Health Planning Management - 2024 - RodrADguez80 Feria - Critical Route For Development of Medical Student Leadership

Received: 27 September 2023
DOI: 10.1002/hpm.3791
SPECIAL ISSUE ARTICLE

- -
Revised: 5 February 2024 Accepted: 9 February 2024
Critical route for development of medical

student leadership competencies in 35 Pan
American Health Organization member states:
A scoping review and thematic analysis
Pablo Rodríguez‐Feria1,2 | Martina Paric1 |

Luis Jorge Hernández Flórez2,3 | Suzanne Babich1,4 |
Katarzyna Czabanowska1,5
1
Faculty of Health, Medicine and Life
Sciences, Department of International Health, Abstract
Care and Public Health Research Institute
The Pan American Health Organization has been
(CAPHRI), Maastricht University, Maastricht,
Netherlands committed to training physicians in leadership compe-
2
Facultad de Medicina, Departamento de tencies since 2008. However, four reviews on teaching
Salud Pública, Universidad de los Andes,
leadership using competency‐based education in under-
Bogota, Colombia
3
Program in Public Health, Schools of graduate medical education (UME) identified only two of
Medicine and Government, Universidad de 35 MS: Canada and the USA. Previous reviews did not use a
Los Andes, Bogota, Colombia
4
systemic approach or qualitative methodology to explore
Department of Community and Global
Health, Indiana University Richard M. factors influencing leadership education.
Fairbanks School of Public Health, Therefore, this review aims to identify facilitating and
Indianapolis, Indiana, USA
5
inhibiting factors in teaching leadership in UME using a
Faculty of Health Sciences, Department of
Health Policy and Management, Institute of scoping review and thematic analysis. Six databases con-
Public Health, Jagiellonian University,
taining grey and indexed literature in English, Spanish, and
Krakow, Poland
Portuguese were searched, including a hand search and
Correspondence authors' consultations.
Pablo Rodríguez‐Feria.
Email: p.rodriguezferia@
Forty‐eight documents out of 7849 were selected based on
maastrichtuniversity.nl eligibility criteria. Braun and Clarke's thematic analysis
guide was used, identifying eight themes: curriculum,
Funding information
Ministerio de Ciencia, Tecnología e intended learning outcomes, teaching methods, assess-
Innovación ment, addressing barriers, supporting organisational
-
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited.
© 2024 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.
844 Int J Health Plann Mgmt. 2024;39:844–859. wileyonlinelibrary.com/journal/hpm

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RODRÍGUEZ‐FERIA ET AL.
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change, building networks, and developing expertise.

Considering these themes, the authors propose a critical
route for teaching leadership in UME in the Americas. First,
institutional design should consider governance gaps, such
as having national and international policies for leadership
training in UME with inter‐professional, trans‐professional,
and citizen‐focused approaches. There is a pressing need to
provide leadership training for physicians and other pro-
fessionals from government, academia, non‐governmental
organisations, hospitals, and national and international or-
ganisations whose missions are related to health or edu-
cation. Networking opportunities for stakeholders in
leadership education and teacher training is also essential.
Second, instructional design reveals knowledge‐do gaps in
member states (MS) when incorporating leadership into the
medical curriculum. This includes using leadership frame-
works, defining learning outcomes, and employing assess-
ment and monitoring tools for leadership education.
Mechanisms to reduce these gaps in MS include the
Equator Network and Evidence‐Informed Policy Networks
fostering knowledge translation and governance.
KEYWORDS
competency‐based education, education, medical, undergraduate,
interprofessional and transprofessional education, leadership,
scoping review, the Pan American Health Organization
Highlights
� Two countries have taught leadership for medical students in

