Management and The Pursuit of WOW, is ranked as the `number one' in
awareness and credibility with business leaders. Australia too is showing
considerable ...
HEALTH PROMOTION INTERNATIONAL # Oxford University Press 1997
Vol. 12, No. 1 Printed in Great Britain
Developing leadership for health: our biggest blindspot While the world swooned to the `Three Tenors' in the most extravagant global opera show ever, another multimedia eventöequally as expensiveöheld its audiences captivated. The trio this time were not focusing on the faint hearted but rather the strong hearted. Management trainers Stephen Covey, Tom Peters and Peter Senge presented for the ¢rst time ever `Worldwide Lessons in Leadership', which was broadcast from Kentucky via satellite to 40 countries. The series aimed to give viewers complete understanding and appreciation of the absolute necessity for all employees to be part of a cohesive team with a common goal, to work towards continuous improvement, full cooperation and constant customer focus. How many health promoters missed the `Three Trainers'? In the United States, industry sees leadership as one of the vital ingredients for success. As a result, companies which are trying to maintain or take the lead are increasingly investing in leadership development. Summer schools, retreats, courses, and now simultaneous telecast seminars abound. Stephen Covey's The 7 Habits of Highly E¡ective People or Peter Senge's The Fifth Discipline are household names. A recent poll has found that Tom Peters, with books like In Search of Excellence, Thriving on Chaos, Liberation Management and The Pursuit of WOW, is ranked as the `number one' in awareness and credibility with business leaders. Australia too is showing considerable interest in equipping industry for the challenges of the next century. For example, in 1995 the Australian government's Industry Task Force on Leadership and Management (Karpin, 1995) concluded that there were considerable opportunities for Australia to improve its economic performance at the world level through better leadership and management skills. A new direction and momentum for training was needed. Subsequently a number of innovative schemes have begun, which will be spurred on by the `World Centre for New Thinking' based in Melbourne. This new independent
institute was launched in September 1996 and is directed by lateral thinker (and also physician) Edward de Bono. How should the health ¢eld respond to these developments occurring in the private sector? Do they have any merit? As we remarked last year (Catford and St Leger, 1995), health promotion is at the cornerstone of the health debate internationally. Country after country in the industrialised world is recognising that major and sustainable improvements in health status can only be won through a public health approach. This realisation also applies to developing nations, as the 1993 World Bank report emphasisedö`If the right policy choices are made, the payo¡ will be high.' But here lies the stumbling block; the science of `delivery' has not kept pace with the science of `discovery'. Although the necessary information to take action is available, often the right decisions are not made; or are not implemented, or are not sustained. Leadership can bridge this gulf. E¡ective leaders in public health are particularly important, not least because of the uncertain and demanding future that lies ahead. For example, some of the challenges facing the health sector in developing countries include: . how to respond to the `double burden' of disease which many countries are now rapidly experiencing; . how to address increasing environmental health problems due to degradation of the environment and rapid urbanisation; . how to secure better equity and access of health services; . what balance to strike between public and environmental health measures, primary and secondary health care; . how to resist demands for inappropriate technology and high cost services of low return; . what new ¢nancing sources and mechanisms to introduce; . what health personnel groups, numbers and education to provide; 1
2
John Catford
. what health sector reforms and strategies to adopt; . what planning, management and training methods to use. The need to provide training for public health leaders is not a new concept. For many years the World Health Organization has held regular seminars for chief o¤cers, and most countries have o¡ered some `topping up' programmes to senior health o¤cials. But most of these programmes have concerned new advances, new content, or new strategies which have been able to build comfortably on public health science platforms established decades beforeöthe `head stu¡'. In contrast, few have focused on the personal qualities and skills which make or break leadersöthe `heart stu¡'. Arguably it is the practice rather than the principles that we still fall short onöthe `how' lags behind the `what'. Several countries, however, have provided management and leadership development to health service executives for some years. For example, the Kings Fund, which is the largest non-governmental organisation (NGO) in Britain concerned with health care development, has a discrete Management College which provides leadership development for individuals and their organisations. Although available to all disciplines, the throughput of public health and health promotion managers has been limited. In the Australian health service there has also been recognition that advanced skills in management and leadership are needed if continued improvements in health gain and the e¡ective use of resources are to occur. This has led to an agreement between Australian states and territories and the Commonwealth governments to invest in an Australian Health Management Network. Drawing on the English King's Fund model and the Welsh `sta¡ college' concept, it will have an interdisciplinary remit with a strong emphasis on outreach. The network will also build on the Public Health Education and Research Program (PHERP) funding initiative of the Commonwealth Department of Health and Family Services, which supports MPH and speciality funding programmes. Perhaps not surprisingly, greater strides have taken place in the USA where, for example, the California-based Health Care Forum o¡ers community leadership training, which focuses on partnering health institutions with their constituencies (Health Care Forum, 1994). Academic programmes and courses are also starting; for
