A core competency framework for healthcare workers to deliver basic public health service in primary healthcare settings in China

Abstract

Background

Basic public health service (BPHS) in China is the most important policy to provide equal access to essential healthcare for all residents, but it lacks a core competency framework for healthcare workers (HCWs) to provide BPHS, which fails to provide theoretical support for the competency assessment and training. This study aims to establish a core competency framework for HCWs to deliver BPHS in China.

Methods

BPHS functions are first identified as the goal of competency enhancement for HCWs, literature research and job analysis are conducted to define the competencies needed to fulfill the functions, then a core competency framework is initially proposed and improved using two rounds of Delphi.

Results

After several iterations among experts, a consensus was reached on the indicator framework for the functions of BPHS and core competencies of HCWs providing BPHS. The core function of BPHS in China consists of one overarching function (To achieve the equalization of BPHS and promote health equality) and eight sub-functions (“Residents’ health literacy improvement” among others). The finalized core competency framework for HCWs consists of 3 areas (specialized knowledge, skills, and conception and values), 19 domains (“Public health and preventive medicine knowledge” among others), 60 subdomains (“Epidemiology and health statistics” among others), and 116 competencies.

Conclusions

The core functions of BPHS and the core competency framework for HCWs to provide BPHS are constructed. This framework could serve as a guide for structured training on HCWs to provide high quality of BPHS and to develop criteria for those HCWs’ competencies assessment.

Plain language summary

China has established a basic public health service system serving over 1.4 billion people, yet it currently lacks clear guidelines for workers delivering these services. Through review of prior research, job analysis, and a structured decision-making technique that combines expert opinions to reach a group consensus, we developed core competency guidelines for basic public health service providers. The resulting framework highlights the specialized knowledge, skills, concepts, and values required. Strengthening public service awareness is a key requirement for basic public health service providers compared to other workers. The results provide a practical tool for delivering low-cost preventive public health services in China and potentially many other low- and middle- income countries.

mlBai et al. develop a core competency framework for Chinese basic public health service (BPHS) workers. They propose to enhance their capabilities across three domains: professional knowledge, skills, and concepts and values.

Introduction

The national basic public health service (BPHS) is one of the priorities of the new large-scale healthcare reform initiated by the Chinese government in 2009 to provide equitable basic public health care for all 1.4 billion residents¹. BPHS is free to all residents, ranging from traditionally provided necessities (e.g., vaccinations) to new services (e.g., chronic disease management)^2,3. The program is an important initiative to shift Chinese health system practices from a disease-focused to a public health-focused approach⁴, which emphasizes the importance of prevention and health promotion. It plays a vital role in enhancing residents’ access to public health services and narrowing health disparities between urban and rural areas. The cumulative investment in the program has exceeded RMB 3.9 trillion ($534.9 billions) so far since 2009, with more than 600,000 primary healthcare (PHC) sectors and 5 million healthcare workers (HCW, professional healthcare workers who deliver BPHS in community health center and, township hospital and village doctors) providing 14 categories BPHS to residents⁵. From an existing research report, China’s BPHS has achieved the anticipated coverage (e.g., the establishment rate of national health records has reached 88.25%)⁶, with the increasing financial subsidies (rising from 15 RMB yuan in 2009 to 99 RMB yuan in 2025)⁷. However, BPHS also faces challenges in terms of insufficient professional capacity of the workforce and lower quality of services⁸.

PHC providers are the most critical implementers of BPHS programs, so they necessarily possess the appropriate competencies^7,9. It has been shown that upgrading the core competencies of BPHS workers can significantly improve the quality and effectiveness of health services, so training more competent BPHS workers is considered a priority (Gong et al. 2024). However, there is currently no dedicated core competency framework for BPHS workers. The evaluation of their competencies primarily relies on educational qualifications and professional titles. Surveys show that less than 40% of BPHS workers have a bachelor’s degree¹⁰, and 31% of BPHS workers are less educated than the requirements for junior-level professional qualification¹. Moreover, current competence-building initiatives lack theoretical underpinnings for core competencies, remaining largely confined to medical service, national standards, operational procedures, and policy regulations for BPHS programs^11–13. No systematic framework for core competencies has been developed. In 2020, China’s National Health Commission released a plan that proposed improving the core competencies of BPHS workers as a top priority for reinforcing the BPHSs quality⁴. Regarding training, more than one-third of HCWs reported that the current training cannot meet the requirement to provide BPHS, for example, the content of training is not contingent with course content and BPHS practice. Therefore, the first question to be addressed is what kind of competencies qualified BPHS workers should possess.

