The need for effective leadership in global health is well acknowledged today, even if there is still heated discussion about what constitutes the ‘right’ kind of leadership. Although we may know leadership when we see it, it is more difficult to analyse and define explicitly. Within leadership studies, it is generally accepted that effective leadership constitutes inspiration, creativity and commitment in action. It is, first and foremost, an attitude and not necessarily restricted a rank or position of authority.
The need for inspirational and effective health leadership is by no means a new concern. It was prominent decades earlier in the drive for Heath for All (HFA) by the year 2000, and as part of the primary health care (PHC) model of health care adopted at the International Conference on Primary Health Care held in Alma Ata, Kazakhstan in 1978 (commonly known as the "Alma Ata Declaration"). Indeed, the Alma-Ata conference called for leadership at various levels including professionals and institutions, governments and civil society organizations, as well as communities and grassroots organizations. The ambitious programme held that HFA could only be achieved through concerted and collaborative action.
What challenges to effective HFA leadership did the WHO anticipate? What kind of leadership did it envisage, and what did it end up with? The WHO Iris portal (an online accesspoint to the WHO’s published material since 1948) contains material which enables us to dig deeper into such questions. Whilst this comes with the obvious caveat that Iris contains mainly official records deriving from WHO workshops, conferences and publications, these often comprise very candid assessments of entrenched problems which can be used to help better understand the leadership concerns in the final decades of the twentieth century.
For instance, we find that the WHO only turned seriously to the question of HFA leadership almost a decade after the Alma-Ata conference. The need to develop leadership capacity appeared ever more frequently in WHO reports and regional meetings, and in response in 1985 the Director General instigated the HFA leadership development initiative. A year later the proposed programme budget of WHO 1986-1987 defined six major objectives which included ‘the building up of a critical mass of health-for-all-leaders’.[1]
One of the chief features of the PHC model was close collaboration between communities and health systems, based on mutual decision-making. Community health workers were envisaged as the go between, and whilst this required effective management, it also depended on effective leadership: PHC needed ‘teamwork’, but also ‘team leaders’.[2] 1986’s ‘Leadership for Primary Health Care’ publication (http://apps.who.int/iris/bitstream/10665/37339/1/WHO_PHP_82.pdf) constituted one of the first attempts by the WHO to research the qualities of leaders and the functions of leadership. Highlighting the important role of community health workers and based on twelve case studies, this publication worked with a broad meaning of leadership and was ultimately intended to be used to help countries achieve improved leadership for their PHC programmes (http://apps.who.int/iris/bitstream/10665/37339/1/WHO_PHP_82.pdf).
Between 28-30th October 1987, the WHO’s Director General, Halfdan Mahler, hosted a Director-General's Round Table on ‘Leadership Development for Health for All’ in, Brioni, Yugoslavia. The aim of this workshop was to discuss fundamental questions including: What is leadership? What drives and motivates leader? What are their values?, and, crucially, what issues or gaps are there in HFA leadership, and the future scenario of HFA Leadership? The resulting document, available on WHO Iris (http://apps.who.int/iris/bitstream/10665/60382/1/WHO_HLD_88.1.pdf) contains the frequently frank thoughts of Mahler and his fellow speakers in terms of the challenges facing HFA.
Hot on the heels of this meeting was another ‘round table’, this time gathered together and published in the WHO journal ‘World Health Forum’. Acknowledging the need for leaders to give the HFA movement momentum, in 1988 the World Health Forum asked eleven leaders to discuss leadership characteristics as well as how they approach and tackle their problems (http://apps.who.int/iris/bitstream/10665/49197/1/WHF_1988_9%282%29_p147-174.pdf). Although the avowed aim of such roundtables and discussion groups was to create practical aides and training tools, in each case there is a powerful sense of diversity of opinion, especially when the questioning moved from ‘what is leadership’ to ‘what is HFA leadership’. Whilst there was general agreement regarding importance and qualities, there was no model of leadership.
On Universal Health Coverage day 2017, questions about effective leadership on HFA are once again under the spotlight. It is worth reflecting not just on how far we have come in developing materials and strategies to bolster leadership for health for all, but also to remember that this role is not confined to those in traditionally recognised positions of power. Health for all requires leaders at all levels.
Alexander Medcalf
[1] http://apps.who.int/iris/bitstream/10665/37339/1/WHO_PHP_82.pdf. 3.
[2] http://apps.who.int/iris/bitstream/10665/37339/1/WHO_PHP_82.pdf. 2.