example, the University of North Carolina School of Public Health doctoral programme. Nevertheless, there is still room for much improvement (Roemer, 1993). Interestingly, most national and international professional bodies concerned with health promotion acknowledge the importance of leadership by presenting awards, giving prizes and bestowing honours of various kinds; for example, the Asian Paci¢c Academic Consortium for Public Health. Yet few of them o¡er skills-based training in leadership. Is this because they are unaware of what could be o¡ered or are not convinced of their value? Despite the interest and growing commitment to public health leadership development, there is an absolute paucity of research on what makes good public health leaders and how leadership can be strengthened. A comprehensive review of the international literature over the last 10 years has not revealed any substantive empirical and systematic study of the practice of public health leadership. Health Promotion International, principally through its editorials, has suggested some of the key attributes (for example, Catford, 1992). A past US Surgeon General has recently published his autobiography (Koop, 1991) and there are other sporadic biographies on public health leaders as far back as Henry Duncan, the ¢rst Medical O¤cer of Health who was appointed to tackle the slums of Liverpool (Chave, 1987). What little material does exist in the health management ¢eld predominantly concerns the acute health sector and focuses on how to run a hospital or medi-business. Whilst the descriptive literature recognises the distinction between management leaders and management administrators, most of the health service literature concerns the latter. There are relatively few case reports on individual leadership role models in public hospitals (e.g. Lawson et al., 1996). However, it should be emphasised that public hospital management does not equate with public health management. Nor does clinical referent power of health professionals within communities necessarily imply leadership competencies in public health. The sorts of interesting and relevant questions that such research could address are: . What are the characteristics of a successful leader in public health in terms of styles, personality, attitudes, and beliefs? . What processes do public health leaders adopt in achieving change?
Developing leadership for health: our biggest blindspot
. What factors seem important in creating and sustaining leadership qualities in terms of their professional life, learning life and personal life? . What critical life in£uences have been important? . Are there di¡erences between leadership styles in di¡erent health systems and cultural contexts? . Are there di¡erences between leadership styles in terms of the stage of development of the public health challenge (for example, pioneers versus settlers)? . Can a theory of public health leadership be developed? . How does this compare and contrast with other leadership theories? . Can the theory be used to distinguish between management leaders and management administrators? . Can public health leadership potential be identi¢ed early on in an individual's career to assist fast tracking of potential individuals? . How could public health leadership potential be identi¢ed at mid-career stage and fostered as part of professional development? . What training approaches should be o¡ered to short-circuit on-the-job learning in public health leadership? . What support mechanisms should be developed for public health leaders to maintain performance and avoid burn out? Sadly we can only surmise about the answers. Such an impoverished situation contrasts strongly to studies of leadership within the private manufacturing sector. The Karpin report reviewed several hundred leadership studies (Craig and Yetton, 1995). Much of the leadership thinking in vogue today comes from this literature. In the absence of alternative sources, it is perhaps not unreasonable that they should be applied to the health ¢eld. The public health scenario, though, is very di¡erent to a line management environment within the manufacturing `for pro¢t' business sector. As we know, the practice of public health is not typi¢ed by vast armies of subservient employees; indeed the line management role in public health or health promotion departments is minimal. Winning political support, intersectoral action and community participation is the major challenge, which our new Reviews Editor, Colin Sindall, touches on in the next article. Performance is built on the ability to analyse, to envision, to
3
