The European Journal of Public Health Advance Access originally published online on April 4, 2007
The European Journal of Public Health 2007 17(6):642-645; doi:10.1093/eurpub/ckm031
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Miscellaneous |
Are public health physicians fading out of management?
Betty J. Pettersen1 and Dag Hofoss1,2
1 Institute of community medicine, University of Tromsø, N-9037 Tromsø, Norway and Næringsparken, Norway.
2 Akershus University Hospital, N-1478 Lørenskog, and Institute of community medicine, University of Tromsø, N-9037 Tromsø, Norway.
Correspondence: Betty J. Pettersen, MD, MPH, Institute of community medicine, University of Tromsø, N-9037 Tromsø, Norway and Næringsparken, POB 243, N-8376 Leknes, Norway; tel: 47 76 05 43 52, fax: 47 76 08 20 06, email: betty{at}poseidon.no
Received July 6, 2005, accepted March 5, 2007
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Abstract |
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Background: Recent developments in health services in the local arena in Norway have challenged the theoretical and applied scientific basis for both public health medicine and management. During the 1990s although public health physicians in Norway increased in number, they worked less with public health, as well as public health management. The effects of these developments on public health management are largely unknown. We studied public health physicians’ involvement in management and their self-reported managerial competence. Methods: Cross-sectional study of physicians working in local public health medicine in all Norwegian municipalities, using a mail-back questionnaire. Results: Public health physicians reduced their administrative tasks and evaluated their own managerial competence rather conservatively and somewhat lower in 1999 than in 1994. Many had supplementary training in management in addition to their medical education and specialty training. Conclusions: Public health physicians may be fading out of management. To address this there is a need for development of both public health management training programmes and provision of adequate resources for managerial activities.
Keywords: management, managerial skill, physicians, public health, self-evaluation
The relationship between public health medicine and management can be described as ambivalent, despite their mutual dependency.1,2
Recent developments in Norwegian health care challenge public health, as well as medicine in general.2–7 Reforms for decentralization of health care have increased the complexity and responsibilities of primary health services.8–10 The new focus on market-modelled financing and remuneration, on individualization and on patients’ rights, call for changes in organization and new ways of dealing with both professionals and users of health services.
The effects on public health management are largely unknown. In an earlier article we have shown a decrease in overall public health work and specifically in management work for public health physicians. Here we present and discuss further data on public health physicians’ involvement in management and their formal and self-reported managerial competence.
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Material and methods |
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We performed cross-sectional studies of physicians in local public health medicine in all Norwegian municipalities in 1994 (N = 505) and 1999 (N = 555), response rates 66% and 70%. Head public health physicians, their deputies and physicians working with communicable disease control were asked to estimate the time spent on management, administrative span (number of services or departments managed) and their managerial competence. The questionnaire, participants and supplementary data are described elsewhere.11
To estimate time used on managerial tasks we used self-reported time. To assess managerial competence we used a survey instrument of 17 statements about different managerial tasks (box 1).
Box 1 Statements regarding managerial competence
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Statistics
Statistical analyses were performed using the statistical software SPSS (release 11.0.0, Copyright © SPSS Inc. 1989–2001). Differences between groups were tested by t statistics for continuous variables; otherwise 
2 statistics were used.
The managerial competence survey instrument used response alternatives on a 5-point Likert scale, where the extreme response alternatives were specified as ‘Master very well’ and ‘Master very poorly’. Using factor analysis we identified four clusters of related items. For each cluster we constructed an additive index.
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Results |
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The number of positions for public health physicians increased from 510 in 1994 to 575 in 1999.
Weekly hours in management work
In an earlier article we have shown that although the number of physicians working in public health increased by 10% an estimation of the total weekly hours done decreased by 3.7% from 1994 to 199911 depending on remuneration model, specialty in community medicine and municipality size. Time spent on management tasks was reduced with 1.6 h per week (16%, P = 0.02), but still 8.3 h per week were used for management.
For the minority (
10%) of public health physicians not working in clinical medicine there were no significant changes in the relative distribution of different tasks.
In 1994, 26 (8%) and in 1999, 69 (18%) of the responders reported using no time for management and no administrative span. When these were excluded, the reduction from 1994 to 1999 was no longer significant.
Administrative span
The proportion of public health physicians having managerial line responsibility was 95% in 1994 and 86% in 1999 (P < 0.001). On average the administrative span in 1994 was 4.6 services, in 1999 3.9 (P < 0.001) (maximum range 11).
