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From know - do to how - why ITM colloquium, 2014 Dr Julie Balen Lecturer, Global Health School of Health & Related Research (ScHARR) The University of Sheffield, UK 25 November 2014 Social scientists in global health

  1. From “know - do” to “how - why”… ITM colloquium, 2014 Dr Julie Balen Lecturer, Global Health School of Health & Related Research (ScHARR) The University of Sheffield, UK 25 November 2014

  2. Social scientists in global health research SOCIAL SCIENTISTS ANONYMOUS…

  3. Inter-disciplinary global health research: worthy goal; fuzzy concept? Anthropology Sociology Psychology Health economics Ethics Statistics Political sciences Management History sciences Law Geography Epidemiology Medicine A complex landscape

  5. Inter-disciplinary global health research: worthy goal; fuzzy concept? Anthropology Sociology Psychology Health economics Ethics Statistics Political sciences Management History sciences Law Geography Epidemiology Medicine A complex landscape – (a bit) more navigable?

  6. Health systems strengthening Leadership is foundational element, but ill defined, under researched & poorly understood especially in complex, resource-poor settings

  7. The Gambia, West Africa

  8. Study design & setting

  9. The study of leadership Leadership – a person, a position or a process? 1. Person : skills, abilities, personality, styles of engagement and behaviours of individuals 2. Position : formal authority and responsibility in an organization 3. Process : a set of dynamic activities and interactions occurring among and between individuals, groups and organisations in a specific context

  10. The study of leadership A summary of the six key leadership styles explored in this study Coercive Authoritative Affiliative Democratic Pace-setting Coaching Modus Demands Mobilises people Creates harmony; Forges consensus Sets high standards Develops operandi toward a vision through participation for performance immediate Builds emotional people for the compliance bonds future Underlying Empathy; Collaborates; Conscientious; Drive to achieve; Self-confidence; Develops emotional Initiative; Self- Empathy; Builds relationships Team leadership; Drive to achieve; others; control Change catalysts Consults Initiative Empathy; intelligence components Self-aware “Do what I tell you” “Come with me” “People come first” “What do you think?” “Do as I do, now” “Try this” The style in a phrase Adapted from Goleman (2000)

  11. Predominant leadership styles Democratic: “ Healthcare delivery entails dealing with life, and in dealing with life, certain issues that are coming up, you can’t predict them. So if they are unpredictable, then that means it’s no longer in your domain. If you do not reach out, reaching out doesn't mean you don’t know.” “I also conduct meetings... frequently call the staff and have a discussion, basically they will show you ways how to manage a facility. So I capitalise on what they say because I may not know exactly what is happening or may not know all, but sometimes their ideas are very good, I take them. ” Pace-setting: “I use the religious aspect, whatever we do to help others no one can pay you, the payment will come after death. This is how I encourage people to strive .” Authoritative: “ So it is context specific, I should think that a leader must always have a particular vision and wants that vision to be embraced by those around them so that we get to that goal.” “My leadership skills, I think I’m just born with it. I don't boast of it but I think I am privileged that God granted me certain things, which through my own innovations I am able to do them so I am a tough leader. ”

  12. A few brief conclusions • Study of health leadership aids in constructing a narrative of local agency • Relocates focus from thinking primarily about ‘interventions’ & ‘ innovations ’… towards people - centered health systems comprised of local actors & their sense of ownership, authority & power • Adding “human dimension” to dominant paradigms in global health discourses

  13. A few brief conclusions (2) This work brings a new perspective to the study of leadership as an inter- subjective phenomenon that exists within a social & political reality & is shaped by particular, culturally determined ways of framing problems & solutions http://www.conferencemanager.dk/islc2014/about-the-conference.html • Brings to light the “ rigour- relevance gap” • Not same as “know - do gap” so well known in global health research/practice • Focuses on the “ why ” rather than the “do” or “how”

  14. Mind the gap(s), please…! RIGROR ---- RELEVANCE Focus shifted to local level; Trans-disciplinarity is important; Inclusive 3. Assimilation 4. Adaptation participatory action research as tool for collaboration & reflection 1. Acquisition 2. Application KNOWLEDGE ---- ACTION

  15. 4 th quadrant: adaptation • To close both gaps, research must adapt to ask the right questions • Reminder of a famous quote (Pablo Picasso): “ Computers are useless. They can only give you answers. ” • Refocus on people (rather than technology & innovation) by addressing locally relevant questions/issues & through better engagement of/with local communities