Competency frameworks are a critical measure for defining and assessing the competencies expected of health service workers. There is a growing body of evidence that competency frameworks can describe the roles and required competencies of public health service workers, and play a crucial role in professional curriculum development and workforce training^14,15. Existing studies have been conducted on the core competency framework for general practitioners, nurses, public health physicians, and other workers^16–18. However, these studies mainly focus on competencies in medical services. BPHS implementation required more competencies to deliver public health service^15,19. Though Cai et al. framed a competency framework for the HCWs who deliver health services related to emergency response (as one category of BPHS), which identified the competencies comprising medical professional knowledge, public health service skills, emergency response abilities, and physical and mental qualities²⁰. Similarly, Wang et al. constructed a competency framework for public health emergency response workers from the dimensions of prevention, response, and recovery. However, there lack of a framework to cover competencies of HCWs to deliver other BPHS programs²¹. Lian et al. developed a competency framework for Chinese family doctors delivering certain BPHS functions²². Although the responsibilities of family doctors and BPHS providers overlap in certain areas, family doctors primarily serve their contracted patients, whereas BPHS workers cater to the entire population. There are still significant differences in the competency requirements for service philosophy, health education, and management approaches between the two groups. Since the implementation of the BPHS program nationwide in 2009, most frontline service workers directly entered primary health organizations to work on BPHS without training²³. They work and train simultaneously, and some of them cannot spare time for training because of the lack of staff in their institutions^4,24. Therefore, further research is needed to develop core competency frameworks for HCWs to provide BPHS, which are fundament of training and competency assessment.

Competency theory states that employee competencies should be goal performance oriented, and that corresponding competencies should be developed based on job objectives^16,25. The “13th Five-Year Plan” for the training of professional and technical workers in health planning and sanitation, issued by the Chinese government in 2017, also points out that the training of professional and technical workers is to carry out training centered on the job functions and competencies^13,23. Therefore, it is essential to first identify the functions that BPHS organizations should possess, to provide a target for the setting of core competencies for workers. This study firstly aimed to identify the functions of BPHS, and then constructed a core competency framework for HCWs to provide BPHS service. The finalized core competency framework for HCWs consists of 3 areas and 116 competencies. This framework aligns with the realities of China and other developing nations, demonstrating both systematic and forward-looking features. The results provide a theoretical basis for further improving the effectiveness of training in the public health sector, while providing insights into the development of preventive health services in low- and middle-income countries.

Methods

Competence theory proposes that competency is a collection of knowledge, skills, attitudes, or motivation related to job performance, and emphasizes that enhancing competency necessitates the prior establishment of clearly defined work objectives²⁵. The provision of corresponding BPHS functions constituted the occupational objectives for BPHS workers, while the fundamental public health functions represent an indispensable series of actions undertaken by the government to standardize public health services, enhance service quality, and promote public wellbeing. These two phases are described in Fig. 1.

Fig. 1. Two phrases to define and build the core competency of the workforce that delivers BPHS.

The diagram illustrates the theoretical basis and process for determining core competencies. Phase 1 primarily establishes the objectives that core competencies need achieve, namely the functions provided by China's BPHS. Phase 2 identifies the core competencies required of primary HCWs to fulfil these functions.

The onion model is an international widely used competence model, which divides competencies into a three-layer structure, with the inner layer including motivation and personal traits, the middle layer including attitudes, values, and self-image, and the outer layer including knowledge and skills²⁶. This study drew on the onion model to categorize the core competencies of BPHS workers.

The research flowchart is illustrated in Fig. 2. The study primarily comprised two phases: (1) identification of BPHS functions, and (2) construction of a core competency framework with functions as the goal. During the first phase, literature search and content analysis were employed to summarize existing literature on BPHS functions, functional frameworks of representative countries (regions) and organizations, and Chinese government policies regarding BPHS. This yielded initial functional indicators, which were subsequently evaluated using the Delphi method. In the second stage, building upon the functional framework established in the preceding phase, a combined approach of literature research, in-depth interviews, and job analysis was employed to obtain the competencies required to fulfil corresponding BPHS functions. This yielded an initial competency framework, which was also evaluated using the Delphi method to refine the final indicator system.

Fig. 2. Flow chart of BPHS functional framework and core competency framework development.

The item generation phase involves determining the constituent items of the functional and core competency framework. The questionnaire design of Delphi phase entails developing corresponding expert consultation questionnaires based on the initial functional and core competency framework. The item evaluation by Delphi involves conducting expert consultation assessments to refine and finalise the framework.

