PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW
LEADERSHIP FOR HEALTH EQUITY
Contact InformationNational Collaborating Centre for Determinants of HealthSt. Francis Xavier UniversityAntigonish, NS B2G [email protected]: (902) 867-6133fax: (902) 867-6130www.nccdh.caTwitter: @NCCDH_CCNDS
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: 978-1-987901-88-7
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 www.nccdh.ca.
La version française est également disponible au www.ccnds.ca sous le titre Leadership de la santé publique pour favoriser l’équité en santé : une revue de la littérature.
1
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 www.nccdh.ca.
The other Centres address aboriginal health, environmental health, healthy public policy,
infectious disease, and methods and tools. Find out more about all NCCs at www.nccph.ca.
PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW
PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW2
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
The National Collaborating Centre for Determinants
of Health’s (NCCDH) environmental scans conducted
in 20103 and 20144 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.
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.
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 Betker1 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 www.nccdh.ca/resources.
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 dissertation1 at http://nccdh.ca/resources/entry/public-health-leadership-to-advance-health-equity-a-scoping-review-and-meta.
d This second document will be available in March 2018.
3PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW
What the literature says about public health leadership for action on health equity
Let’s Talk: Health equity (2013)
Let’s Talk: Health
equity explores how
the concept of health
equity applies to
public health practice. PART OF THE LET’S TALK SERIES
LET’S TALK
H E A LT H E Q U I T Y
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 negotiation18 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
PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW4
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 model25
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 theory26 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 goals25
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 individual29 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.
5PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW
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 effect35 is a concept that describes
how commitment within policy, political and decision-
making 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
contributes to
successful public
health leadership
for health equity? An
appreciative inquiry
provides an overview
of factors and conditions that should be
considered to support action on health equity.
WHAT CONTRIBUTES TO SUCCESSFUL PUBLIC HEALTH LEADERSHIP FOR HEALTH EQUITY? An Appreciative Inquiry
SUMMARY
“ Health inequalities are fundamentally societal
inequalities that we can overcome through public
policy, and individual and collective action” 1
Dr. David Butler-Jones, Chief Public Health Officer of Canada
PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW6
The empowerment of leaders at multiple levels of
the public health system is possible
Leadership can occur at all levels of the public health
system12 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)
Collective impact
is a collaborative
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.
COLLECTIVE IMPACT AND PUBLIC HEALTH: AN OLD/NEW APPROACH – STORIES OF TWO CANADIAN INITIATIVES
PART OF THE
LEARNING FROM
PRACTICE SERIES
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
7PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW
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.
Learning Together series (2012)
Our Learning
Together series on
population health
status reporting
explores the use of
indicators to inform
public and population
health policies.
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
This document summarizes the National Collaborating Centre for Determinants of Health (NCCDH) Population Health Status Reporting Initiative.
LEARNING TOGETHER:COLLABORATING TO IMPROVE POPULATION HEALTH STATUS REPORTING
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 health. Public health practitioners and organizations from across Canada have identified the need for resources, tools, and collaborative learning on this topic.1
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.
Equity-integrated population health status reporting: Action framework (2016)
The six National
Collaborating
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.
EQUITY-INTEGRATED POPULATION HEALTH STATUS REPORTING: ACTION FRAMEWORK
PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW8
Let’s Talk: Universal and targeted approaches (2013)
Our document Let’s
Talk: Universal
and targeted
approaches offers
insight on reducing
disparities all along
the socioeconomic
gradient.PART OF THE LET’S TALK SERIES
LET’S TALK
U N I V E R SA L A N D TA R G E T E D A P P R OAC H E S
TO H E A LT H E Q U I T Y
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.
9PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW
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 levels31 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
“
PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW10
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
11PUBLIC HEALTH LEADERSHIP FOR ACTION ON HEALTH EQUITY: A LITERATURE REVIEW
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