Strategic Management and Leadership for Health Professionals — Skills To Leverage Resources To Achieve Health Goals

Abstract

Introduction The recent approach to healthcare considers the broader determinants of health to improve population health. One is able to positively impact health goals only when these are addressed through multi sectorial coordination.(1) Marc Lalonde in 1974(2) was among the firsts to elaborate the need to look beyond health care organizations to impact health. His report paved the way for an international debate on the role of non-medical determinants of health, including individual risk behavior setting the tone for a new public health discourse and practice in the decades to come.(3) Lalonde's framework groups health determinants in four areas [Figure 1]. There are different weightages assigned to contribution of the four areas to population health. Behavior contributes to around 50%, Environment around 20%, Biology around 10% and health care 20%.(4) There is no data from developing countries on contribution to health by these four broad areas but environment with lack of safe water, sanitation, lack of safety standards at work place and home is likely to be a larger contributor to health. Health system is certainly not a major contributor to population health. Figure 1 Four domains of determinants of population health While the traditional patient-health care provider driven approach held the health professional within the realm of health sector where the majority of time was spent to operationalize mechanisms for disease-centered care. Rampant surge of non-communicable diseases requires a boarder action that promotes good health. The current disease scenario seeks the health professional to look beyond the health sector. After achieving the eradication of small pox, polio and elimination of Guinea worm, and substantial reduction in HIV/AIDS, Leprosy etc. in India, it is now required to move ahead and look at health in a comprehensive manner to achieve sustainable and equitable improvement in health. In India, non-communicable diseases (NCD) account for 60% of deaths followed by communicable, maternal, perinatal and nutritional diseases (28%) and injuries (12%).(5) The root causes of all these diseases are - lifestyle and pollution for NCDs; inadequate water and hygiene etc. for communicable diseases; malnutrition, illiteracy and lack of resources to access timely health care for maternal child health conditions; and unsafe vehicles, houses and road conditions for accidents. It is clear that prevention of deaths in all four major groups of diseases can be done only if other sectors are adequately engaged and the health sector is involved in providing excellent medical care. Thus, the new approach requires policy makers across all sectors to be realize the consequences of their decisions on health and be accountable for population health.(6) Similarly, health ministers, policy makers, health systems scientists, program implementers and other health professional should actively engage with other sectors while continuing with efforts in traditional disease control approaches. It demands for a new skill set where the health professional in his new role interacts with key influencers in other sectors to make decisions that do not lead to ill health and improve health. Influencing others, identifying windows of opportunity, art of advocacy, negotiation and networking form the key skills for a health professional to achieve health goals through multi-sectorial efforts. Last thirty years have also seen a global surge to use health promotion approach to improve health. Health Promotion can be used effectively to address both communicable and non-communicable diseases by going beyond boundaries of health sector.(3) Influencing Others As one moves up the ladder of leadership, one's priorities need to shift from doing own work to managing team and spending more time in networking. In public health, the team leader interacts with other health professionals, bureaucrats, politicians within the Ministry of health and other ministries. One is required to influence and convince them to be able to generate interest in health and actions required. This also gains prospects for his team to positively impact policy making or implementation of a program to improve health of the population. This helps in better planning and execution where the team's goals are aligned with the current needs of the society. In addition to technical knowledge and analytical skills, good communication skills and networking help in advocacy. The ability to visualize future scenario, identify windows of opportunity and negotiation skills further drive the leader towards success. Identifying windows of opportunity Identifying windows of opportunity is the key to influence the policy environment and decision makers within and outside the health sector. A leader should identify opportunities, take advantage of these and engage in activities involved to achieve goals. Some examples of such opportunities in India are presented below: The New health and education policies are being drafted. These present several opportunities to engage people from various organizations/capacities to provide inputs, especially on the role and responsibilities of other sectors in improving health. Like education Policy should include healthy life style education in school children. Pre-service and In-service training of bureaucrats, public health professionals, social sciences and related sectors. New legislations: New Public Health Act being drafted Outbreaks: Any outbreak of disease gets more