Literature search and content analysis

A preliminary functional framework was constructed from three sources. Firstly, papers were retrieved from PubMed, Web of Science, Google Scholar, the China Biomedical Literature Database, and China National Knowledge Infrastructure (CNKI) to identify literature related to BPHS functions²⁷. Medical Subject Headings (MeSH) and free-text terms were used in combination to enhance sensitivity for potentially relevant literature, such as: basic public healthcare worker, community health worker, public health physician, general practitioner, family physician, family doctor, function (e.g., serve, act, action). Inclusion criteria encompassed all types of research—including cross-sectional studies, retrospective studies, and longitudinal studies—published in Chinese and English between 1991 and 2020. Since the concept of BPHS gained widespread adoption in 1991²⁸, literature predating this year was excluded. Additionally, we excluded studies not explicitly focused on BPHS or non-governmental organization initiatives, as our emphasis was on publicly funded health services. Secondly, functional elements of BPHS were retrieved from 11 countries (regions) or organizations, including the World Health Organization, the United States, the Pan American Health Organization, and the World Bank. Thirdly, Chinese governmental documents concerning the functional components of BPHS were systematically analyzed^11,29. The following information was extracted from relevant literature: the composition of BPHS functions, service content and priority levels, as well as the countries and regions where these were developed and implemented. The findings were compiled into a table. Identical items were consolidated, while differing entries were categorized and presented in sequential order. Finally, to ensure consistency with the BPHS functions of relevant countries and regions and to avoid omitting key functional elements within the context of China’s primary-level public healthcare, we convened expert meetings to review and refine the functional entries, thereby establishing a preliminary draft of the functional framework.

The criteria for inclusion of experts comprised: (1) possessing 10 or more years’ experience in clinical, nursing, teaching, or management roles within basic public health service units; (2) holding an associate senior or higher professional title; (3) holding a bachelor’s degree or higher in public health. A total of 13 specialists participated in the discussions. These included some authors, who were HCWs from public health administrative departments and hospitals.

With regard to the construction of the core competency framework for BPHS workers, we also searched domestic and international literature on core competencies (e.g., ability, core competencies, capability) for BPHS workers, and comparatively analyzed the basic competency elements of BPHS workers in various countries/regions. The following elements were ultimately extracted from appropriate literature: the core competency dimensions for BPHS workers, the competency framework, specific indicators, and evaluation criteria.

In-depth interviews

Using a purposive sampling method and the principle of information saturation to determine the final sample size, 10 managers and 35 HCWs who provide BPHS were selected for in-depth interviews in primary health organizations (43 community health service centers and 48 township health centers) in Chongqing Municipality. Chongqing is a municipality of significant economic influence in China, and was undergoing rapid development in its BPHS. Since the implementation of BPHS in 2009, Chongqing has steadily expanded its service content, quality, and coverage, becoming a model region for standardized provision of BPHS in China. HCWs in Chongqing have accumulated extensive experience throughout this process.

The interview questions for managers included the number of staff in their organization, the status of their competencies, and their competency needs to complete the corresponding services. The interview questions for frontline staff included assessment of their own service capacity, participation in training, and needs for core competencies. The interview texts were sorted and analyzed, and keywords with the same attributes were categorized to extract core competency elements.

Job analysis

The work content of China’s BPHS and specific competency requirements were sorted out by reviewing the National BPHS Specification (Third Edition 2017) and the National Technical Specification for BPHS^1,8. This was supplemented by observations made by directly observing the work activities of HCWs who had provided BPHS with informed consent for observations to be made. These observations collected information on the relevant competencies for the BPHS functions.

Delphi method

Delphi method was a consensus-based technique that collected expert opinions through several rounds of surveys or interviews²⁹. It had four distinguishing features: anonymity, replication, controlled feedback, and statistical group responsiveness^30,31. Among the different Delphi methods, we chose the modified Delphi method, which includes two rounds of surveys conducted from August to November 2019.

Selection of Delphi experts

This study used purposive sampling technique to select consulting experts to form an expert group to serve the Delphi consulting process. The expertise and qualifications of experts were determined based on the following criteria.

(1) National or provincial decision-makers who have worked in the fields of BPHSs, primary health management, disease prevention, and control for more than 10 years.

(2) Senior BPHS experts with rich knowledge and experience (including primary health institution leaders and frontline staff directly involved in BPHS work and management).

(3) National coverage: Representatives from eastern, western, northern, and southern China to ensure nationwide applicability of results.

