Dynamism and change / by Aldo Neri

Dynamism and change 11 In short, health's hour strikes when the political clock shows that society is ready for global change, to the degree and in the direction that each national culture and circumstance determine 11 T here is no simple way of un-derstanding the role of lead-ership in health service re- forms. Little is available in the way of specialised analytical studies on the subject, and opinions tend to be based far more on observation of specific experiments in institutional change, or on the direct partici- pation of the holder of the opinion in such processes. The necessary subjectivity of these views does not detract from their interest nor invalidate the conclusions, but it does limit the possibilities of extrapolating them to different contexts. Let me stress at the outset that various types of leadership are pos- sible in the health sphere , depend- ing on the level within the health system at which we are considering the possibilities and difficulties of a process of reform. The local level of the health services is one thing and the global level of the system in question is quite another. Nonetheless , there are certain general types or categories of lead- ership which , at some risk of over- simplification, can be identified and are found at the various levels of the health system, though of course they have varying degrees of influence or impact upon its development. There is firstly what I shall call bureaucratic leadership, which de- rives from the position held by the person concerned in the organi- zation and the degree of power that it confers on him. On that will depend , to some extent, his or her ability to induce or inhibit changes in that organization. But let us try to get our concept of leadership in general a little clearer. Leadership exists where there is an ability to convince W ORLD HEALTH , April 1988 by Aldo Neri others and to get them to follow. It is the convincing that makes the real difference between leadership and the mere exercise of authority. This is no small distinction : some things can be changed by invoking obedience, but it rarely brings about the sort of far-reaching changes that really affect the run- ning . of an organization like the health service, where so much de- pends on human attitudes. Leaders who push think that they are facilitat ing process, when in fact they are blocking process.. . They think that their leadership position gives them absolute authority, when in fact their behaviour diminishes respect. from The Tao of Leadership Tzu Conversely, authority without leadership is often more than suffi- cient to repress any aspiration to re- form. In brief, we might say that he who inspires conviction in others has the power either to generate or to neutralise change , whereas he who only induces obedience is much more effective in inhibiting change than in bringing it about. A second form to be considered is what we might term prestige leadership. Essentially this is pro- fessional leadership, operating in- ternally within the various profes- sions; but its archetype, in view of its impact on the health service as a whole or on any local part of it, is medical leadership. The structure of the health sector has sometimes been caricatured as a "feudal caste system," both as regards the relations between dif- ferent professions and as regards the internal relations specific to each profession. To put it another way, the interests and values of those who attain the highest rank and distinction in each profession are accepted as the doctrine and viewpoint of that profession by the public at large , and even more so by other political sectors. The health professions- medicine in particular-vaunt an unchallenge- able aristocratic precedence over the others, while the differing social origins of those who hold certain posts oblige the health sector to reflect the social power structure prevailing in each country. Matters are made worse by two tendencies that are widespread in the medical profession: its conser- vative bent with regard to the prac- tice of medicine, and its frequent acceptance of the fallacy that changes which are good for physi- cians are also necessarily good for people's health and happiness. An extreme example of this attitude is the time it took to replace the old delivery bed , designed for the mid- wife 's convenience, by the present- day bed , designed for the birthing position which many primitive peo- ples already knew was the most suitable one for a woman in labour. A third model of leadership is es- sentially political in nature. What counts in this case is not so much direct authority exercised in the health structure, nor the prestige of professional opinion, but the fact of exercising power in society, in a context wider than just the medical field. This model can often be com- bined to a greater or lesser degree with one of the other two cited here . Nothing prevents the high- rank official and the prestigious physician from also wielding a more 9 global form of political power in their own community, but for the present let us try to distinguish what is peculiar to each individual attribute. As an example of this kind of leadership we might take Dr Fidel Castro, the President of Cuba, a political helmsman with views of his own in the health sphere , who initi- ates and carries out specific changes in the system. But there are other equally authentic though less prom- inent instances. They are to be found notably in countries that have a tradition of community in- volvement in health service man- agement, through lay people who enjoy a high social and political prestige in their own circles and who form boards or other non- bureaucratic bodies for partici- pation in the health system. The United Kingdom and the United States are examples of this model. The foregoing will suffice to give a schematic picture of the most ob- vious ways in which persons or small groups exercise, for good or ill, effective leadership in the health system. Let us go on now to consid- er the question of what conditions can actually help to bring about 10 those changes in the system that will benefit the community in gen- eral, by creating a context in which positive leadership can yield its fin- est fruits. Those conditions depend both on factors intrinsic in the health services themselves and on other factors that affect and typify society as a whole. Among the former, there can be no doubt that major technological innovations offer major opportu- nities to bring about qualitative and quantitative changes in the delivery of health services. The modern che- motherapy of