Leadership and Effecting Change in Public Health

Introduction

The concept of leadership has mutated significantly in the recent past. Previously, the barrier between leadership and management was obfuscated, with the two ideas viewed as one and the same. As such, leaders were envisioned as managers who ensured things went according to plan by exercising control over the employees (Hayes, 2014). However, this leadership thought has since been abandoned with clear differences established between the concept and management. Leadership today is seen as a behavior that may be innate or learned, with theorists also recognizing various forms in which it comes in. The present understanding has been sparked by the chaotic nature of systems, with change a commonplace in any organizational context. The contemporary leader is thereby one who effects change and has the necessary skill sets, attitudes and values to guide their followers through normative and change processes. Rowitz (2014) defines a leader as one who inspires others into action while offering guidance to their activities. More importantly, he argues that leadership occurs at five levels: Personal, team, agency, community and the professional level. This paper discusses the team, agency and professional levels of leadership, analyzing key interrelated concepts and drawing parallels between the various levels. 

Team Level of Leadership

It is inevitable that public health professionals will find themselves working in teams at some point. Teams are formed in order to implement a multidisciplinary approach to health issues and problems, where different skills, talents and abilities are tapped into (Rowitz, 2013). Forming teams enables service provision in a comprehensive manner, with different perspectives to a problem addressed. In the simplest definition, teams are groups of people who act towards a common goal (Rowitz, 2013). The need for order, guidance and cooperation in teams is the driver to team level leadership.

A number of change strategies, collaboration and empowerment are required at the team level. As the team leader, it is imperative to offer guidance in change situations. This involves maintaining focus on the mission and purpose of the team and reminding all members of the same (Hayes, 2014). This helps to ensure that the intervening change does not disorient the group and scatter their activities away from their primary goals. Secondly, there is need to communicate with each member equally about the change process and its possible impacts. This is essential for the purposes of overcoming inertia to change and consequently fostering adaptation. More importantly, team leaders must be committed to value based change. Social justice is the overarching value in public health practice encompassing equity and access to care(Amy, 2008). Public health team leaders should guide their followers into confronting political and social systems in ensuring social justice. A balance is however needed between focusing on their core mandate and championing value based change to avoid deviating from organizational mission and vision. In terms of collaboration, the team leader must build social capital within the team members to enhance trust and build cohesion. They should take all necessary steps to create positive relationships between team members and hence make collaboration during tasks seamless. Empowerment is also critical as it gives members the freedom to utilize their talents and skills in the best possible manner, increasing their commitment and overall performance. Empowerment can be realized through organization values and leadership actions. These include providing necessary tools for working in teams and delegating actual power to team members. Other strategies include the use of human resource management tools like bonuses and rewards to motivate team members (Amy, 2008). Similarly, the organizational structure can also empower teams by fostering innovation and offering teams autonomy. Overall, empowerment, collaboration and change strategies are critical to the team level of leadership.

There are evident links between leadership, power, values, and ethics at the team level. Power refers to the ability and possibility to exert influence over events. Laverick (2009) identified several forms of power that including the power over, power with and the power within. Leadership in teams confers almost all the forms of power in question but requires more of the power with, which is concerned with fostering collaboration and building social capital and the power over, which encompasses stamping authority and exercising influence. Power over should be used to enhance power with, implying that team leaders should use their authority and influence to foster collaboration between team members. Values on the other hand refer to an enduring belief that a certain code of behavior is more socially preferable than its direct opposite. Every leader should have their own values that they remain true to. In the same way, teams should clarify their values, communicate them to the members and align their activities to them (Amy, 2008). While values decide what is right and wrong at the personal and team level, ethics are institutionalized principles of morality governing the greater public health sphere. A leader’s values should augment with the team’s for effective performance.  Thereby, values determine leadership performance, which also extends to what type of power is used and how. Leadership use of power then determines whether teams operate ethically or not. This is the link between values, leadership, power and ethics. If leadership is founded on the right values then it uses power to positively influence team members and foster collaboration. How they use power on the other hand determines the adherence to ethics. See Fig 1 below.



Fig 1: The link between values, leadership, power and ethics at the team level. 

There are various strategies for effective change management within individuals and teams. From Kotter’s eight stage model, it is clear that first one has to establish the urgency for change (Hayes, 2014). They should identify the threats or opportunities that necessitate the proposed change and share the same with the rest of the team. Additionally, there is need to form powerful coalitions in the change process. As stated before, the immediate response to change is resistance and thus the change agent will need to work hard and ensure that all stakeholders are onboard. Their support to change guarantees its successful implementation. Other strategies include setting up a vision for the change including underlying values and communicating it clearly. This opens up the path for implementation of the change after which the leader will only be required to overcome obstacles with their team while celebrating their short term wins. Building on the change and entrenching it into the corporate culture will ensure permanence. All these changes should be value based- the leader must stick to their core values and those that underpin the organization. Value based leadership ensures value based change, controversy and crisis management (Contu, 2007). This implies that in the end, though the team would have experienced a shift in structure or operations, it shall remain grounded on their values, vision and mission.  

