LEADERSHIP FOR HEALTH EQUITY PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW

Transcription

1 LEADERSHIP FOR HEALTH EQUITY PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW

2 Contact Information National Collaborating Centre for Determinants of Health St. Francis Xavier University Antigonish, NS B2G 2W5 tel: (902) fax: (902) The National Collaborating Centre for Determinants of Health is hosted by St. Francis Xavier University. We acknowledge that we are located in Mi kma ki, the ancestral and unceded territory of the Mi kmaq people. Please cite information contained in the document as follows: Betker, RC and the National Collaborating Centre for Determinants of Health. (2018). Public health leadership for action on health equity: A literature review. Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University. ISBN: Production of this document has been made possible through a financial contribution from the Public Health Agency of Canada through funding for the National Collaborating Centre for Determinants of Health. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada. This document is available in its entirety in electronic format (PDF) on the National Collaborating Centre for Determinants of Health website at La version française est également disponible au sous le titre Leadership de la santé publique pour favoriser l équité en santé : une revue de la littérature.

3 ACKNOWLEDGEMENTS This paper was authored by Claire Betker and Dianne Oickle. Reviewers Sume Ndumbe-Eyoh, Knowledge Translation Specialist, National Collaborating Centre for Determinants of Health Gaynor Watson-Creed, Deputy Chief Medical Officer of Health, Nova Scotia Health Authority THE NATIONAL COLLABORATING CENTRE FOR DETERMINANTS OF HEALTH The National Collaborating Centre for Determinants of Health (NCCDH), hosted by St. Francis Xavier University, is one of six National Collaborating Centres (NCCs) for Public Health in Canada. Funded by the Public Health Agency of Canada, the NCCs produce information to help public health professionals improve their response to public health threats, chronic disease and injury, infectious diseases and health inequities. The NCCDH focuses on the social and economic factors that influence the health of Canadians and applying knowledge to influence interrelated determinants and advance health equity through public health practice, policies and programs. Find out more at The other Centres address aboriginal health, environmental health, healthy public policy, infectious disease, and methods and tools. Find out more about all NCCs at 1

4 Introduction Strong and effective leadership in public health is essential to improve health equity, both operationally and ideologically. A leader s commitment to social justice values is necessary to address the socioenvironmental factors that determine differences in health within and across populations. This commitment is demonstrated in a leader s everyday actions, behaviours and decisions. 1 Embedding equity within formal and informal leadership structures is a foundation for organizational capacity and readiness to take action on health inequities. 2 An important finding of the literature review was that there is very little theoretical and empirical literature examining public health leadership to take action on health inequities, making the definition, development and support of leadership in this area very challenging. The literature review did, however, provide important insights that are relevant to public health equity action and are explored in this summary, including: elements and theories of leadership; distinguishing followers and leaders; differentiating leadership and management; and considering leadership at all levels. The National Collaborating Centre for Determinants of Health s (NCCDH) environmental scans conducted in and revealed that the development of effective leadership for health equity is a priority area for public health. a Leadership was recognized as essential to influence policy, priority setting, resource allocation, partnership and collaboration, as well as the implementation of health equity interventions. However, leadership for health equity in public health systems was perceived as being inconsistent and at times absent across jurisdictional contexts and organizational levels. An important finding in both scans was the apparent disconnect between the commitment and intent expressed by leaders and the tangible actions taken to advance health equity in communities and populations. In 2016, a scoping review and metasummary on public health leadership for action on health equity was completed as a PhD dissertation research project. b,1 As part of the dissertation research, a comprehensive literature review was conducted to help refine the research questions and inform the analytical framework for the subsequent scoping review. This summary highlights key concepts from the general leadership literature that are transferrable and can inform public health action on health equity. The NCCDH collaborated with the author to produce a summary of the literature review. c The results of the full scoping review are explored in a second document, d including what the literature identified as essential leader attributes and strategies to support and develop public health leadership to take action on health equity. Public health leadership to advance health equity: A scoping review and metasummary (2016) The full dissertation Public health leadership to advance health equity: A scoping review and metasummary by Dr. Claire Betker 1 addresses the dearth of literature supporting action by public health leadership on health equity. It can be found in the NCCDH online Resource Library at a The NCCDH s 2017 environmental scan, to be released in March 2018, emphasizes leadership and organizational capacity to advance health equity and public health s interface with the larger health system. b This research was initiatied when the dissertation author, Dr. Claire Betker, was an NCCDH staff member and the NCCDH acted as a valuable collaborator in the formative and early stages of the scoping review research. c This document is a summary of the literature review portion of a larger scoping review research project. The complete literature review can be read as part of Dr. Claire Betker s dissertation 1 at d This second document will be available in March