During both periods 70% of all were managerially responsible for four or more services, most commonly general practice, environmental health, physiotherapy and public health nurses. There was a reduction from 1994 to 1999 in the proportion having personnel and budget responsibility for all but two services, most marked for environmental health (9%) (table 1).
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Managerial training
In 1994, 58% and in 1999, 55% had one or more types of postgraduate managerial training (P = 0.66).
Self-reported managerial competence
The four clusters of variables identified by factor analysis were named integrating, producing, entrepreneurial and administrating factor, corresponding to Adizes’12 theory of managerial roles.
There was a statistically significant reduction from 1994 to 1999 in the average scores on two of the four factors. The reduction was most pronounced for the producing role and rather small (table 2).
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The responders estimated their managerial competence rather conservatively (table 2). In both the years the highest scores were for the integrating managerial role.
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Discussion |
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Weekly hours in management work
By law each municipality must appoint a head public health physician.8 The responsibilities of the obligatory position are at the discretion of the municipalities and the public health physicians. During the 1990s a decreasing proportion of public health physicians had managerial responsibility, still between one-fourth and one-fifth of working hours were spent in management.
The reductions may reflect a tendency to redefine the public health physicians’ authority from executive to advisory.13–14 Transferring executive authority to other health professionals or managers trained in law or business administration may have reduced the need for some managerial work by public health physicians, especially as regards human resources management.
The decrease might also reflect more secretarial assistance or new technology support. However, unpublished data from our study indicate a reduction in secretarial services from 1994 to 1999, and Norwegian local public health physicians’ access to and use of internet resources is low.15–17
The population's and the authorities’ demand for more clinical work,18 together with strong economic incentives, may have led physicians to give priority to clinical work at the expense of public health work, including management.
Administrative span
The increased proportion of public health physicians having no human resources management in 1999 compared to 1994 may reflect the increased number of public health physicians.
The mixture of services managed changed. The majority was responsible for a core set of services: general practitioners, environmental health, physiotherapy and public health nurses. But fewer public health physicians managed environmental health in 1999 than in 1994. This service also had the highest reduction in working hours. Environmental health may have become considered an integrated part of other services, or constitute so little work that the responders did not consider it a specific management area. Both explanations give rise to just as much concern as the fact itself.
The administrative span in both the years comprised of services and departments focusing clinical medicine and individuals. This supports the notion that public health management was more health services management than actual public health management or health of populations’ management: public health lose to clinical medicine.11,19,20
Managerial training and self-reported competence
Both in 1994 and 1999 a substantial and stable portion of local public health physicians had some postgraduate managerial training. Showing a drive and ability to training, the question is whether the training was adjusted for their actual challenges.
Yet, on the average our responders scored cautiously on managerial competence. This may reflect the unpleasantness of rating one's own competence. We prefer, however, to interpret it as an indication that doctors in public health consider their managerial duties difficult, recognizing their shortcomings and conceding that their managerial performance might be improved.
The doctors scored highest on the integrating managerial role, which is on statements on guidance, motivation, cooperation and solving of conflicts. These are more familiar tasks as they are components of clinical training and practice.
Score reduction from 1994 to 1999 was most pronounced for the producing role, focusing follow-up of standards and routines in the medical as well as in the economic area. During the study period quality assurance was focused parallel to financial constraints on primary health care. The reduction in the doctors’ self-appraisal may well reflect the dilemma of performing better under worse conditions.
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Conclusion |
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Local public health physicians in Norway still perform a considerable amount of managerial work in a broad administrative span, and many have supplementary management training. Yet, they score themselves cautiously on managerial competence and they work less with public health.
The change is neither profound nor sudden, yet it is a significant change, which merits attention and action. Public health and health care require managerial expertise in public health, linked to medical knowledge and experience, also in a local context.21 The problem addresses both the need for development of evidence-based public health management in the training programmes for health professionals7 and provision of adequate resources for their managerial activities. Central and local government have, however, put little effort into seeking organizational solutions, on identifying specific competencies and qualities, developing training methods and training physicians for this.
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Funding |
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This study was funded partly by the National Institute of Public Health, The Norwegian Medical Association, University of Tromsø, Norwegian University of Science and Technology in Trondheim and Foundation for research in Nordland County.
Conflict of interest: None declared.
Key points
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References |
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