There are several principles that must be adhered to for proper team governance. These include participation where all team members take part in team activities. Notably, there are different types of team members with some influential, others dormant or dominant (Hayes, 2014). This predisposes the group to participation of the few and non-participation of others, hence requiring a deliberate plan for uniform participation. Elsewhere, there is need for proper accountability mechanisms including a central authority. Team members should be accountable to one another including the leader. Equally importantly, there is need for transparency in decision making and implementation. Apart from following rules and regulations, information should be freely accessible regarding all plans. As Northouse (2015) notes, effective groups build trust based on openness, honesty, respect and consistency which is in essence adhering to the principle of transparency. Another principle is responsiveness, which implies immediate reaction to the needs of various stakeholders. Transparency, accountability and participation are the main principles of governance in team leadership. Others include inclusivity, consensus and the rule of law. 

Agency Level of Leadership

To understand the relationships between leadership, power, values and ethics at the agency level, it is important to delineate its nature first. The agency level of leadership involves controlling larger resources and more people. The public health leader at the agency level is placed at the helms of an entire organization, department and other units as the final authority. This places a number of complex duties and responsibilities on their hands. To start with, they have to fully understand how the agency operates in order to offer adequate guidance. If it is a government entity, private or a non-profit, they have to familiarize with its systems to the core in order to exercise leadership over it. Elsewhere, the large sizes of agencies implies that delegation is more rampant as one cannot be in charge of all duties. Public health leaders must therefore face the infamous leadership paradox: delegating control while remaining in charge (Contu, 2007). While teams are supervised by higher authorities, agency level leadership requires the leader to come up with their own measures of performance while also taking into account client satisfaction. This means that the leader must always find out whether their agency satisfies all the stakeholders involved and meets expectations. More importantly, while teams are formed for a given purpose that they have to stick to, public health agencies monitor new trends and issues and seek to address them. Therefore, the leader has no boundaries of action and may be called upon in new territory all the time.  Generally, the scales of operation at the agency level are broader and more sophisticated.

The relationships between leadership, power, values and ethics at the agency level are manifestly different from the team level. To begin with, leadership is what determines the values of the agency unlike in the team context where a leader has to align their values to the team’s. Agency leaders are responsible for coming up with directional strategies which include the mission and vision statements as well as the values that govern behavior at that level (Rowitz, 2014). Therefore, the leadership is the fundamental block that not only helps in coming up with value systems but also rallying the rest into observing them to the latter. The role of the leadership in crafting and entrenching values is essentialized by the limited control on individual actions that a leader holds at that level. The head of a state department of public health cannot supervise all staff or even the managerial levels. Their best bet is to be an influence and create a culture that is predictable, consistent and in line with the organization’s mission and vision (Hayes, 2014). Thereby, they have to come up with a list of values that govern everyone’s behavior and lead by example in observing them. Such values include integrity, service, commitment, loyalty and so forth. These value sets are overriding and everyone else has to adjust their core values in order to match them. Therefore, leadership precedes values at the agency level of leadership.

Elsewhere, ethics come before power. Operating in an agency level entails the engagement of activities with wide reaching consequences that demands a consideration of ethics prior to exercising power at any point. Agency leadership involves engaging with the community, empowering them and collaborating with them to achieve various public health goals (Rowitz, 2013). Several ethical issues emerge in the process such as maintaining human dignity, confidentiality and acting in their best interest. Without such considerations, the exercise of power at the agency level may be ethically wrong and invoke the wrath of the community and other stakeholders. Being in charge of an agency also places lots of power on the leader for instance in restructuring the organization, offering rewards and bonuses and so forth. Without ethical standards like integrity, abuse of power is likely. Notably, agency leaders may be too powerful to be held accountable by members of an agency and thus their actions may proceed in an inappropriate manner for a long period of time. There is need to have a good grasp of the ethics underpinning their work at all times and appreciate their role in regulating their power. In the end, multiple factors related to the agency level of leadership necessitate proper ethical balances prior to exercise of power. 

More importantly, leadership is built on core values and ethics. There should be a distinction between core values and organizational values in this respect. The core values are attached to the leader and govern their behavior at a personal level. They may entail compassion, integrity, determination, service among others, and such are what propels someone into leadership through their ethical adherence (Contu, 2007). Depending on the core values of a public health leader at the agency level, it is possible to predict whether they can be ethical leaders or not. The high stakes in agency leadership often require proper scrutiny of core values and ethical grounding of a person prior to them attaining leadership positions and exercising power. Therefore, public health leaders have to possess the right core values, which then lead them into ethical grounding and becoming the ideal leader. It is only at this point that they can exercise power correctly in their areas of influence. The crux of it is that agency level leadership offers access to lots of power that cannot be accorded to persons with no character and values. The link is therefore core values-ethics-leadership-values-power. Notably, organizational values come right before power as they offer extended guidance on how affairs should be conducted at the agency level (Fig.2 below). 


Professional Level of Leadership

Public health leaders are also required to contribute towards the furtherance of the profession. They should undergo professional development, allow employees to enjoy the same, belong to professional bodies and run for office in such bodies. This is what entails that professional level of leadership. Further, they should allocate both material and non-material resources like time in the building of their professional knowledge and that of others.