  16. Summary comments Successful inter-disciplinary teams need disciplinary experts & cross- discipline “bridges” HPSR focused on geographical & financial access to medical technologies, innovations & service rather than on people – who form the core of health system Concept of leadership can add human dimension to dominant models of conceptualizing/researching health systems/policy HPSR needs to draw more on inter-disciplinarity; to be co- created/adapted at & by local level, through community participation & reflection in action (4 th quadrant)

  17. Future outlook - ScHARR Building inter-disciplinary team for participatory action research on leadership & health systems strengthening in The Gambia & Ghana – at the norming (i.e. “searching for funding”) stage… Team currently conducting research into (among other things): • Lived-experience of health systems in urban informal settings of Northern Nigeria (where the state is relatively absent) [Muhammad Saddiq] • Real-life functioning of global health partnerships & their embeddedness within national contexts, focusing on Ethiopia [Henock Taddese] • Biomedical dominance & professionalization of health workers in Nigeria through a case study of Global Fund HSS grant [Samuel Lassa] • Impact of biomedical knowledge on evidence-informed health policy making, focussing on malaria control in Senegal/Gambia [Maelle deSeze] • Using cross-media data mining & analytics in Ebola control – dispelling myths

  18. Acknowledgments Special thanks to all key informants who participated in this study Imperial College MRC Gambia Dr Lesong Conteh Prof. Umberto d’Alessandro (co -I) Prof Peter Smith Prof. Tumani Corrah (co-I) Dr Momodou Jasseh (co-I) Mr Serign Ceesay The Gambia Government Mr Sulayman Janneh Dr Adama Demba (co-I) Ms Marie Rose Thorpe University of Oxford Mr Landing Bojeng Dr Simukai Chigudu (student) MRC Drivers & Assistants I gratefully acknowledge funding from Imperial College London and the National Institute of Health Research, UK Ethical clearance obtained from The Gambian Government/MRC Joint Ethics Committee and Imperial College London Ethics Committee

  19. References – further reading 1. Bennet, S., Agyepong, I.A., Kabir S., Hanson, K., Ssengooba, F., Gilson, L. Building the Field of Health Policy and Systems Research: An Agenda for Action. PLoS 2011;8(8) 2. Chigudu, S., Jasseh, M., d’Alessandro, U., Corrah, T., Demba, A., Balen, J. The role of leadership in people-centred health systems: a sub-national study in The Gambia Health Pol., Plan . 2014 3. Curry, L., Taylor, L., Chen, P.G.C., Bradley, E. Experiences of leadership in health care in sub-Saharan Africa. Human Resources for Health . 2012;10(1):33 4. Gilson, L., Hanson, K., Kabir S.,, Agyepong, I.A., Ssengooba, F., Bennet, S., 2011 Building the Field of Health Policy and Systems Research: Social Science Matters. PLoS Medicine 2011;8(8) 5. Goodwin, N. Leadership and the UK health service . Health Policy. 2000;51(1):49 – 60 6. Goodwin, N . 2010 Understanding Context and its Impact on The Leadership Challenges of Chief Executives in the English NHS. Monograph Series 7. Harman S., Rushton, S. Analyzing Leadership in Global Health Governance Global Health Governance. 2013; 7(1):1-19 8. Hartley, J., Hinksman, B. 2003 Leadership Development: A Systematic Review of the Literature. The NHS Leadership Centre, UK 9. Huang Y.X. & Manderson, L. The social and economic context and determinants of schistosomiasis japonica, Acta Tropica . 2005;96(2):223-231 10. Patel, V.M., Warren, O., Humphris, P., Ahmed, K., Ashrafian, H., Rao, C., et al. What does leadership in surgery entail? ANZ Journal of Surgery . 2010;80(12):876 – 83 11. Sheikh, K., Gilson, L., Agyepong, I.A., Hanson, K., Ssengooba, F. Building the Field of Health Policy and Systems Research: Framing the Questions. PLoS Medicine. 2011;8(8):1 – 6 12. Siddiqi, S., Masud, T.I., Nishtar, S., Peters, D.H., Sabri, B., Bile, K.M., et al. Framework for assessing governance of the health system in developing countries: gateway to good governance . Health Policy. 2009;90(1):13 – 25 13. Smith, P.C., Anell, A., Busse, R., Crivelli, L., Healy, J., Lindahl, A.K., et al. Leadership and governance in seven developed health systems . Health Policy . 2012;106(1):37 – 49

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