A total of 17 BPHS experts from national and provincial research institutions, professional societies, CDC, health administrative departments, and community health service centers were selected to participate in the Delphi consultation process. During the expert selection process, potential experts were contacted (initially via email, later via phone), and the research overview and objectives were explained in detail to them. They were asked if they were interested in volunteering. Experts who were willing to participate in the consultation and keep it strictly confidential signed an informed consent form. This study received ethical approval from the Ethics Committee of the Army Medical University.

Questionnaire design

A Delphi expert consultation form was designed based on the initial functional framework, which included the following three parts:

(1) Delphi survey explanation, used to introduce the research field and clarify how to complete the survey;

(2) General information of experts, such as age, professional title, position, education, major, work experience, etc.

(3) Consultation questionnaire (main tool), including the overall function and subdomain importance and operability scores of BPHS, expert authoritative information (indicator familiarity and indicator judgment criteria), and consultation methods.

The process for Delphi questionnaire design is illustrated in Fig. 2 (steps 1–4). First, the initial functional framework was developed through literature review and expert meetings as described in Section 2.1. Second, professionals engaged in BPHS institutions were invited to provide suggestions on the draft framework. In this way, the draft questionnaire for the BPHS functional framework (including overall functions and sub-functions) was finalized. Third, the questionnaire was pre-tested with a sample of 3 HCWs providing BPHS who reviewed the appropriateness and clarity of the questionnaire items. Fourth, the pretesting resulted in appropriate embellishment of the formulation of the overarching and subdomains, as well as the connotations of the subdomains. Meanwhile, the respondents’ interpretations were evaluated, and the questionnaire was finalized and provided to the experts for consultation.

The Delphi survey questionnaire for the BPHS functional framework included one overall function and eight subdomains. Experts rated the importance and operability of each item on a 5-point Likert scale. Finally, experts could delete, add, and modify items at all levels, but were required to clearly explain the reasons. Expert authoritative information includes the level of understanding of items and the basis for judging them.

Setting a consensus level

The Delphi consulting method was based on the level of expert consensus to determine whether to accept or reject consulting projects. Most studies had set 70% as a criterion^32,33, and this study referred to these studies to establish acceptance and rejection criteria.

Procedure

Figure 2 illustrates the Delphi consultation process (steps 5–8). In the first round of Delphi consulting, consulting experts evaluated the importance of the overall and subdomains of BPHSs, the level of understanding of items, the criteria for judging items, and the degree of impact of items. We used descriptive statistical methods to analyze the results of the first round of surveys and provide feedback to experts. According to the exclusion criteria, items that were excluded by consensus through negotiation (i.e., if more than 70% of experts scored a certain indicator ≤ 5 points, then that item would be excluded from the second round of the survey questionnaire). Besides, the items suggested by experts for modification were discussed through expert meetings, and the revised items were added to the second round of survey questionnaire. In the second round, consulting experts rated the importance of various items based on the feedback from the first round, and proposed suggestions for addition, modification, or deletion. The final framework (including overall functionality and subdomains) was submitted to experts for discussion, and final consensus was reached, forming the final framework.

Statistical analysis

The authority coefficient (Cr) referred to the degree of authority used to evaluate the technical ability of experts in evaluating items, which was determined by two factors: the expert’s judgment basis (Ca) and familiarity with the indicators (Cs). The calculation formula for Cr is:${\mathrm{C}}_{\mathrm{r}}=\left({\mathrm{C}}_{\mathrm{a}}+{\mathrm{C}}_{\mathrm{s}}\right)/2$. The higher the level of expert authority (Cr>0.9), the more reliable the evaluation results were³⁴. Median and mode were used to describe the central tendency of experts’ ratings of items at different levels. The coefficient of variation (CV) was used to describe the degree of dispersion of experts’ ratings for various levels of items. The expert opinion was relatively unanimous when the CV was <0.3.

Results

Initial BPHS functions

Supplementary Table1 showed the comparisons of the frameworks of public health functions in different countries/regions around the world. Public health functions from all 11 countries/regions mentioned “health surveillance analysis and needs assessment” and “health promotion”, and “public health manpower training and development” and “public health governance, legislation and law enforcement” were included in the public health functions from all 10 countries/regions. And the public health functions of more than half countries/regions (6-9) involved the following 7 functions: “public health research”, “infectious and non-infectious disease prevention and control”, “health service assurance”, “public health policy and planning formulation and implementation”, “response to disasters and public health emergencies”, “health protection”, and “assessment of quality, effectiveness and accessibility of health services”. Besides, only 4 public health functions are considered “social mobilization” and “multisectoral cooperation and partnership building,” and 2 public health functions mentioned “health services for key populations. Generally, the functions of health promotion and public health system construction for all residents were emphasized in all regions and organizations, while less attention was paid to multispectral cooperation and health services for key populations. After expert meeting, the draft functions of BPHS in China was initially proposed, which comprised one overall function (To improve and protect public health, promote the equalization of BPHS and health equity) and the following eight subdomains: improvement of residents’ health literacy, community health surveillance, community health needs assessment, health management for key populations in the community, disease prevention and control, health emergency management in community, multisectoral collaboration, policy and planning making and evaluation.