the Americas.
� Facilitating and inhibiting factors of leadership education were
determined.
� The systemic approach was used to create the leadership crit-
ical route.
� The leadership critical route targets diverse professionals and
citizens.
1 | INTRODUCTION
The Pan American Health Organization (PAHO) consists of 35 member states (MS). Currently, these MS are
grappling with health inequities, as their health systems struggle to provide equitable access to healthcare and
public health services for refugees, migrants, women, the lesbian, gay, bisexual, transgender, and queer/questioning
846
- RODRÍGUEZ‐FERIA ET AL.
(LGBTQþ) community, and indigenous peoples.1,2 This situation has been ongoing since 1990 when various MS
implemented political and health reforms that resulted in limitations within the health systems, marked by social
exclusion, poverty, and inequity.3 In response, PAHO launched the “Public Health in the Americas” initiative in 1999
with the goal of strengthening leadership capacities in the MS.3
In 2008, PAHO identified six competencies needed for primary health care physicians, with the fourth com-
petency emphasising “working in a team and developing leadership with the rest of the health team and the
community.”4 In 2013, PAHO enacted the Core Competencies for Public Health and the Essential Public Health
Functions (EPHF).3 Leadership is a cross‐cutting dimension of the EPHF and linked with the competency domain
“policy, planning, regulation, and control”.3
Other actors in MS, including universities, have been urged to teach leadership via competency‐based edu-
cation (CBE) to the health workforce (HWF) by such organisations as the Andean Health Body‐Hipólito Unanue
Convention (ORAS‐CONHU), associations, civil societies, federations, and hospitals.5–10 Undergraduate medical
education (UME) is crucial in understanding advances in leadership education in medicine. However, reviews of
leadership in UME have been limited, with experiences identified in Brazil, Canada, and the USA (n = 3/35,9%).11–15
The Brazilian experience did not mention leadership competencies.16 The lack of literature in the region may
suggest the need to strengthen the governance of UME‐related actors and addressing knowledge‐do gaps in
reporting and using research evidence.
It is important to explore recommendations for HWF education globally. Frenk and colleagues have analysed
challenges and opportunities in HWF education, both before and after the COVID‐19 pandemic, considering
institutional design, instructional design, and educational outcomes.17,18 They describe education systems using
three components: institutional design, instructional design, and educational outcomes (Appendix 1). The outcomes
are interdependence in education and transformative learning, which are reached via leadership development.
Leadership as an educational outcome can contribute to health equity, enabling HWF to engage in patient‐centred
and population‐focused health systems.17,18 Frenk et al.'s components can be contextualised in the Americas using
the systemic approach employed by PAHO and its MS to analyse critical factors in health‐related topics, cat-
egorised as contextual, structural, process, and outcome and impact.19–22
Matsas, Webb, James, and their colleagues aimed at studying competency frameworks, curricular content,
delivery, and assessment methods.11–13 They have not studied the factors that play a role in teaching leadership in
UME, and they have not used qualitative research to analyse leadership in UME.11–15 Therefore, this review aims to
establish the factors that facilitate and inhibit the teaching of leadership in UME using thematic analysis.
2 | METHODS
Reviewing leadership in the HWF has been conducted using systematic reviews12 or scoping reviews.11,13 We
decided to conduct a scoping review based on Munn et al's indications.23 We collected literature on leadership CBE
published in English, Spanish, and Portuguese, a scope not achieved in previous reviews.11–13 We also sought
evidence on facilitating and inhibiting factors in teaching leadership.
This review applied six stages based on three guidelines.24–26 Identifying the research question, identifying
relevant studies, study selection, charting the data, collating, summarising, and reporting the results, and consul-
tation exercises. Microsoft office® and Preferred Reporting Items for Systematic reviews and Meta‐Analyses
(PRISMA) extension for scoping reviews were used.27
2.1 | Search and eligibility criteria
This review provided the search strategy for each database and hand searching (Appendices 2 and 3). The Joanna
Briggs Institute (JBI) suggests running the search in two phases, using two databases to identify key words and
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index terms and then conducting the search in each database. The population, concepts, and contexts were used to
build the search strategies. Population considered UME with an interprofessional and transprofessional education
(IPE/TPE) approach. The concept was ‘leadership’, and the context included terms such as ‘curriculum’. The in-
clusion criterion for the population was studies on UME with IPE/TPE. The concept pertained to factors that