5 PART OF THE LET S TALK SERIES What the literature says about public health leadership for action on health equity LET S TALK HEALTH E QUITY Let s Talk: Health equity (2013) Let s Talk: Health equity explores how the concept of health equity applies to public health practice. The literature review revealed a very interesting situation regarding the status of the literature on public health leadership for action on health equity. While there was a large body of writing on leadership from many sources, including academic research, grey literature and opinion-based writing that can be applied across professions and structures, the presence of literature on public health leadership was limited. Much of what was available counted as secondary sources, including opinion pieces, commentaries and some grey literature. There was even less writing on public health leadership to address health equity specifically. Description of leadership Public health leadership is defined by the Public Health Agency of Canada (PHAC) as follows: The ability of an individual to influence, motivate, and enable others to contribute toward the effectiveness and success of their community and/ or the organization in which they work. It [public health leadership] involves inspiring people to craft and achieve a vision and goals. Leaders provide mentoring, coaching and recognition. They encourage empowerment, allowing other leaders to emerge. 5(p12) In short, leadership is about influence that moves individuals, groups, communities and systems toward achieving goals that will result in better health. 6(p31) While there was literature describing the characteristics of effective leaders in other sectors, 7-9 literature examining public health leadership and its effectiveness was not available. Effective leadership in other sectors was described as visionary, with leaders acting intentionally and using skilled communication to turn vision into action, 10 as well as being able to motivate people and generate the energy required to cope with change. 11 Leadership was described in relation to followers, peers, supervisors, organizations, settings and culture. 12,13 More recent descriptions of leadership found in the literature were less focused on the individual, highlighting the shift to viewing leadership outside the attributes of a single person. Leadership was described as shared, distributed, relational, complex, social, situational and dynamic. 12,13 Broad leadership attributes were described as proximal (expertise, knowledge, communication and problem-solving skills) and distal (values, cognitive abilities and the personality of the leader). 14 A focus on social justice and the use of evidence, 15 as well as the ability to align different views into a common mission, 16 were significant when it came to strengthening the value system of a public health organization. Vision, values, communication, relationships and the abilities to make change happen and renew followers were considered essential elements of leadership. 10 The ability to communicate with a wide variety of audiences, 17 alongside skills related to conflict resolution, 18 negotiation 18 and collaboration, 19 were also considered necessary for effective leadership. Moreover, an appreciation for when change is needed, including the value of incremental change, or when the status quo 3

6 is preferable, combined with a solutions-focused approach, was seen as an important aspect of a leader s role. 10,20 Finally, the ability to maintain and develop relationships, 21 including attention to external influences through partnerships and networks, was a key feature relevant to public health leaders. A focus on social justice and the use of evidence, 15 as well as the ability to align different views into a common mission, 16 were significant when it came to strengthening the value system of a public health organization. Theories of leadership Many leadership theories were identified by authors as being applicable to public health settings. For example, the review of the literature highlights three leadership theories that are particularly applicable to public health practice. Transcendent leadership has a focus on leadership of self, 22 where leaders are aware of their own biases, prejudices and weaknesses. 23 It works through dialogue, shared understanding and collective decision making. 23,24 The five practices of exemplary leadership model 25 outlines five essential practices of leaders as follows: modelling the way, inspiring a shared vision, challenging the process, enabling others to act, and encouraging the heart by recognizing achievements and showing appreciation to others. Complexity leadership theory 26 describes leadership that adapts to changes in people and systems (adaptive), aligns the actions of individuals and groups (administrative) and facilitates the flow of knowledge and processes (enabling) between levels of an organization, as well as between communities and organizations. Taking a closer look A critical analysis of the literature revealed several key areas that merit deeper consideration for how they apply to public health leadership action on health equity. The following section highlights literature findings for three of these areas, including the relationship between leaders and followers, the distinction between management and leadership, and the roles leaders play at various levels within an organization. Leaders and followers Relationships between leaders and followers matter. Because leaders need to appeal to what motivates and drives their followers, a relationship develops between them. 27 The integrity of the relationships between leaders and followers determines how they work together towards achieving common goals 25 through shared power and joint participation. 28 Being an effective leader demands investing in individuals and teams (followers). When leaders mentor, act as role models, precept and offer individual attention, it represents an investment in the interdependent capacity of followers and of leaders themselves. 10,25,29 Effective leadership is necessarily balanced with followership within and between public health organizations, systems and practitioners. 30,31 Followership refers to the demonstration of courage, credibility and commitment to a purpose outside the individual 29 while demonstrating a high degree of teamwork. 32 It is important for leaders to enable these skills among staff, and to be effective followers themselves. 4