Characteristics of the experts

In the first round of the Delphi survey, questionnaires were sent to 17 experts, and 16 of them responded (Table 1). These 16 experts hail from 10 provinces/municipalities across the eastern, central, and western regions of China. Their research fields encompassed primary health care services, health policy development and analysis, health manpower, management of BPHS projects, general medicine, chronic disease prevention and control, among others. All were professionals engaged in research, management, and practice related to BPHS. Their workplaces included medical colleges and universities, community health service centers, research institutions related to BPHS, health industry associations, and health administrative institutions. All 16 experts who participated in the first round of the survey also completed the second round. All experts had more than 10 years of work experience (ranging from a minimum of 11 years to a maximum of 52 years, with a mean of 26 years and a standard deviation of 15 years). Among them, 14 experts (86%) had more than 20 years of experience in their respective fields.

Table 1.

Experts’ characteristics

Characteristics		Number	Percentage
Age	30～39	5	31.3
	40～49	5	31.3
	50～59	1	6.3
	60 and above	5	31.3
Educational level	Doctor	4	25.0
	Master	6	37.5
	Bachelor	6	37.5
Professional title	Senior	8	50.0
	Associate senior	4	25.0
	Middle	4	25.0
Research field	Primary Health Care Services	3	18.8
	Community Health Management	3	18.8
	Health Project Management and Evaluation	1	6.3
	Health Policy Development and Analysis	1	6.3
	Health Service Management	2	12.5
	Health Manpower	1	6.3
	Management of Basic Public Health Service Projects	1	6.3
	General Medicine	1	6.3
	Health Economics	1	6.3
	Health Education and Health Promotion	1	6.3
	Chronic Disease Prevention and Control	1	6.3
Years of experience in BPHS	10～19	7	43.8
	20～29	3	18.8
	30 and above	6	37.5
Work unit	National Research Institutions	3	18.8
	Provincial Industry Associations	4	25.0
	Provincial Centers for Disease Control and Prevention	3	18.8
	Provincial Health Commissions	2	12.5
	Medical Colleges and Universities	1	6.3
	Primary Health Care Institutions	3	18.8
Region	North China	5	31.3
	East China	5	31.3
	Central China	2	12.5
	South China	1	6.3
	Western China	3	18.8
Response rates to questionnaires	Round 1	16	94.1
	Round 2	16	100

During the first round of consultation, 17 questionnaires were sent to seventeen experts, sixteen of whom responded (response rate was 94.1%), and all 16 questionnaires in the second round were returned (response rate was 100%). Except for the expert authority coefficient of “health emergency management in community,” which is 0.875, the expert authority coefficients of the total function and other subdomains are all above 0.9, and the average Cr is 0.94, which indicates that the authority of experts is good.

Results of Delphi survey for BPHS functions

Table 2 presented results of two rounds of Delphi for BPHS functions. After the first round of Delphi, except for the subdomain “policy and planning making” which has a median importance rating of 8 and a multitude of 9, the median and multitude of the importance ratings of all the other functional indicators are 9, and the CV value of all the functional indicators is less than 0.3, indicating that there is a good central tendency for the overall function and each subdomain. Nine experts proposed 17 modification suggestions: experts suggested to modify the overall function to “To improve and maintain public health, promote the equalization of BPHS and health equity.” and experts proposed to merged two subdomains, “community health surveillance” and “community health needs assessment” into “community health surveillance and needs assessment.” They also suggested to modify two subdomains (“disease prevention” to “disease prevention and control” and “policy and planning making “ to “policy, planning making and evaluation”) and add one new subdomain (“residents” health information management”). Finally, one overall function and eight sub domains were included in the second round of survey.

Table 2.

