverse early career to senior global public health professionals from the US and from low-and middle-income countries.
Salient Activities 1. Attend three in-person didactic training meetings and complete online modules.

2.
Be attached at a national training site to be engaged in leadership activities through team mentorship.

4.
Complete M&E activities and logbook on a regular basis. 5. Planned orientation, mid fellowship and final meeting held to enable familiarisation of participants to the program, sharing and presentations of projects conducted by fellows for constructive feedback.

6.
Complete required report at the end of the program and present at each meeting. 7. Communicate regularly with site and national mentor. aimed to bolster global health leadership and practice. This development process involved literature reviews, validation, creating relevant content and establishing processes for measuring participant growth. In the case of Afya Bora the core competencies included 12 skill-based core competencies and 5-7 skills were related to each competency in the "skills logbook" that the fellows completed by the end of the program. STAR's GH competency framework includes eight core domains that focus on leadership development, including a combination of power skills and essential perspectives. In addition to the core competency domains the team identify 8-10 knowledge-based content areas (i.e., HIV, TB, MCH) and 8-10 skills-based technical areas (i.e., epidemiology, supply-chain management) where fellows could also focus their training based on their job requirements. The core domains were taught using mentorship groups, virtual exchanges and online learning modules [19]. Opposed to a skill log, STAR developed a milestones model based on the Accreditation Council for Graduate Medical Education (ACGME) milestones framework to capture the "level" of competency and opportunities for growth among STAR participants [20]. Throughout both programs, participant data has been analysed to understand where the key learning gaps of global health professionals are as they are entering into the program.
(2) Strengthening local leadership and global bridge builders Afya Bora's success in inter-professional training were the program's outputs of nurses, physicians, and public health professionals who attained equal standards of exposure and experience which will in future enhance team building and cohesiveness among health professionals. For STAR, many of the host country nationals often serve as internal consultants and as cultural brokers between the Ministry of Health and the US government. One of the great successes is being able to nurture local leadership that is both conversant with local context, can navigate the complexities of the donor environment and can communicate effectively to achieve desired results. Both programs have indicated successes in strengthening north-south and south-south collaboration, which enhanced the establishment of strong and functional national, regional and global networks that will facilitate sharing of experiences, ideas and resources for a common goal of improving global health.

(3) Providing opportunities to develop applied leadership skills
Health systems are complex and continuously changing over time; they are situated in a variety of contexts and cover a range of service levels [21]. GHL training should provide opportunities to learn strategic leadership skills that fit different health systems and should enhance technical, cognitive and emotional competencies of the future leaders. A 360-degree leadership approach might help future leaders to lead from any position and at any level of healthcare system (such as policymaking or clinical service) while relying on the core leadership characteristics [22][23][24][25]. This approach could be incorporated into GHL trainings to teach future leaders to face different health system challenges through introspection and mindfulness.

(4) Virtual Learning
While the majority of STAR Learning was delivered through virtual programming due to the considerable distances between participants, Afya Bora, a regionally based program, used a hybrid approach of in-person and online learning. However, with the unanticipated COVID-19 pandemic, all learning has been required to shift to virtual, thus creating an opportunity to develop dynamic learning content that addresses the gaps, reduces costs and enables participants to connect globally.

GAPS IN GHL TRAINING PROGRAMS (1) Knowledge and Skills
While both fellowships developed robust programs that aimed to prepare their multi-disciplinary participants for a world in applied global health leadership, some skills gaps were observed as participants entered into the program. Among the key findings from implementing the STAR baseline competency assessment were knowledge/skills gaps related to gender equity, ethics and health equity and social justice. In addition, participants identified several technical and content areas in which they desired training to be more effective in their roles. Similarly, as Afya Bora evolved, the needs for consideration on some critically relevant courses were observed. Table 2 below includes both the core competencies and many of the additional gaps identified or observed by both programs. Future training for the GHL should aim to standardize content in the modules and emphasis should be given to equal prioritization of the technical content and leadership development courses [21,26,27].