The relationship between values, ethics, leadership and power are evidently quite different from those at the team, agency and community level. At the professional level, leadership and power are largely driven by an individual’s core values. Unlike team and agency level where there are practical benefits of leading and yielding power, professional leadership may be more of volunteering and thereby instigated by one’s own desire to make a difference (Rowitz, 2013). The power held in that position is less of the power over and more of the power with, given that leadership basically entails bringing public health practitioners together and chatting the future of the profession. Therefore, the core values are the basic driver to leadership and power at the professional level, without which there may never be an attempt at leadership. Important to note, many public health leaders and organizations downplay the value of professional development and deem it as a waste of resources. This is because belonging to professional organizations and other duties associated with the same are not obligatory but are rather driven by intrinsic motivation (Hayes, 2014). Elsewhere, values and ethics are drawn from power at the professional level. Professional bodies come up with regulations, codes of behavior and values that govern the conduct of their members. The evident difference between these interactions at the professional level and Rowitz’s (2014) other levels are that the professional level does not espouse linear relationships. Core values inspire one to seek both leadership and power, from which power allows one to draw ethical standards and values. The relationship between power and leadership on the other hand is reciprocal. One becomes a professional leader through the power they acquire from their skills and abilities to lobby for top positions, while the power to enforce leadership values and ethics is born out of the leadership role. The illustration is as in fig 3 below:


Fig 3: Relationships between power, ethics, values and leadership at the professional level. 

Rowitz’s (2014) five levels of leadership include the personal, team, agency, community and professional levels. The professional level stands out for having reciprocal relationships between power and leadership as well as not having a hierarchical kind of sequence in as far as the relationships are concerned. Core values equally contribute to power and leadership creating reciprocity between the latter facets. 

There are several strategies that can be applied for effective change management at the professional level. The best change management model to examine in relation to the professional level is Lewin’s unfreeze, change and refreeze model (Hayes, 2014). This involves beginning by dismantling the status quo. In the present day, professional development is not considered highly in public health contexts. Many practitioners exist without joining public health professional bodies or attending courses that contribute to their growth. Therefore, the first strategy is to explain to all why the status quo cannot continue and why there is need for professionalism in public health. The advantages of professionalism should be laid bare and adequate prepping accorded to all professionals in preparation for a new practice. This entails use of effective communication strategies to ensure that there is persuasion. Stakeholder support is also needed at this point in order to strengthen the voices of change in the public health domain. Once this is done, practical shifts should be initiated including assigning resources for professional development for all in the public health sector and making it mandatory to undergo such endeavors to gain promotions and other advantages. During the change process, there shall be lots of negativity and suspicion from forces of discontent (Contu, 2007). The management should be keen to dispel rumors and communicate directly and honestly at this point. This change should then be institutionalized by ensuring that it becomes the new norm of public health practice. Reward mechanisms can be used to ensure its permanence while other supportive mechanisms must also be identified and emphasized on. More importantly, successes should be celebrated to normalize the new professional framework.

The latest level of leadership from Rowtz’s (2014) model is communication. This entails being able to be frank about one’s strengths as well as weaknesses in the presence of others in order to help achieve improvement. It is important to note that as leaders, public health professionals must commit to lifelong learning, expanding their skills and abilities (Hayes, 2014). There are no better learning opportunities than those within, with the actual experiences in the profession able to develop them better as leaders. Leaning from one another offers practical experiences from the field and expert viewpoints on how to improve rather than mere theoretical insights offered by some trainings. Some of the change management strategies that can be used in enhancing communication in public health include developing forums and structured avenues for public health discussions, making use of journals, newspapers and other platforms to share experiences and above all inculcating a culture of knowledge sharing amongst public health leaders. This shall help in actualizing the communication level of leadership in public health.

Conclusion

Clearly, the concept of leadership has endured significant transformation in the present day. Apart from being viewed as a behavior that can be nurtured and a change management tool, public health has envisioned six levels upon which it occurs. At the personal level, one is required to develop their leadership qualities and nurture the right values. This is the fundamental level at which leadership occurs. The team level requires skills like negotiation, consensus building and accountability. Public health leaders may also be called to lead at the agency, community, professional and communication levels. In all these contexts, they should be careful to understand how leadership interacts with values, ethics and power. Each level has distinct interactions that should be well understood. More importantly, there is need for acquiescence with change management strategies that apply at each level of leadership. 

References

Amy, A. H. (2008). Leaders as facilitators of individual and organizational learning. Leadership & Organization Development Journal, 29(3), 212–234.

Contu, P. (2007). Health promotion and health services. Management for change.

Hayes, J. (2014). The theory and practice of change management. Palgrave Macmillan.

Laverack, G. (2009) Public Health: Power, Empowerment & Professional Practice. London. Palgrave Macmillan.

Northouse, P. G. (2015). Leadership: Theory and practice. Sage publications.

Rowitz, L. (2013). Public health leadership. Jones & Bartlett Publishers.

Rowitz, L. (2014). Public health leadership: Putting principles into practice (3rd ed.). Burlington, MA: Jones & Bartlett Learning

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