attention of politician, bureaucrats and media for example, water borne diseases such as Polio, Dengue, Jaundice, Cholera can be used to leverage action in water supply and sanitation; Flu to promote hygiene and dengue to mobilize municipalities, corporations and local self-governments for health starting with elimination of mosquito breeding within and outside households etc. Professional bodies of health and related professions: The potential of these professional bodies is underutilized. They hold regular conferences and bring out journals where these aspects can be highlighted especially in the sessions attended by politicians and bureaucrats. Political agenda: ‘Swachh Bharat Abhiyan’, for example, is an opportunity to push for universal safe water and sanitation and will go a long way in preventing common diseases. ‘Swachh Hospital Abhiyan’, as part of this campaign builds on this opportunity to eliminate hospital acquired infections. Health Impact Assessment unit needs to be established in the Ministry of Health and Family Welfare and empowered to review the impact on health of all projects in all other sectors Advocacy Advocacy is essential for every health professional to promote effective interventions to address public health problems. Advocacy is the act of pleading or arguing in favour of something. It highlights to change the “what is” into a “what should be".(7) It is a process adopted by an individual or a group to influence policy and resource allocation decisions within political, economic, and social systems and institutions. Advocacy can include many activities that a person or organization undertakes including media campaigns, public speaking, publishing research etc. The information for advocacy can be packaged in many ways including the following depending on the audience: Press Release, Fact Sheet, Power Point, Website/Internet, Television/Radio spots, Article in newspapers, magazines, Research Update, Policy Brief, White paper, Talking Points, research Summary, Publication in Journal etc. One opportunity often missed is short encounter with an important person such as a minister or a top bureaucrat. We can use these opportunities to convey a message effectively. This is often referred to as ‘one minute’ message. A one-minute message includes: The statement of the issue, Evidence to support the issue. An example of the problem, the desired policy action ideally, only one main point should be communicated or, if that is not possible, two or three points at the most. Negotiation Negotiation is a common everyday activity from birth till death. It is a process by which we attempt to influence others to help us achieve our needs, while at the same time taking others’ needs into account. It is a fundamental skill, not only for successful management but also for successful living. This important skill is essential while negotiating to include health action in other sectors.(8) The suggested steps for a successful negotiation: Identify your own goals, priorities and bottom-line before you negotiate Identify your strong points and weak points in negotiation Find out and understand other person's or party's agenda and priorities. Try to accommodate these without compromising on yours. Clear message of what you want and why? How it will best appeal to the person you are negotiating with. Identify the possible outcomes and practices to deal with unfavorable outcome Be prepared to deal with deadlock by revisiting your own priorities and other person's priorities and start with pointing out areas of agreement and move to negotiate areas of disagreement. Networking Networking is a force multiplier in your advocacy efforts to achieve your professional and personal goals. You can do much more through your effective, relevant contacts in your network if you cultivate and sustain it. Networking is the exchange of information or services among individuals, groups, or institutions; specifically: The cultivation of productive relationships for employment or business.(9) Ability to network is becoming more and more important. Maintaining good relations fosters trust and fidelity commitment.(10) Virtual Networking: Internet has made networking very easy. Various professional and social networking sites such as Linkedin, Facebook, Researchgate, Blogs, Twitter and e mail need to be used effectively to reach out those in your and your contacts network easily and fast to communicate and mobilize like-minded persons and groups. These networks help in: Establishing new contacts (both individuals and groups). Keeping in touch with old contacts especially those in distant places in other cities and other parts of the world with whom you may not be able to maintain face-to face contact. Researching potential contacts who may add value. Face to face Networking: Strong way of making new contacts and effectively maintaining old contacts. Attributes that help in networking: Listening skills focus on others, empathy and intimacy Understanding body language: Ability to observe and interpret body language of others Open attitude to new ideas which should also be reflected in body language during the interaction with others. Creating a positive atmosphere: According to Market Watch, more than 85% of success comes from the ability to create good atmosphere and only 15% from professional competence. Practice and deliver an effective message in short time say in one minute or a small talk to cash in the opportunity of casual short encounters with influential persons such as a politician or a bureaucrat. Networking is an arrangement where several individuals or organizations share a common interest. The main activity is information sharing and facilitating. Well-functioning networks usually have an efficient “node” or secretariat. There are three forms of networking. The first helps manage current internal responsibilities, the second boosts personal development, and the third opens one's eyes to new directions and the stakeholders one would need to enlist [Figure 2].