Leadership and Management
By Joseph Dwyer and Sara Wilhelmsen
A broken health system is a silent killer. People get sicker and die in disproportionate numbers just as they do during an epidemic. Yet the culprit is not lack of knowledge. Nor is it always a shortage of funds. Technically and medically, we know what to do to reduce illness and save lives. But what is sorely amiss is the dearth of knowledge and skill to manage these very complicated health systems. Dr. William H. Foege sums up the issue as "global health waits expectantly for management to match its science."
Simply put, global health initiatives must recognize the critical need for investing in the leadership and management skills of those running health systems. Doing so is a key step in getting countries back on track towards making progress on the ambitious Millennium Development Goals (MDGs). More important, it is essential if countries are to meet the health needs of their own populations and ensure the sustainability of long-term health interventions.
Linking leadership and management to results
Building the management and leadership capacity of health care managers and practitioners is an important step in improving service delivery. When leadership and management are strengthened, the rewards for the health system are high.
In Brazil, for example, the Secretariat of Health of Ceará mandates that public servants receive leadership training to apply for management positions. This process has broken the mold of just promoting people, prepared or not, to leadership positions. The improvement in health results was significant, illustrating the link between transparency, governance and health outcomes. In one municipality, infant mortality dropped from 26 to 11 deaths per 1,000, while the percentage of women receiving pre-natal care increased from just over 50 percent to 80 percent. Overall, 70 percent of the 25 municipalities that participated in the leadership development process were able to reduce their infant mortality - some by as much as 50 percent.
In order to establish a link between the strengthening of management and leadership practices and the strengthening of health systems overall, as was seen in Brazil, those working in the health sector at all levels - governmental, institutional, academic and other - must commit themselves to the monitoring and evaluation of data that validates this connection.
Although performance planning and evaluation systems and performance-based financing mechanisms are gaining popularity as ways of holding managers accountable for results, measuring the impact of leadership and management has been a major challenge. A breakthrough related to this challenge has been a change in thinking from seeing improved leadership and management as a means to an end, not an end unto itself. True measurement of leadership and management capacity can be undertaken when those working in health systems have the expertise and capabilities to clearly identify their challenges, mobilize resources, select meaningful indicators, and measure results.
When we look at health leaders and managers as a critical part of the workforce and plan for them accordingly, we will go beyond the skills of medical practitioners to the skills of planning, motivation, procurement systems, and accountability for results (including monitoring and evaluation) that are fundamental in making a health system effective.
Investing in Leadership and Management
High-level efforts by the U.S. Agency for International Development (USAID), the World Health Organization (WHO), the Rockefeller and Gates Foundations, and others have shed light on the importance of investing in leaders to strengthen global health systems. WHO's three-country study of South Africa, Togo and Uganda provides insight into the challenges faced by health managers. Fortunately, many are acknowledging the need for change and taking action. At the country level, the ministries of health in Kenya recognize that effective leaders and managers are the foundation to achieve both Kenya's National Vision 2030 and the MDGs for health. This had led to a systematic, intensified reform process and new policies requiring leadership and management development for those entering the health sector.
It is this kind of country ownership and action paired with investment by the global community that shows the potential to produce more effective health systems. Countries have a responsibility to develop and support policies that address health leadership and management at all levels and in all aspects of the health system. Donors have an accountability to ensure their approach will influence positive change and deliver results.
What does building leadership and management capacity look like?
Government mandates such as Kenya's, and regional resolutions for improving leadership and management such as the one drafted at the East, Central and Southern Africa Health Minister's Conference in 2009, are one approach to building leadership and management capacity. Integrating a focus on these areas into the earliest stage of a health worker's career - while they are still preparing to join the field - is another. Four universities in Nicaragua have been taking this pre-service approach over the past few years. Another method is offering those tasked with leadership and management responsibilities professional development opportunities, such as ADRA International's Professional Leadership Institute, which offers in-service trainings once a year to health sector workers in Africa, Asia, and Latin America.