7 Dr. David Butler-Jones, Chief Public Health Officer of Canada SUMMARY Management and leadership The relationship between managers and leaders is a critical element of public health practice. The terms management and leadership are often used interchangeably to describe positions of authority in an organization, though their formal roles can be quite different. Management most often focuses on the administration of regular activities, 10 such as the implementation of public health programs and interventions. Leadership provides vision in the development of organizational and program goals, objectives and strategy. 11 However, leadership tasks may have a management component, such as priority and agenda setting, 33 and those in management positions often have leadership roles, 10 such as motivating and aligning staff. In other words, a manager can also be a leader, and a leader can also manage. It is the pairing of a leader s vision with leadership skills that enables them to implement and sustain change. 34 The tasks of planning, budgeting, organizing, staffing, scheduling and implementing are needed to support action resulting from the original vision. After a project s or organization s vision is defined, the tasks of agenda setting, aligning people and bringing communities together are also needed to direct the various processes at hand. In this way, leaders and managers are symbiotic. Leadership at multiple levels of the public health system The nutcracker effect 35 is a concept that describes how commitment within policy, political and decisionmaking structures at the top when combined with bottom-up demand for action from civil society creates sufficient pressure to influence the forces that determine health inequities. When a public health leader works with multiple stakeholders at the system, political and local levels, it encourages meaningful participation that influences the assessment, development and implementation of policy and interventions. 21 Coordinated leadership at local, regional, national and international levels that includes (but is not limited to) the public health sector can influence health equity. 16 Partnerships are nurtured by public health leaders through skilled communication and the empowerment of community leaders. 37 What this means for action by public health leadership on health equity Leadership within a public health system spans professions, disciplines and positions and is not isolated to a job title. Several key learnings emerged from the review of the literature supporting the development of public health leaders to advance health equity. What contributes to successful public health leadership for health equity? An appreciative inquiry (2013) The NCCDH publication What WHAT CONTRIBUTES TO SUCCESSFUL PUBLIC HEALTH LEADERSHIP FOR HEALTH EQUITY? An Appreciative Inquiry contributes to successful public health leadership for health equity? An Health inequalities are fundamentally societal inequalities that we can overcome through public appreciative inquiry policy, and individual and collective action 1 provides an overview of factors and conditions that should be considered to support action on health equity. 5