Results of Delphi survey for the BPHS functions

Items	Importance
	Median	Mode	Coefficient of variation (CV)	% score of >7	% score of ≤5
First round
Overall function	9	9	0.056	100	0
To improve and protect public health, promote the equalization of BPHS and health equity
Subdomain
1. Improvement of residents’ health literacy	9	9	0	100	0
2. Community health surveillance	9	9	0.158	93.8	6.3
3. Community health needs assessment	9	9	0.207	81.3	18.8
4. Health management for key populations in the community	9	9	0.056	100	0
5. Disease prevention	9	9	0.078	100	0
6. Health emergency management in community	9	9	0.208	81.3	18.8
7. Multisectoral collaboration	9	9	0.179	87.5	12.5
8. Policy and planning making	8	9	0.229	87.5	12.5
Second round
Overall function
To improve and maintain public health, promote the equalization of BPHS and health equity	9	9	0	100	0
Sub-domain
1. Improvement of residents’ health literacy	9	9	0	100	0
2. Resident health information management	9	9	0.056	100	0
3. Community health surveillance and needs assessment	9	9	0.093	100	0
4. Maintain health across the entire lifecycle	9	9	0.056	100	0
5. Disease prevention and control	9	9	0	100	0
6. Health emergency management in community	8	9	0.16	93.8	6.2
7. Multisectoral collaboration	9	9	0.183	87.5	12.5
8. Policy, planning making, and evaluation	7	7	0.209	75	25

Following the second Delphi survey, medians and modes of the importance for overall function and all subdomains were between 7 and 9, and CVs for all items were less than 0.3. Consensus was reached on the importance of the overall function and all subdomains, with over 70% of experts giving a score of 7 or above for all items. Besides, experts suggested to modify the overall function to “To achieve the equalization of BPHS and promote health equality,” and experts suggested to modify the “health management for key populations in the community” to “maintain health across the entire lifecycle”. After two rounds of Delphi, the BPHS functions in China consisted one overall function and eight sub-domains, and the connotations of each sub-domain were explained in Supplementary Data 1.

Primary core competency framework

As revealed by the results of the literature review in Supplementary Data2, the core competencies required for the provision of BPHS functions cover professional knowledge, practical skills, and service concepts. The following 6 competencies were the most frequently considered in the worldwide countries/regions: skills of analysis and assessment, policy and planning making, risk factors surveillance, health promotion, communication, and leadership. After research group discussion, 13 competencies from the literature were included in core competency for HCWs to deliver BPHS in China, such as professional knowledge, practical skills, and people-centered service concept. Results of interviews, totally 17 competencies were included in core competency for HCWs to deliver BPHS in China, which ranged from professional knowledge, skills, and public health service concepts. After job analysis, 63 competencies are required to deliver the 14 programs (Supplementary Note in Supplementary information) of BPHS according to the National guideline of basic public health services.

Based on the onion model³⁵, after integration of the core competency from literatures, interviews, and job analysis, research group formed the primary core competency framework of HCWs to delivery BPHS, which included 4 areas (specialized knowledge, practical skills, concepts, and values), 18 domains, 63 sub-domains, and 141 competencies was initially constructed (Supplementary Data 3 & Supplementary Data 4).

Experts’ authority levels (Cr)

During the two rounds of consultation, 16 questionnaires were sent to sixteen experts, sixteen of whom responded (response rate was 100%). The judgment coefficients of all areas, domains, subdomains, and core competencies were between 0.8 and 1.0, and the familiarity coefficients are all above 0.9, which indicates that the experts possess adequate knowledge of the issues. The expert authority coefficients of the items at all levels and the competencies are all above 0.8, which hinted that the experts are qualified to evaluate the competency items and that the accuracy of the judgments is high.

Results of Delphi survey on the framework of core competencies to deliver BPHS

The results of the first round of Delphi expert surveys are shown in Supplementary Data 3 and 4. As for rating of importance, except that the medians and modes of two subdomains (III-51 and III-52) were 5.0, the rest ranged between 7 and 9, and the CVs of only 9 items (II-14, III-49, III −50, III-51, III-52, IV-61, IV-96, IV-121, and IV-124) are greater than 0.3. Regarding to ratings of feasibility, medians of 12 items (I-3, I-4, II-13, II-16, III-46, III-60, III-62, IV-77, IV-78, IV-133, IV-135, and IV-136) and 2 items (III-52, IV-69) were 5 and 6 respectively, and the modes of 14 items (I-3, I-4, II-13, Ⅲ−46, Ⅲ−60, Ⅲ−62, Ⅳ−69, Ⅳ−77, Ⅳ−78, Ⅳ−117, Ⅳ−131, Ⅳ−133, Ⅳ−135, Ⅳ−136) and 1 item (Ⅱ−16) were 5 and 3 respectively, and CVs of 13 items (II-16, III-22, III-23, III-49, III-52, III-54, III-60, IV-96, IV-103, IV-124, IV-135, IV-136, and IV-141) were greater than 0.3. These results suggest that there is a good central tendency in the experts’ importance ratings for most indicators.