influenced teaching leadership via CBE, and the context included leadership interventions done in universities. This
review was limited by using published literature in only three languages and selecting works from 1970 to the last
day of search. CBE has been documented for only the past 10 years (Appendix 4).28–30
2.2 | Information sources
Six databases were used to collect literature between March 17 of 2021, and June 11 of 2021. Hand searching was
conducted from January 6th to 10th March 2022. Corresponding authors were emailed for more information when
necessary.
2.3 | Selection of sources of evidence
Initially, duplicate literature was removed based on title and population characteristics. Then, literature was
excluded by title, abstract, and full text. These two steps were done by three researchers, and if there was a
mismatch, they discussed it to resolve the disagreement. Eligibility criteria were applied in the full‐ text screening,
conducted by one researcher and reconfirmed by a second one. A third researcher was involved if the two previous
researchers could not resolve the mismatch.
The eligibility criteria included quality markers not mandatory in a scoping review, but this was reported as a
drawback in this study design.26 Appraisal tools were used for quantitative, qualitative, mixed methods studies and
grey literature.31–34 This step was done by one researcher and checked by a second. Each tool provided three
categories: (a). ‘strong’ or ‘yes’, (b). moderate, ¨I cannot tell¨ or¨? ¨, and (c). ‘weak’ or ‘no’. Authors were contacted if
literature was ranked in the last two categories or for extra information. Literature ranked ‘weak’ or ‘no’ was excluded.
2.4 | Data charting process, data items, and synthesis of results
The JBI template contained a data charting25 adapted to include information about facilitating and inhibiting
factors, and other items (data extraction available on request). The data chart was filled in by one researcher and
verified by a second. Inductive thematic analysis was applied to analyse textual data from the factors. Thematic
analysis is an appropriate qualitative analytic method with the necessary flexibility to analyse ‘rich’ sources of
data.35 It can be used to identify, analyse, and report on themes that are present in the data. By relying on an
inductive approach, the identified themes remained strongly linked to the data. The research question was used to
focus the analysis on identifying facilitators and inhibitors from the collected data; these were then grouped
together as factors that influence the development of leadership teaching in UME.
The steps described by Braun and Clarke were followed for data analysis. The first step in the process was to
read the full data set to become familiar with it. A second reading was done in ATLAS.ti (version 23.0.7.0) and initial
descriptive codes were created. During this phase, analysis of the data generated 195 unique initial codes. These
were then grouped together based on similarity and used to identify potential themes. These themes represent
patterns of meaning within the data set and capture something important about the data in relation to the research
question.35 Afterwards a thematic map was created with initial codes forming main themes and sub‐themes. This
map and the process leading up to the identification of relevant themes was discussed with the other authors until
848
agreement was reached on the generated themes and sub‐themes, and their final definitions and names. Subse-
quently, the thematic analysis with the fully worked‐out themes was described, and an inductive process in this
review was used to produce a thematic map. Finally, authors connected the thematic map with the systemic
approach to create a critical route which can be used to teach leadership in UME.
3 | RESULTS
Figure 1 displays the literature search and selection process. It included 48 documents of 23 studies on teaching
leadership in UME (Appendix 5). The thematic analysis resulted in the identification of eight themes and their
subthemes (Figure 2): curriculum, ILOs, teaching methods, assessment, addressing barriers, supporting organisa-
tional change, building networks, and developing expertise.
3.1 | Curriculum
This theme refers to the set of courses, subjects and learning experiences that are part of the educational pro-
gramme. Data coded into this theme showed clusters of several facilitators and inhibitors. Inhibitors like having an
already overcrowded curriculum, competition for teaching time, or student time constraints make it more difficult
to include leadership in current curricula. A constraint here is that there are no clear national curricula or guidelines
available for implementation, meaning educators must tailor make the content. Having a dedicated course, clear
curricular content, dedicated space in the curriculum, agreed upon priorities, and a course tailored to meet student
needs, may facilitate the implementation of leadership in UME. Additionally, relying on a spiral curriculum and
integrating leadership throughout the full programme may facilitate the creation of a curricular framework that
clearly defines what content is included based on learning outcomes.
F I G U R E 1 PRISMA diagram: databases, registries, handsearching, and consultation. PRISMA, Preferred