(2) Sector Gaps
While there is a tendency to believe that global health is the responsibility of health professionals, global health issues, such as emerging and re-emerging diseases, affect all economic sectors and life in general. Both programs boasted a high proportion of clinical professionals (i.e., physicians and nurses) or public health professionals (i.e., technical advisors, implementation scientists). This sectorial gap is also reflected in the literature on global health, where a focus among professionals like lawyers, law enforcing institutions, agriculture, wildlife is not seen. In order to align global health workforce development with the UN Strategic Development Goals, future global health programs should be developed to include exposure to these sectors [28].

CHALLENGES (1) Operational
Both programs have indicated issues of concern in the implementation of the programs and include those related to operational procedures (program development and identification of relevant content, recruitment of experienced and competent faculty, determination of effective delivery modes, recruitment of fellows, monitoring and evaluation) and financing. The programrelated operational issues, such as delay in fellow response, technical issues such as broadband connection, funds mobilization have been reported and pose major challenges in effective and timely completion of assignments and Monitoring & Evaluation (M&E) reports [29].  (2) Funding Donor fund disruptions and the lack of unrestricted funds created stress and uncertainty on GHL program implementation. While it is recognized that there is a funding transition towards domestic financing for global health, sustaining these efforts will depend on creating the systems that ensure a core set of funds are available to support basic administration and the fellows' livelihood throughout the training [21,30]. Future GHL programs are encouraged to develop realistic sustainable funding models at the outset that will ensure streamlined, regular and predictable financing, perhaps adopting a hybrid funding structure that includes core funds to support the underlying infrastructure and supplementary funds focused on the fellows. Both programs also required significant technical and programmatic support during the start-up period, funding to "build" a rigorous program must also be considered by donors. Lastly, as seen with the M&E paper, that lack of funding for "impact" evaluation post the award period means that there is limited ability to codify and understand the true impact of these programs on the ultimate goal -global health leadership.

(3) Sustainability
Sustainability of programs depends on three key areas including academic, technical and financial sustainability. This case report has indicated clear academic sustainability of health professionals trained in global health leadership. The content of the programs have built capacity of the alumni in leadership skills including communication, implementation science, grant writing, research and publication skills, project management, human resources and budgeting. These skills are fundamental in developing a pool of competent human resources for addressing global health challenges. In addition, faculty from the U.S. teamed with faculty from the African institutions in training the fellows. This form of collaborative teaching built capacity among the faculty across all nine institutions in Africa and U.S. for training global health professionals from different countries and different disciplines. Capacity has also been built in writing fundable research projects and providing an opportunity to network across national, regional and international programs. With these successes in mind, future GHL should target understanding the dynamics of global to local governance and sustainable funding to improve GHL training programs that will benefit future leaders.
Based on the successes and gaps of two global leadership programs (STAR and Afya Bora) we have developed a model graph to include our key recommendations for future global leadership programs (see Figure 1).

Figure 1 Model Program
Components for Global Health Leadership Program.
The proposed Model Program of Global Health Leadership informed by the experiences of STAR, Afya Bora and reinforced by the literature, presented above and the three key pillars for a successful Global Health Leadership program are borrowed from the Donabedian's Process Improvement Framework which measures overall quality and align improvement work in health delivery settings [31]. This framework is based on input, process and outcome components. Details about the (input) educational content can be found in Table 1 of this manuscript, while content of the (process) competency components can be found in Table 2. The success metrics of the model stand on the continuous financial, management, mentorship and political support of the implementing partners. However, flexibility is allowed depending on the programmatic design in each of the model components and depends on the available resources, goals of the program, and intentions of the program partners. The length of a program depends entirely, if the fellows are familiar with the host institution or not. If they are not familiar, a longer fellowship increases the value and outcomes of the fellow to the organization.