communicate, to empathise, to enthuse, to advocate, to mediate, to enable, and to empower a wide range of disparate individuals and organisations. These agents for better health lie far beyond the `known' territory of the health sector and they seldom have any allegiance or accountability to the public health innovators per se. Furthermore, the goals and values of public health are very di¡erent. Responsibility is not to shareholders or even employees, but rather to the general public through an often convoluted and imperfect political process. As a consequence, the balance and nature of skills in `management administration' required for public health will be markedly di¡erent to the manufacturing sector. However, the same may not be the case for `management leadership'. Public health leaders may well have much in common with other leaders, particularly from other values-based social institutions such as political parties, religious organisations and trade unions. The handling of sensitive issues such as organisational^professional con£ict is likely to feature strongly in public health leadership, and similarities may be able to be drawn from other disciplines, for example accountants. But what are the distinguishing features of a leader? There are two major features. The ¢rst is that they are personally responsible for signi¢cantly changing the attitudes, behaviours and actions of a large number of people; and, secondly, that they have achieved these results to a degree far beyond that which would have been expected from a person in a purely hierarchical or managerial position. A continuum of leadership exists from the indirect (non-authoritarian)öthrough `behind the scenes' scholarly work and advocacyöto the direct (authoritarian)öthrough `upfront' communication and action. In public health terms this would mean that leaders would have made an exceptional personal contribution to the improvement of health at a population level by winning support and action from others. Results could have been achieved at local, regional/state, national or international levels in policy and strategies, intervention programmes, workforce development, infrastructures and ¢nancing, or research, development and demonstration. Howard Gardner has recently presented a theory of leadership through eleven biographies of twentieth-century leaders, beginning with Margaret Mead and ending with Mahatma Gandhi. Coming this time from an educational rather than a management background, he considers
4
John Catford
four factors are essential for e¡ective leadership. They are: (i) a tie to a community or audience; (ii) a rhythm of life that includes isolation and immersion; (iii) a relationship between the stories that leaders tell and the traits they embody; and (iv) arrival at power through choice of the people rather than through brute force. Warren Bennis, another of the founding fathers of modern management, in reviewing Gardner's Leading Minds, comments that leaders are `pragmatic dreamers, whose ability to get things done is grounded in a vision that includes altruism' (Bennis, 1996). Perhaps this is where leadership qualities of di¡erent disciplines come together. In considering how we can develop and promote leadership in health promotion, it is necessary to consider quite speci¢cally three di¡erent roles of leadership. As `Creator of vision and strategy', we search: Where should we be heading? Who should we involve? Where are the barriers? What are the critical success factors? Can we `surf' new developments? As `Manager of perception and meaning', we re£ect: Where have we come from? What have we learnt? How do we motivate others? How should we communicate? How do we achieve a win^win? As `Facilitator of organisational e¡ectiveness', we learn: How do we focus on outputs and achieve results? How do we manage change? How can we use people, teams, time and money e¡ectively? Each of these will require di¡erent learning styles and options. Drawing on the lessons learnt from the industrial sector, leadership development components are likely to be diverse and overlapping. They include distance-learning education, workshops, seminars, residential training courses, national and international study visits, development programmes for organisations on site, peer-support networks, and mentoring programmes for middle and senior levels. To encourage participation, courses should be given university award accreditation so that they can be used towards Masters or Doctorate degrees.
A leadership gap is present in health promotion and public health more generally. If no action is taken now the situation can only get worse. This would be the unanimous view of the leadership and management development professionals in industry because of three basic observationsöwe do not understand leadership, we do not research leadership, we do not invest in leadership. As a result, we have a huge blindspot which is already causing us to trip and stumble. As we look over the horizon into the next century, the picture is getting bigger and the terrain is more hazardous. Leadership development could be the critical success factor that we need the most. John Catford Editor in Chief REFERENCES Bennis, W. ( 1996) The leader as storyteller. Harvard Business Review, January^February, 154^160. Catford, J. (1992) Health promoter's survival kit: learn to be smart and quick. Health Promotion International, 7, 1^2. Catford, J. and St Leger, L. (1995) Moving into the next decadeöand a new dimension. Health Promotion International, 11, 1^3. Chave, S. (1987) Recalling the Medical O¤cer of Health. King Edward's Hospital Fund for London, London. Craig, J. and Yetton, C. J. (1995) Leadership theory, trends and training: summary review of leadership research. In Karpin, D. S.(ed.) Enterprising Nation; Renewing Australia's Managers to meet the Challenges of the Asia-Paci¢c Century. Report of the Industry Taskforce on Leadership and Management Skills, Research Report, Vol. 2, Chapter 26. Australian Government Publishing Service, Canberra. Health Care Forum (1994) Lead your community to health. Health Care Forum Journal, May^June, 117^118. Karpin, D. S. (1995) Enterprising Nation; Renewing Australia's Managers to meet the Challenges of the Asia-Paci¢c Century. Report of the Industry Taskforce on Leadership and Management Skills. Australian Government Publishing Service, Canberra. Koop, C. E. (1991) Koop: The Memoirs of America's Family Doctor. Random House, New York. Lawson, J. S., Rotem, A. and Bates, P. W. (1996) From Clinician to Manager. McGraw-Hill, Sydney. Roemer, M. I. (1993) Higher education for public health leadership. International Journal of Health Services, 23, 387^ 400.