Reporting Items for Systematic reviews and Meta‐Analyses. [Colour figure can be viewed at wileyonlinelibrary.com]
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FIGURE 2 Facilitators and inhibitors: thematic map for undergraduate leadership medical education in the
Americas.
3.2 | ILOs
ILOs help define the competencies students are expected to acquire upon completing a course or programme.
Having consensus and alignment between teaching activities and ILOs, that are clearly defined, focused on
developing key competences and in line with internationally recognised competences, are identified as facili-
tators. Moreover, having clear, well‐formulated leadership ILOs and a focus on career development beyond the
medicine programme can greatly facilitate this process. Additionally, integrating leadership to real‐world con-
texts, having a link to local culture, context, and values as well as a focus on developing cultural competence
and exposure to diversity improves ILOs. The absence of these elements would inhibit teaching leadership
in UME.
3.3 | Teaching methods
This theme refers to strategies, techniques, and approaches used by educators, and includes any activities or
instructional practices applied to facilitate learning. Several things stood out in this theme that facilitate leadership
teaching in UME. For example, having mentoring or coaching sessions, small group learning, peer interaction
focused on reflection and giving as well as receiving feedback, were identified as facilitators. Learning should be
student centred, project and case based, with role‐play and simulation exercises. A multiple methods approach is
recommended, with active participation, freedom for students to choose projects and activities that place students
in leadership roles. Tailor made exercises supported with examples and experiential teaching facilitate leadership
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development. Ideally, learning laboratories are created through a variety of activities. A solid understanding of
leadership principles, theories and approaches should be the basis for teaching. The absence of these elements
would inhibit teaching leadership in UME.
3.4 | Assessment
This theme provides insights on assessment, which is the process of evaluating learning progress and achievement
through a variety of methods that are used to appraise, measure, and document students' knowledge, skills, and
competencies, aligning with intended learning outcomes. This theme shows that having consensus on assessment
methods, creating measurable ILOs, developing assessment tools, and integrating assessment practices to support
teaching are important facilitators. To better support ILOs and improve learning for students, it is recommended to
include self‐assessment and reflection as an assessment strategy. Understanding and measuring the impact of the
leadership course or training is considered an important practice, which can also help enhance the position of
leadership education in UME. Continuous evaluation and revision of the course are also considered best practice.
3.5 | Addressing barriers
This theme included broader barriers that need to be addressed to improve leadership education in UME. For
instance, teacher/professor/university staff (hereby teacher) and student interest are needed to facilitate the
implementation of teaching leadership. To do this, it is necessary to explain the importance of leadership for
UME, to address why educators are reluctant to teach leadership, and to make people understand that this is a
teachable skill. To accomplish this, it is suggested to designate a ‘leader for change’, who can challenge current
leaders (if necessary) and address challenges to implementation (i.e., barriers identified in the other themes). In
general, analysis of data sources suggests that a system change is needed to address barriers and make sure
elements that facilitate the implementation of leadership education in UME receive support from relevant
stakeholders.
3.6 | Supporting organisational change
In line with the previous theme, this one focuses on creating a momentum for change within (and beyond) the
actors. Several technical issues were identified in this theme, like the need for designated financial resources,
teaching resources and materials, and addressing any logistical constraints that may emerge. Broad support and
stakeholder buy‐in is considered a facilitator as well. This includes faculty support (including institutional support)
and a willingness to invest the necessary time to ensure the success of leadership education in UME, student
support, government support and support from stakeholders in the community.
3.7 | Building networks
Collaboration stands central in this theme, and building networks that allow for interprofessional and interdisci-
plinary collaboration is considered a facilitator. Collaborating with other schools and organisations, building, and
maintaining these relationships, encouraging team collaboration, engaging with the local community, and ensuring
there is a link to the health system, were all suggested facilitators to teaching leadership. Building an engaged
learning community and creating learning networks is also considered a facilitator. Additionally, building networks
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can lead to a better understanding of social responsibility and advocacy, which creates opportunities for students to
step into leadership roles. The absence of these elements would inhibit teaching leadership in UME.
3.8 | Developing expertise
Finally, staff would need to develop expertise to facilitate the implementation of leadership education in UME. Lack
of expertise and knowledge on leadership are clear inhibitors, whereas experience in leadership is considered a
facilitator. It is suggested that educators function as role models for students. In this sense, they ought to be
enthusiastic and engaged teachers, and provide opportunities for continuous professional development to ensure
expertise remains up to date. Different teaching perspectives can be an inhibitor, and as other themes have shown,
building consensus is an important facilitator. Organisations that experience more hierarchical structures may also
struggle with facilitating leadership education, as broader system change is needed to ensure good implementation
of leadership in UME.
4 | DISCUSSION
Factors related to leadership in UME were studied using two methodologies. This is the first review proposing the
critical route with eight components for UME leadership with an IPE/TPE and citizen‐focused approach in the
Americas. This route contains eight components: situational and normative frameworks (C1), networking (C2),
thematic scope (C3), IPE/TPE & citizens (C4), developing expertise (C5), curriculum (C6), and methodological
framework related to constructive alignment (CA) (C7), and tools to monitor and evaluate (C8). These components
are connected within the systemic factors: contextual, structural, process, and outcome and impact (Figure 3). The
critical route can overlap with some themes from the thematic map.
4.1 | Component 1: Institutional design
Till and colleagues provide advice for integrating leadership development into medical education.36 The first piece
of advice concerns understanding the evidence and logical foundation for leadership development in the
FIGURE 3 The critical route for leadership education in medical students in the Americas.
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curriculum. We support this advice, and it is related to our theme of "addressing barriers," which emphasises the
significance of leadership and the fact that leadership can be taught. The first governance gap (GG‐1) is that the
actors involved in UME believe that leadership cannot be taught and do not show interest in teaching it. The PAHO
and ORAS‐CONHU are organisations whose mission is governance, education, and health issue documents that
promote leadership competencies, as has been done in the continent.4,7 It is equally important for national‐level
organisations to advocate for leadership education in HWF, as is the case with the academia in Mexico.37,38 In
the case of Mexico, academia has taken an active stance in advocating for leadership education in the HWF,
recognising its importance in addressing diverse thematic scopes. In 2015 and 2022, this country defines leader-
ship, differentiating it from management, and states that leadership can be taught through CBE and subsequent
evaluation. In 2017, the Colombian government and medical students, among others recommended leadership
competencies to transform medical education in the country.39
Another piece of advice given by Till and colleagues was to support teachers in leading the development and
integration of leadership in the curriculum.36 This advice is partially connected to our approach since it emphasises
the importance of selecting and supporting teachers in teaching leadership. However, we consider that the theme
of “developing expertise” refers to the active involvement of teachers and their acquisition of leadership and ed-
ucation competencies to be able to teach it to others. In a previous review, we analysed the selection and training of
teachers for leadership in UME.14 Teachers are part of governance because they participate in university com-
mittees which are vital in UME (GG‐2). Similarly, teachers without leadership and education competencies create
knowledge‐do gaps (KDG‐1) because they lack both the knowledge and the ability to teach leadership. For instance,
it is worth noting that a university in the Netherlands trains its faculty through CBE to deliver classes using
problem‐based learning and blended education to teach leadership.40 Blended education has gained special
importance after COVID‐19 as it utilises digital technology and allows teachers and students to engage in online
and in‐person learning activities, both individually and in groups.18
Consistent with ORAS‐CONHU's recommendations, identifying actors, their networks, and powers contribute
to leadership in the HWF, fostering knowledge generation, exchange of best practices, and community building.41
Likewise, Figueroa et al. conducted a literature review to identify challenges of leadership for health at three levels:
macro, which is international and national; meso at the organisational level; and micro at the individual level.42
Networks, as highlighted by Figueroa et al., strengthen macro and meso levels, improving situational and normative
frameworks, and emphasising the importance of leadership education. Governance creates networks among
stakeholders interested in health and education, addressing governance gaps where inadequate networks hinder
teaching leadership in UME. Similarly, these efforts also strengthen the methodological framework as leadership
frameworks based on competencies, ILOs, and other assessment tools are being shared. In a previous review, we
mapped the actors that teach leadership in UME and their networks across multiple continents.14 Governance
creates networks among stakeholders interested in health and education, such as the government, PAHO, hospitals,
patients, civil societies, and academia, including teachers, students, and the public. A third knowledge‐do gap is
continuing with professional silos and not including citizenship as a key actor to address health challenges (KDG‐3).
Similarly, the second KDG‐2 is the absence of networks to establish leadership frameworks, as well as ILO, and
assessment tools for teaching leadership.
We agree with ORAS CONHU as they emphasise that education is embedded in the social context and health
services that workers and health organisations face in their daily lives.41 Our review found that the theme "ILO"
should be linked to the local culture, context, and values. Therefore, actors should have clarity about the thematic
scope of leadership education, which is related to national, continental, and global health challenges. In fact, Frenk
et al. propose the next thematic scopes for leadership: social determinants of health, health equity, one health,
planetary health, communication using social media, and artificial intelligence (AI).18 We support the contention of
Frenk et al. that AI has the potential to strengthen health education. AI, such as ChatGPT or Google's BARD,
contributes to the improvement of the systemic approach. It establishes tools such as generating checklists for
leadership generation processes in the health and education systems, allowing monitoring and evaluation. It also
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reinforces normative frameworks for HWF leadership training by sharing experiences, resources, and creating
networks. Finally, it determines facilitating or inhibiting processes in leadership education.
This review implements UME with IPE/TPE to be in line with Frenk et al as IPE/TPE is vital to reach inter-
dependence in education and transformative learning.17,18 Nevertheless, we were not able to find in the consulted
literature, leadership in UME with an IPE/TPE approach. However, the theme "building networks" through inter-
professional and interdisciplinary collaboration requires that leadership education not only be focused on UME but
also on continuing medical education, health science students, and students from other disciplines. In fact, a uni-
versity in the Netherlands has been teaching leadership in UME with an IPE/TPE approach at the undergraduate
and postgraduate levels for over a decade.14 It is important to mention that leadership training should include
citizens, as they play a role in public policy regardless of their academic background. The third knowledge‐do gap is
continuing with professional education in professional silos and not including the citizenship as a key actor to
address health challenges (KDG‐3).
4.2 | Component 2: Instructional design
In line with Webb et al., Matsas et al., and James et al.,11–13 our study also identified factors that affect leadership in
UME. Among the factors identified in this review is the theme of ‘curriculum’, which is related to lack of time and
content overload. Till et al y Webb et al. propose integrating leadership training into the longitudinal elements of
the curriculum, which is related to the spiral curriculum and encompasses leadership as transversal component of
UME.12,36 However, Webb et all found that the literature did not report on the process of integrating leadership
training into an existing curriculum.12 KDG‐4 refers to document the process of teaching leadership in universities,
considering institutional and instructional designs, inhibiting and facilitating factors, as well as how to address these
factors.
We agree with Frenk et al. that the critical adoption of competency‐driven approaches is important for
transformative learning.14 We identify two key factors to teach leadership in UME in the Americas: ‘Identified
curricular framework’ and ‘alignment with internationally recognised competencies’. Universities can identify na-
tional and international frameworks, and then they may adopt or adapt leadership frameworks. In the first case, a
framework can be taken ‘as it is.’ Alternatively, a second option involves a process of knowledge translation for
contextualising the framework. Indeed, a review has studied the methodology and actors involved in the identi-
fication and contextualisation of 10 leadership frameworks.15 These frameworks should include various compe-
tencies that have gained importance post‐COVID‐19, as Frenk et al. have mentioned, and we join the call for
emotional intelligence, communication, teamwork, and ethical deliberation. A review examined over 20 frameworks
and grouped them into eight domains based on the Public Health Leadership Competency Framework Model,43 and
this model aligned with Frenk et al new competencies after COVID‐19. The review concluded that emotional in-
telligence had ≤50% convergences among them.
The leadership frameworks allow for the development of ILOs. Contrary to the previous reviews that studied
the course content,11–13 we focused on studying the ILOs, which are part of the CA.44 The latter begins by defining
leadership, competencies, and ILOs. Regularly, ILOs are formed by one or two verbs, which have a close relationship
with the teaching methods. It is worth noting that a review identified over 20 definitions of leadership that have
been used in UME and IPE/TPE.14
One of the most important aspects is the assessment of leadership education. Supported by ORAS CONHU,
Frenk, Matsas, Webb, James, and their colleagues,11–13,17,41 the theme of "Assessment" is part of the methodo-
logical framework, and its importance lies in the monitoring and evaluation of leadership education. The factors and
recommendations from the reviews focus on achieving consensus among actors to create standardised tools for
measuring the outcomes and impacts of leadership training, as well as uniform classification of ILO. The availability
of unified tools would facilitate effective assessment and enable studying best practices as well as evidence‐based
854
approaches for actors involved in leadership education within UME with an IPE/TPE approach. ORAS CONHU, for
the development of an educational proposal, recommends asking the following questions during the evaluation:
What is being evaluated? Why is it being evaluated? Who evaluates? And how is it evaluated?41
4.3 | Enhancing components 1 and 2: Dissemination of information
We endorse the recommendations of ORAS‐CONHU regarding: i) disseminating knowledge about CBE in lead-
ership, ii) conducting qualitative and quantitative research contributing to the design of public policies, and iii)
designing and conducting research on sociopolitical and educational dimensions.7,41 Despite the fact that this re-
view sought literature on CBE for medical students that met the inclusion criteria, leadership education in the
Americas may exist that has not been disseminated through publications or includes methodologies and reporting
of insufficient quality. Indeed, Glujovsky et al studied the adherence of Enhancing Quality and Transparency of
Health Research (EQUATOR) in MS.45 They asked to editors from journals that were indexed in the Latin American
and Caribbean Health Sciences Literature about reporting guidelines such as Strengthening the Reporting of
Observational Studies in Epidemiology and PRISMA. Ninety‐eight editors answered the survey and no more than
35% of them knew these guidelines. PAHO has a network with the EQUATOR Network to strengthen the written
communication of evidence generated in health research, including the guideline for Reporting Evidence‐Based
Practice Educational Interventions and Teaching.
Evidence‐Informed Policy Networks (EVIPNET) are important for strengthening governance in leadership
education. Firstly, EVIPNET has been used in MS like Brazil and Chile to support evidence‐informed policy-
making.46,47 Secondly, EVIPNET has a six‐step framework that addresses governance and knowledge‐do gaps, such
as prioritising education and leadership while considering various actors. Furthermore, EVIPNET emphasises
written and verbal communication, such as policy briefs and deliberative dialogues. Finally, EVIPNET has an
execution phase that emphasises the importance of facilitators and inhibitors that citizens and healthcare workers
may have.
4.3.1 | Recommendations
To use the critical route

C1: Contextual and structural factors are related to the existence and availability of literature issued by actors
whose mission is governance, health, and education. The literature should cover topics on the importance of
leadership and its teaching, as well as norms for teaching leadership. A process factor would be the percentage of
implementation of normative plans, along with inhibitory and facilitative factors for implementing normative plans.
C1 faces GG1 and KDG4 as literature demonstrates the importance of leadership and its teaching by multiple
actors.
C2: A contextual factor is having methodological guidelines for mapping actors and citizens who are interested
in education and leadership. A structural factor would be conducting actor mapping to create and maintain net-
works and establish operating agreements for education in leadership. A process factor would be the percentage of
execution of operating agreements. C2 aligns with GG3 and KDG2 because leadership is about working with others
to face health challenges.
C3: A contextual factor includes the health plans outlined by MS, which should indicate health and education
priorities for those interested in leadership. A structural factor is the availability of planning exercises among actors
involved in health and education priorities. Process factors are related to making leadership training interventions
visible to address thematic scopes. Each of the gaps mentioned in this article underscores the importance of
highlighting leadership.
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C4: It is based on the idea that everyone is a citizen, especially children and adolescents who are also citizens. A
contextual factor is the characterisation of actors and their demand for leadership education including students,
teachers, and citizens. A structural factor is the availability of infrastructure, as educating citizens requires the
necessary infrastructure, such as classrooms for conducting workshops, and meetings. A process factor is the ac-
tivities carried out to provide leadership to medical students with an IPE/TPE focus and to citizens. To resolve
health challenges, as a society, we need to include leadership teaching to multiple professions and citizens (KDG3).
C5: GG2 can be overcome by C5 as a contextual factor is mapping continuing education and training oppor-
tunities for teachers in leadership, planetary health, and education, so that teachers have the possibility to receive
training when they desire. A structural factor is the availability of continuing education strategies in leadership for
students and citizens. This includes the existence of courses that teachers can take to strengthen their teaching in
leadership and education. A process factor is the activities of formal training they have undergone regarding
leadership and education. For example, they should receive continuous training in the eight leadership domains.
C6: Awareness and availability of an institutional educational plan to handle GG2, which is a university pro-
posal to educate students, and related to contextual and structural factors. A process factor would be the actions
taken to include leadership as a cross‐cutting competency in the universities.
C7 and C8: Contextual factors include literature about leadership definitions and leadership frameworks, ILO,
and monitoring and evaluating methodological frameworks. C7 and C8 are intertwined with KDG2 about CA and
networks. A structural factor is the availability of literature about leadership education in medical schools. A
process factor would be the adaptation and adoption of literature about leadership theory into medical education in
the Americas.
Outcome and impact factors across the components are used to determine the percentage of variation and
causes. This helps study the variation between the institutional vision and the current state of leadership CBE in
students, teachers, and citizens.
Disseminating research in education with a social and political competence for the strengthening of public policies
and networks
A mechanism for information dissemination is the publication of both grey and indexed literature. Publishing en-
ables the creation of networks to adapt or adopt leadership competency frameworks,17,18 promote education that
transcends professional silos,17,18 and study the rigour of leadership education evaluations for feedback into the
process.17,41 Therefore, it is necessary to promote the use of the EQUATOR NETWORK, which have international
accepted guidelines for reporting research for health.48
Mansilla et al. identified more than 10 resources and activities promoted by EVIPNet in the Americas to
support evidence‐informed decision‐making49 For instance, the Introductory course on evidence‐informed policies
is available online. It allows to search, evaluate, contextualise, and apply evidence from research. Afterwards, actors
formulate and implement policies to foster leadership education in the Americas.50
5 | CONCLUSION
A thematic map is proposed with the factors that influence leadership in UME. They are considered to create the
critical route for teaching leadership in UME. We invite actors to use this route, as it contemplates leadership in
multiple professions and the community, and it has been based on international recommendations for teaching in
the HWF and the systemic approach. Furthermore, it highlights the governance gaps and knowledge‐do gaps that
MS can face and offers ideas about how to overcome them.
A CK N O W LE DG EM E N T
We would like to thank Natalia Giraldo Noack for proofreading this article English version, as well as conducting
a peer review of the manuscript according to established peer review guidelines. We also thank Daniela