tuberculosis is still one of the most obvious examples of this. How much benefit can result from these factors that are internal to the system will depend to a huge extent on those other factors that operate in society as a whole. There are periods when the majority of in- dividuals in a given society, or at least the main sectors of power that control it, lack all aspiration to change and are sunk in a sluggish conformity that greets with hostility any innovative proposals put to them. Such an attitude is engen- dered both by the kind of wide- spread prosperity seen in many de- Nurses in training in Peru. "Leadership exists where there is an ability to con- vince others and to get them to follow. " Facing page: A traditional midwife in El Salvador gets a practical lesson in hygiene from a public health nurse. Photos WHOfT. Feynes and WHO veloped countries, and by the polit- ical dominance which closed mi- nority groups exercise, in many under-developed countries , over majorities which have neither real representation nor an informed awareness of the true situation. In either of those two cases, the health service will be strongly shaped by the corporate interests represented by professional bodies , industrialists , health-related enter- prises, trade unions with privileged social welfare schemes, business groups, and all the technical and administrative bureaucracies of the state and the social security system. In such circumstances the tendency to maintain the status quo is very marked, because often the indi- vidual sectors have insufficient power to make major changes but enough to frustrate any attempts at change by others. The result is a per- W o RLD HEALTH , April 1988 petual stalemate , with every group invoking the higher interests of the health of the people , while giving priority to its own sectional inter- ests. Only occasionally do those sets of interest coincide. Then there are times in the life of a society when the community is open to the spirit of innovation. This may be encouraged by revolu- tionary political situations-not a very frequent occurrence-or by some major global crisis that per- suades people of the need to clear away old structures and promote new attitudes. This felt need for change is contagious, spreading throughout the social fabric. And that is just when the political lead- ers should include health slogans in their innovative platforms. Let us not forget that , in normal circumstances, health is not a very paying proposition for the political leader. It is almost impossible to keep both the popular majority and the power interests satisfied. More- over, reforms in depth tend to pro- voke too many conflicts in the early stages , whereas their benefits are only felt in the longer term. In short , health's hour strikes when the political clock shows that W ORLD HEALTH, April 1988 society is ready for global change, to the degree and in the direction that each national culture and cir- cumstance determine. And in that context the best health leadership, at whatever level , will be the lead- ership that is most consistently im- bued with the spirit of political change which is motivating society at that moment in history. We must bear in mind that Latin America is going through a period of severe crisis. What is more , owing to the widespread failure of authoritarian solutions, a majority of countries are now looking to the democratic system as the key to their future. Their social ineffec- tiveness, and the inefficiency of many of their economic, social and political institutions, cry to heaven for reform. Many countries have embarked on that reform or are about to. The debate on reform of the health system must be conduct- ed in the conclaves of the political parties as well as in the usual corpo- rate and academic circles, since it is largely from the political parties that will emerge the dynamic lead- ership we need if we are to succeed in promoting the health of our peoples. • A mental_ health component l?articularly in countries with a more devolved type of goverpment, responsi- bility for a health serviceJi.es at different points on the pe g Even with more 1 centralised systems 'many decisions concerning local functioning are taken at the local level. lt follows that, for action to improve health, leadership develop- ment has to occur at all levels of the system, WHO has not the resources to take responsibility for organizing development workshops for all such personnel. But it can take the lead incc;Jeveloping a format for such activities wnic n be replicated by the relevant he 9rities in other, member countri . ; 11· Several countrie ave included men- tal health within therr primary health care programme, in line with the recommen- dations of the .Aima-Ata Conference in 1978. The implications of this have to be made plain to all those responsible for health care_ At the moment there are many mental health· professionals (usu- ally psychiatric nurses) working at district and other provincial levels of the health system, Their tr · · · has usually en- couraged them . ·provide a treat~ ment service for tho e patiemts who turn up at clinics. They are 'seldom aware that they could also be taking a leadership role in ensuring that the health service within their district contains a mental health component throughout. As a step towards overcoming this problem in one area of Africa, a WHO workshop on Leadership Development in Mental Health.w(;ls held last year in · Arusha, United R ublic of Tanzania, ·· with finangil:ll '~u ' om the Danish :• Agency for lnt I 'D.evelopmentl' (DANIDA). lt was attended by 22 participants drawn from East and Central African countries of the African Mental Health Action Group. They came from regional or district levels within countries and were invited as teams consisting of a mental health worker and a more general health worker from the same administra- tive unit. The National Mental Health Co- ordinators from :t pia .{whi<:;h helped to arrange the . co' d from , Uganda. also attended. · The workshop .starte with an account of the Tanzanian 1mental health pro- gramme, which puts emphasis on including a mental health component within primary health care. lt then dealt with ways in which .. local projects could be planned, and underscored the need for community involvement in both plan- ning and carrying P.l!t projects. Finally, the teams preparecFproppsals for spe- , cific projects ~ Riph1 th~Y themselves 'could try to 1undertak~ Q,ver ~he next1 12 months. SimHar~1courses are planned in the future, esp~ciall{one for the more southern countries of the African Mental Health Action Group. John Orley 11