In order to understand the benefits of building capacity through these approaches, perhaps it is best to start with what happens in the health system when people lack these skills. It has been well-documented that poor leadership and management result in low staff morale, high staff turnover, and unacceptable levels of vacancy, all of which waste financial and human resources. More recently, it has also been documented that a shortage of doctors, nurses and allied health professionals does, in turn, lead to higher maternal and child mortality.
One example of how investment in leadership and management can make a difference in even the most challenging of circumstances comes from Afghanistan. There, the ministry of public health works to strengthen the leadership and management of the central and provincial levels by making managers more aware of their role as stewards of the health system. Under a program supported by USAID, more than 1,800 health professionals throughout 13 provinces have been reached, with gratifying results. These managers have been able to increase vaccination coverage and access to family planning services, resulting in improved child and maternal health. The most significant improvements: an increase of almost 70 percent in health facility births and a 28 percent increase in family planning consultations.
These examples show how all levels of the health sector recognize the great need for leadership and management as well as illustrate that models for practical preparation do exist.
Conclusion
We potentially face billions of dollars in wasted resources if the people who drive the health system have not been prepared with the management and leadership skills to take proven medical programs and practices to scale. The evidence for the critical role of leadership and management in closing the gap between what is known about public health problems and what is done to solve them is clear. Policies that support leadership and management at every level of every initiative, organization, government agency, hospital, and university to prevent needless deaths are needed and the time is now. If we are going to make a difference in global health, we must invest in leadership and management.
Joseph Dwyer is the director of the Leadership, Management & Sustainability Program at Management Sciences for Health (MSH). Sara Wilhelmsen is a senior program officer in MSH's Center for Leadership & Management.
It is true that, effective leadership is essential in all sectors of health. When it comes to non communicable diseases management it is a fact that physical activity is to be encouraged very scientifically. The problem of CVDs in future years is threatening. But, the countries are not investing in creating right kind of leadership in physical activity area. It is very clear in India, where the status of physical education is very low and the government also is not serious in this area. People need to be given enough knowledge on the area of physical activity. It is my view that the Global Health Organisation should concentrate specially on some countries where the physical activity is not encouraged or rather not programmed properly. Please think to organise special symposia on the world Health Organisation’s documents like ” Diet Physical Activity and Health” “Future Burden of Health”.
Kindly examine this request of mine and do the needful.
with regards
dr rajasekahr.
— Dr.K.V.Rajasekhar on 2010-01-26
A thought provoking article which applies equally to all health systems regardless of country, availability of infrastructure or level of development. As a manager within the UK National Health Service I recognise everything described within our own system, building capability and capacity in management and leadership can only be a good thing, particularly when direct links are drawn to health outcomes. This is frequently overlooked and effective infrastructure management is seen as a bureaucratic waste of money which gets in the way of providing “real” healthcare.
— Kate Turner on 2010-02-12
As an ophthalmologist who has worked in prevention of blindness in Africa for 20 years, I have seen the futility of much of the clinical training that figures so prominently in wish lists and budgets. What use to train nurses, primary care workers and others who work unsupervised and without basic supplies? What use to train doctors who do not have the support necessary to deliver services?
— Susan Lewallen, MD on 2010-02-16
Very insightfull article thank you very much. I am currently doing my Masters Degree at the university of Pretoria in Advanced Nursing Management and your article is extremely relevant
— Dorette Kotze on 2010-02-17
Highly informative article. A physician with the PEPFAR AIDS Prevention Nigeria Project, I look forward to attending an MSH training. Didn’t make last year’s listing
— Abiola Ogunenika on 2010-03-09
This aspect is critical for HS performance indeed. There is the need to disseminate existing modules and materials. The Managers who Lead is an comprehensive and fine tool but the opportunities and logistics to utilize it is usually a challenge.
— lucy lopez on 2010-04-20