(11) Figure 2 Three forms of networking based on what you want to achieve Netweaving Networking has long been cited as an effective means of making new professional contacts and as a way to expand career horizons. Now there's a new twist to this long time career tool-Netweaving. Netweaving is a concept focused on more effectively developing reciprocal business relationships that has far-reaching potential. In Netweaving, the focus is on “How can we help each other?” and the approach is more relaxed and reciprocal.(12) Other Important Skills/Concepts Three pillars of leadership It important for leaders in health care to continuously upgrade their skills in three domains which are Technical: The health sector is dynamic and it is important for a leader to keep updating his technical knowledge. Cognitive: A leader is required to learn new skills to deal with technological advances and keep pace with emerging technology such as using social media to strengthen and retain his networks. Emotional competencies: Emotional competencies contribute to improved professional performance and determine success in life. It also important for one to have a good family and social relationship.(13) Emotional competencies can be learned at any age in life. To be a successful leader one needs to regularly review one's emotional competencies and improve these by learning from interactions one could have done better. Managing difficult colleagues One always comes across people who are difficult to deal with. A leader has to get work done from all his team members, hence must deal with such people effectively. A difficult person is anyone who causes anyone else irritation, upset, stress or anxiety. There are three levels of difficult persons;First level - are difficult some of the times and it includes almost everybody; Second Level - when a person's behavior affects more than one person on a regular basis; Third level - includes persons who purposely hurt or harm others through their behavior. Such persons are rare but really test your skills when you come across them.(14) Difficult colleaguescan be dealt by sharpening the following skills: Separate person from problem. Practice to keep your focus on the problem you are discussing and not on the person. If you keep your focus on the person, even non issues will become issues. Agree on parameters with the person Agree with the person what are the issues that need to be addressed and resolved. Focus your conversation on logic and issues. Look for options that will be agreeable to both of you. Managing 360 degrees Successful leaders and managers manage in all three directions at the same time; downwards- their subordinates, upwards - their bosses, and horizontally - their peers. This is referred to as managing 360 degrees. The skills of managing team always receive attention in most training courses on leadership. The skills of managing up and across are very often neglected. These skills are equally, if not more, important to succeed.(15) To reach leadership position and become an effective leader one must acquire skills to manage 360 degrees. Walk the talk A leader is always under watch by his team and peers. Every step you take, every word you speak, your body language and behavior are under continuous observation. As a leader one is asking his team to have some values and skills. He has to demonstrate these in his day-to-day work and behavior and only then others will take him seriously. Conclusion The three domain model, based on leadership theories, gives a good insight into areas requiring attention in learning leadership skills.(16) All three domains [Figure 3] need attention at every level of career. However, as one moves up in hierarchy, the priority shifts from managing self to devote more time to managing teams and when at the top managing with an eye on what is changing in health and other sectors. In the first domain address skills for managing self(12) and in the second domain the skills of building and leading teams,(17) managing bosses and peers.(14) The third domain includes change management skills(18) and this concluding article covers leveraging your contacts to achieve your goals and other skills such as managing difficult people, concept of 360 degree leadership and need for the leader to walk the talk. Figure 3 Three domains leadership capacity development model Recent understanding of health determinants outside of health sector contribute much more to health and there is a need for public health professionals to convince their peers, administrators and politicians within the health sector to influence other ministries and departments to address these determinants to achieve sustainable improvement and inequities in health. The inequities in health are due to underlying causes such as poverty, lack of water and sanitation, livelihood etc which are essentially in sectors outside health. The health professionals while continuing to advocate for more resources to improve health care need to get other ministries, sectors and departments at all levels to take actions for improving population health. To do this they must acquire skills to identify and use ‘windows of opportunity’, advocacy, networking and negotiation.