8 PART OF THE SERIES The empowerment of leaders at multiple levels of the public health system is possible Leadership can occur at all levels of the public health system 12 and leadership competencies for public health practice apply across organizational positions and professions. 38 Attributes such as skill, knowledge and expertise strengthen leadership at any level of an organization, 31 and as such, leadership responsibility and accountability are not simply formalized in job descriptions or organizational plans. 39 Public health leaders understand that quick fixes to complex public health issues are not feasible, and that they need to be dedicated to long-term processes with incremental movement and results. 22 Public health leadership that reflects the core values of health equity and social justice is characterized by relationships, innovation and a focus on collaboration and partnership development. 40 Empowering leadership, whether in formal positions of authority or among front-line staff, is only possible when the individuals in these positions have the skills, knowledge and authority to make decisions when representing the organization. 25 Supporting the development of relational skills such as commitment and integrity among public health practitioners at all levels strengthens leadership capacity in public health organizations. Organizational culture that supports the values, assumptions and behaviours necessary for momentum on health equity facilitates public health practitioners to be effective in leadership positions. 2 Both the external environment and the formal and informal systems of an organization can support or undermine its members, including leaders. 41 The successful development of leadership skills at any level depends on organizational supports for practice, role clarity and a defined scope of practice, 40 in addition to ensuring that adequate resources and processes exist so public health staff can practice these skills. Collective impact and public health: An old/new approach Stories of two Canadian initiatives (2017) LEARNING Collective impact FROM PRACTICE is a collaborative COLLECTIVE IMPACT AND PUBLIC HEALTH: AN OLD/NEW APPROACH STORIES OF TWO CANADIAN INITIATIVES community development approach in which public health can be involved in projects to achieve social change. Our case study titled Collective impact and public health: An old/new approach Stories of two Canadian initiatives offers an in-depth portrait of two Canadian organizations that have used this strategy. Public health leadership is relational The concept of being relational can be applied to both leadership and integrity, and both are central to leadership practice in public health. Relational leadership is rooted in how leaders see their place in the world, how they hold themselves morally accountable to issues and other people and are always in relation with other issues rather than being separate from them. 39 Relational integrity, on the other hand, refers to the need for leaders to be responsive to what is going on around them, to recognize that they are influenced by their environment and to realize that formulaic answers don t work for every situation. The term also refers to the leader s personal values and morals and how the leader responds in times of uncertainty and doubt. 39 6

9 COLLABORATING TO IMPROVE POPULATION HEALTH STATUS REPORTING ABOUT THE POPULATION HEALTH STATUS REPORTING INITIATIVE The National Collaborating Centre for Determinants of Health (NCCDH) is working with Canadian public health organizations and practitioners to improve the methods used to produce population health status reports. Through the Population Health Status Reporting Initiative, the NCCDH aims to better illuminate health inequities and support the development of effective and equitable policies. OBJECTIVES 1. Learn about how to effectively integrate an equity lens into public health surveillance and reporting 2. Model innovative and collaborative practice in learning and evaluation related to the integration of health equity into population health status reporting 3. Support Capital Health (Halifax, Nova Scotia) in the development of a high quality and effective population health status report that effectively integrates and communicates equity issues 4. Share learnings from the project in accessible and innovative ways Population health status reporting is a vital tool for addressing the social determinants of health and advancing health equity. The way that health data is collected and shared shapes our perception of population Public health leadership occurs in a multi-sectoral, relational and dynamic environment, which influences the actions that can be taken and makes strong and ongoing relationships necessary. The values and morals of leaders at all levels establish the culture of public health organizations as a whole, providing the space for the issues that are prioritized for action. The interactions between leaders and those they work with are shaped by the context of the organizational environment. 42 Public health leadership occurs in a multi-sectoral, relational and dynamic environment, which influences the actions that can be taken and makes strong and ongoing relationships necessary. Leaders can use data to demonstrate inequities One of the unique contributions of public health leadership when it comes to collaborative work on health equity is the ability to demonstrate where inequity is present. Public health leaders who use new methods of integrating and displaying data, telling evidence-based stories, and engaging communities in the design and planning of research and programs 43(p19) will make decisions about strategies to address health inequities that are rooted in evidence of where inequities exist in their communities. While there is sufficient data to identify health inequities in Canada, the ability to evaluate interventions is limited due to gaps in the literature. 44 Because of these gaps, health care and public health leaders often lack evidence on the impacts of their decisions and actions on health equity. 45 In the absence of evidence on effective action, knowledge of the pathways between the social determinants of health and inequities and of alternative theories of change underpinning different approaches can also help entities to think through what might work, where action should be targeted and who should be involved. Learning Together series (2012) LEARNING TOGETHER: This document summarizes the National Collaborating Centre for Determinants of Health (NCCDH) Population Health Status Reporting Initiative. health. Public health practitioners and organizations from across Canada have identified the need for resources, tools, and collaborative learning on this topic. 1 Our Learning Together series on population health status reporting explores the use of indicators to inform public and population health policies. Equity-integrated population health status reporting: Action framework (2016) The six National EQUITY-INTEGRATED POPULATION HEALTH Collaborating STATUS REPORTING: ACTION FRAMEWORK Centres for Public Health (NCCPH) collaboratively developed the Equity-integrated population health status reporting: Action framework document to support the development of monitoring and equity interventions. 7