856
Rodríguez‐Sánchez and Fredy Leonardo Carreño Hernández for reviewing the abstract, titles and text of this article
in order to achieve the eligibility criteria. A researcher received a PhD grant from the Colombian Ministry of
Science, Technology, and Innovation (Convocatoria 906: doctorados en el exterior 2021). All other authors received
no funding to participate in this review.
C O NF LI C T O F I N T E R ES T S T A T E M E N T
Authors declare that they have no competing interests.
D A TA AV A I LA BI LI T Y S T A T EM E N T
The data that supports the findings of this study are available in the supplementary material of this article.
E T H IC ST A T E M EN T
Not applicable.
O R C ID
Pablo Rodríguez‐Feria https://orcid.org/0000-0002-3817-1513
Katarzyna Czabanowska https://orcid.org/0000-0002-3934-5589
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A U TH O R BI O GR A PH IE S
Pablo Rodríguez‐Feria, a PhD candidate in the Department of International Health, Maastricht University, the
Netherlands. His PhD focus is leadership competency development in undergraduate medical education. His
research examines leadership competency‐based education in diverse workforces, including health, public
health, and the health allied professions. He has a special interest in interdisciplinary and transprofessional
education, conducting reviews, and promoting knowledge translation. He works in the Universidad de los Andes
in Bogota, Colombia and Maastricht University, the Netherlands. He serves as a peer reviewer for the Pan
American Journal of Public Health and for Public Health Reviews.
Ms. Paric is a lecturer and PhD researcher in the Department of International Health at Maastricht University.
She holds Master of Sciences degrees in Social and Cultural Anthropology from the KU Leuven, awarded with
- 859
distinction, and Governance and Leadership in European Public Health from Maastricht University. institutional
affiliations: Department of International Health and Care, at the Public Health Research Institute (CAPHRI),
Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, the Netherlands
Luis Jorge Hernández Flórez is an associate professor at the School of Medicine at the Universidad de los
Andes in Bogota, Colombia. He has worked in the Colombian government, multiple universities in Colombia,
and the Pan American Health Organization. He directs the public health department at the Universidad de los
Andes, and he gives classes in undergraduate and postgraduate education. His research area includes knowl-
edge translation, environmental health, education, bioethics, and the healthcare system. He is member of the
International Society Environmental Epidemiology and the Colombian Association of Public Health.
Professor Suzanne Babich is Associate Dean of Global Health and Professor of Community and Global Health
at the Indiana University Richard M. Fairbanks School of Public Health in Indianapolis, Indiana, USA. She directs
the Doctoral Programme in Global Health Leadership, a unique professional distance doctoral degree pro-
gramme for mid‐ to senior‐level health practitioners working full‐time around the world. She holds faculty
positions in the School for Public Health and Primary Care, Maastricht University, The Netherlands and l'Ecole
des Hautes Etudes en Santé Publique (EHESP), the French national school of public health, Paris and Rennes.
She is Chair of the Board of Accreditation, European Agency for Public Health Education Accreditation
(APHEA). She holds a doctorate in public health from the Department of Health Policy and Management at the
Gillings School of Global Public Health, University of North Carolina at Chapel Hill.
Prof. dr. habil. Katarzyna Czabanowska is a professor of Public Health Leadership and Workforce Develop-
ment and Head of the Department of International Health, Care and Public Health Research Institute
(CAPHRI), Maastricht University, the Netherlands, Honorary Member of the UK Faculty of Public Health. She is
a Past President of the Association of the Schools of Public Health in the European Region (ASPHER), and a lead
author of the WHO‐ASPHER Competency Framework and the Road Map to Professionalising the Public Health
Workforce in the European Region.
S U P P OR T I N G IN F O R M A T I O N
Additional supporting information can be found online in the Supporting Information section at the end of this
article.
How to cite this article: Rodríguez‐Feria P, Paric M, Flórez LJH, Babich S, Czabanowska K. Critical route for
development of medical student leadership competencies in 35 Pan American Health Organization member
states: a scoping review and thematic analysis. Int J Health Plann Mgmt. 2024;39(3):844‐859. https://doi.org/
10.1002/hpm.3791

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SPECIAL ISSUE ARTICLE

Critical route for development of medical

Pablo Rodríguez‐Feria1,2 | Martina Paric1 |

844 Int J Health Plann Mgmt. 2024;39:844–859. wileyonlinelibrary.com/journal/hpm

change, building networks, and developing expertise.

� Two countries have taught leadership for medical students in

2.1 | Search and eligibility criteria

2.2 | Information sources

2.3 | Selection of sources of evidence

2.4 | Data charting process, data items, and synthesis of results

F I G U R E 1 PRISMA diagram: databases, registries, handsearching, and consultation. PRISMA, Preferred

3.3 | Teaching methods

3.5 | Addressing barriers

3.6 | Supporting organisational change

3.7 | Building networks

3.8 | Developing expertise

4.1 | Component 1: Institutional design

4.2 | Component 2: Instructional design

4.3 | Enhancing components 1 and 2: Dissemination of information

To use the critical route

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