Besides, experts suggested“concepts” and “values” should be combined into “concepts and values”. Experts also suggested that 1domain, 7 subdomains, and 11 competencies should be added, and 1domain, 8 subdomains, and 14 competencies should be deleted. Experts modified 1 area, 5 domains, 14 subdomains, and 32 competencies. Based on our inclusion and exclusion criteria, 3 areas, 18 domains, 60 subdomains, and 131 competencies were eventually included in the second round of the expert consultation questionnaire.

The results of the second round in Supplementary Data 3 and 5 showed that the scores of medians and modes for all items ranged from 7 to 9 for importance and feasibility, and that the CVs for all indicators were less than 0.3, which indicated that all items were important and feasible. Besides, 1 domain was added, 3 subdomains and 2 competencies were modified, and 2 competencies were deleted. We organized a roundtable discussion with all the experts of BPHS to decide on final items for the framework. Following this discussion, the finalized core competency framework for HCWs to provide BPHS includes 3 areas, 19 domains, 60 subdomains, and 116 competencies as shown in Supplementary Data 6.

Discussion

BPHS is a core component of the primary health care, an integrated, comprehensive, sustainable, and cost-effective approach to enhancing equality of public health, and a crucial initiative to protect the health of China’s 1.4 billion people and implement the prevention-oriented healthcare policies³⁶. The core competencies for HCWs to deliver BPHS play a key role in the promotion of the BPHS program³⁷. This study constructed the functional framework of BPHS based on integrating the international reports on public health functions and understanding goals of BPHS. This functional framework included one overall function (explaining the goal of BPHS) and 8 subdomains (summarizing the objectives of BPHS), which provided a guide for assessment of BPHS implementation and guide for the development of core competency for HCWs to deliver BPHS.

The framework of core competencies of HCWs delivery BPHS developed through job analysis, qualitative interviews, and literature study, with the guide of the core functions of BPHS. This framework included 3 constructs (knowledge, skills and conceptions) and has the following characteristics: our core competency model emphasizes HCWs’ expertise in public health concepts, principles, and cross-disciplinary knowledge more than other models. This is based on two main considerations. The first is the educational background of HCWs to deliver BPHS in China. As most of them were transferred from the nursing profession, they have insufficient mastery of professional knowledge related to public health services, so they need to strengthen the training of related knowledge more than general practitioners and public health physicians¹⁸. The second is the international adoption of the framework. By strengthening the public health knowledge and skills of HCWs to provide BPHS, it facilitates the provision of low-cost, wide-coverage preventive public health care services in low- and middle-income countries with limited financial resources, so as to improve the health of the population and share the pressure on health care institutions, which is a low-cost strategy that can be scaled up.

The core competency model could be utilized to competency building for all HCWs of BPHS. Compared to existing research identifying competency elements for family doctors and general practitioners¹⁰ in delivering disease treatment components of BPHS, the core competencies developed in this study encompass a more comprehensive range of BPHS functions such as monitoring community water safety, school sanitation, and participating in policy formulation. It highlights public health thinking and public service awareness, so this competency model is applicable to all kinds of BPHS program staff rather than a single type. As for staff who do not directly provide BPHS (e.g., administration, finance staff, etc.), they are not required to possess all the competencies listed in this model. Depending on the job role, they will have the corresponding subset of competencies in the model.

Besides, our framework emphasizes intrinsic traits. Professionalism decisively influences the competency of BPHS providers. Given the large service population and low economic rewards of BPHS, HCWs must possess not only technical skills but also strong professional ethics and a patient-centered service philosophy to enhance service quality. Therefore, emphasizing professional literacy is essential for competency development. While such intrinsic professional qualities may prove challenging to alter through short-term training, incorporating them into our competency framework will help policymakers, administrators, and trainers prioritize these principles. Thus, enabling their continuous reinforcement through subsequent work, training, and performance evaluations.

The core competency framework took into the requirement of the development of BPHS. With the development of economy and society, people’s health needs are more diversified^1,38, the BPHS programs are expanding, and the work content of HCWs to provide BPHS is correspondingly enriched^36,39, with increasingly high competency requirements for them. Meanwhile, workers with general medicine or public health backgrounds gain advantages in BPHS positions⁶, and it is far from enough to rely solely on medical school education to supplement these workers, but mainly through the continuing education of serving staff to strengthen their competence. Therefore, our model should not only meet the current training needs, but also grounded in the future development of public health services, prospective and demanding to put forward the core competencies of HCWs, in order to prepare for the future challenges of BPHS field. Beyond the focus on competencies such as vaccination and health education in traditional BPHS, our model emphasizes more on the importance of management capacity and partnership building. This is because future BPHS programs place more emphasis on effective collaboration with the government, community organizations, private institutions, etc. to enhance the accessibility of public health resources^40,41. Scientific research capacity is also depicted because it is critical to the future career development of HCWs²⁰.

Besides, the core competency could be modified with development of BPHS. Core competency model contributes to defining and standardizing the work of BPHS. However, the lifespan of a competency model is usually limited (typically 3–5 years)^10,42. The development of a competency model is an iterative process, and the model should be regularly reviewed and dynamically updated based on ongoing feedback from the use of the competency model as new thoughts and future challenges in the field evolve⁴³. The Public Health Agency of Canada, in adequately monitoring and evaluating the impact of core competencies on public health practice and systems, suggests that core competencies should be kept updated and relevant⁴⁴. As the social determinants of health diversify and public health issues continue to change, the practice of BPHS has to be constantly adapted, and the core competencies describing the knowledge, skills, and concepts required for that practice need to be updated accordingly⁴⁵. The competency model proposed in this study is constructed based on current survey and information, and is a foundational model that is also time-sensitive. There is a need to dynamically update the core competency elements on the basis of a full assessment of the impact of the core competencies on the existing practice of BPHS to ensure that the core competency model is able to meet the public service needs in a timely manner. However, the strength of our model lies in the categorization and stratification of the competencies, integrated into a systematic framework. This framework provides a flexible perspective that helps to understand the dimensions to which future additional competencies belong, thus ensuring the framework’s expandability. We can even expand and adjust the competency model appropriately according to the different service positions or by categorizing workers into different professional tiers (junior, intermediate, senior).

To the best of our knowledge, this is the first study to systematically develop a core competency framework for BPHS based on competency theory. This framework will provide a foundation and specification for the design of training programs, along with a basis for job descriptions and employee career planning, as core competencies are widely used to redefine major health professions curricula and design in-service training programs.

Regarding the potential limitations of the study, firstly, it needs to be clarified that this competency framework was developed as a baseline overview of knowledge, skills, and conceptions and values of HCWs for BPHS, but it cannot be directly used as a certification standard to define BPHS providers or determine who is certified to provide BPHS or a similar credential. Secondly, this framework needs further studies to test and transfer into a scale to quantitatively assess the core competencies of HCWs providing BPHS. Development of training programs based on this framework and validation of their implementation pathways across different regions should be the next step.

Conclusion

Improving the professional competence of practitioners is widely recognized as a priority to reinforce the BPHS system. According to competency theory, this study constructs a framework of core competencies for HCWs who deliver BPHS in PHC sectors based on the clarification of the core functions of BPHS. It reveals that the goal of BPHS is to achieve service equalization and health equality, and that the services needed should focus on inter-sectoral cooperation and life-cycle health maintenance. The core competencies of HCWs should reinforce partnership building and cultivate a people-centered concept, apart from professional knowledge and skills. This framework provided a guide for structured training on HCWs to provide high quality of BPHS and to develop criteria for HCWs competencies assessment related to BPHS provision. Besides, the core competency framework for HCWs in China provides an important reference for other low- and middle-income countries seeking to expand access to BPHS.

Author contributions

Haonan Bai: Conceptualization, Methodology, Writing—original draft, Writing—review and editing. Shengxiang Liang: Investigation, Conceptualization, Methodology, Data curation, Writing—original draft. Hexiang Huang: Investigation, Methodology, Data curation, Project administration. Lu Liu: Methodology, Investigation, Data curation. Xingneng Luo: Methodology, Investigation, Data curation. Jiani Zhou: Conceptualization, Methodology, Writing—review and editing. Ying Li: Conceptualization, Methodology, Resources, Supervision, Project administration, Funding acquisition, Writing—review and editing.

Peer review

Peer review information

Communications Medicine thanks XuanXuan Wang and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. A peer review file is available.

Data availability

The data supporting the research findings are provided in the tables and supplementary documents. The literature research data is in Supplementary Table1. The job analysis and in-depth interview data is in Supplementary Data 2. The Delphi expert consultation data is in Supplementary Data 3, 4 and 5.

Competing interests

The authors declare no competing interests.

Supplementary information

The online version contains supplementary material available at 10.1038/s43856-026-01472-2.