10 PART OF THE LET S TALK SERIES Let s Talk: Universal and targeted approaches (2013) LET S TALK UNIVERSAL AND TARGETED A PPROACHES TO H EALTH E Q U ITY Our document Let s Talk: Universal and targeted approaches offers insight on reducing disparities all along the socioeconomic gradient. Through continuous quality improvement and monitoring/surveillance, data can be used by public health practitioners to demonstrate that interventions are targeting the most disadvantaged populations those experiencing the greatest burden of health inequities and that strategies are having an impact on specific indicators. Interventions that target the needs of the most disadvantaged groups do not always reach others who experience relative disadvantage as a result of their place on the social gradient. 46 Proportionate universalism recognizes that public health programs should include a range of universal strategies (i.e., provided to the whole population) that are also resourced and delivered with intensity relative to the level of social need. 47 Public health leaders who draw on their sense of social justice in combination with data are willing to take risks and implement strategies based on community priorities. Using this type of decision-making process for health equity interventions reinforces the importance of public health leaders intimate connection with their communities. It also ensures that they have a deep understanding of the pathways linking the social determinants of health and health inequities. Good leaders and good followers work together Together, good leadership and followership can build environments that encourage trust, relationships and positive outcomes. 48 Followers are never powerless, because power is a relationship not a possession 49(p16) and, therefore, the quality of the relationships between leaders and followers matters. Relationships support the shared and distributed nature of public health leadership. 8

11 Followers are never powerless, because power is a relationship not a possession 49(p16) and, therefore, the quality of the relationships between leaders and followers matters. In the same way that individuals are never only a follower or a leader, 31 followership applies at all levels of an organization and is not restricted to those in subordinate positions. 49 Practitioners in formal positions of authority are also followers, not just of other levels of authority but of the very relationships they build and nurture. Because the distribution of power between formal and informal leaders and followers affects the achievement of outcomes, 48 organizations are more effective when there is a balance of followership and leadership at all levels 31 where there is a sense of collective ownership over outcomes. Conclusion State of the literature and research gaps While many features of leadership identified in the literature may apply to a public health setting, much of the leadership research does not consider the unique characteristics of the public health practice environment, how public health action for equity depends on collaboration with health and non-health partners, or the focus on change at a population level. There are a number of sources on leadership theory and development; however, there is very little literature that looks closely at how this research applies to public health. 15,21,50 Two systematic reviews confirm a lack of research specific to leadership within the public health realm. 42,51 One review notes that the research on public service leadership lacks a comprehensive theoretical approach and is fragmented. 51(p126) There is even less literature that specifically considers public health leadership to advance health equity, the effectiveness of public health leadership on action regarding health equity or how public health leadership can be strengthened or developed. 52,53 Despite the reality that leadership in public health is necessary to achieve health equity, 54 definitions of public health leadership do not typically include a commitment to addressing the social determinants or the goal of health equity. Most of the leadership literature comprises opinion-based secondary sources, and several important theories relevant to public health practice are not noticeable in the leadership literature, such as intersectionality and critical social theory. 1 9

12 Future areas for research in public health leadership for health equity There is a need for further empirical and theoretical research in the area of public health leadership for health equity. In particular, further research would enrich the field of public health leadership by exploring the following topics: The relationship between management and leadership in public health organizations The influence of leadership on continuous quality improvement processes to consider the effectiveness of equity interventions on health outcomes The integration or use of relevant theories, such as complexity theory, intersectionality and critical social theory, to inform research on public health leadership and health equity Areas of focus for strengthening public health leadership specific to reducing health inequities (i.e., what works) Relational components of public health leaders and communities to address health equity Definitions and descriptions of public health leadership that specifically include the concepts of health equity and social justice Development of leadership knowledge and skills at all levels of public health organizations, including the front line and across disciplines How leadership is developed within the community, organizations and civil society in partnership with public health Followership as an area of knowledge and skill to advance health equity 10

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16 NATIONAL COLLABORATING CENTRE FOR DETERMINANTS OF HEALTH St. Francis Xavier University Antigonish, NS B2G 2W5 tel: (902) fax: (902) web: