Leadership is central to governance.Its understanding is, therefore, paramount to good governance. The concept of “God” came into being as people searched for a guiding principle that governs the universe. Blackholes were identified that govern the movement of stars in the galaxies. Stars were identified that govern the planets revolving around them. Planets are identified to govern the satellites revolving around them. The nucleus is identified to govern the electrons that orbit it atoms. The soul is known to govern all beings. A father or a mother govern the family unit. A sarpanch is identified to govern a village. A chairperson is identified to govern an enterprise or an organization. A general is identified to lead the army. A Chief minister/ Governor is identified to govern a state. A Prime minister or a President is identified to govern a nation.
While inorganic systems are simple and obey the fundamental laws, organic systems – either biological or social – are complex, self-regulating, and adaptive. The elements that constitute these organic systems are interdependent and interconnected. They will be in a constant cyclical evolution with a shifting center.
Health systems, that started with the simple doctor-patient interaction, have evolved into one of the most complex social systems over the last two centuries. Today, healthcare involves teams of numerous health professionals – clinical, technical, and managerial and the responsibility of leading these teams changes with context. In the beginning, either a doctor used to visit the house of a patient or vice versa. Hospitals came into being at the turn of the last century. Nursing was brought into eminence by Florence Nightingale in the early nineteenth century. The erstwhile profession of a compounder who would mix herbs, potions and metals, gradually evolved into that of a pharmacist. Many doctors started converting their homes into clinics and nursing homes.
Medicine is as old as civilization. Medical traditions from different points in time, beginning with Ayurveda and expanding into AYUSH (Ayurveda, Unani, Siddha, and Homeopathy) survived in India despite the advent of modern allopathic medicine. At the dawn of India’s independence, hospitals were mostly under the public health system with a few being run by non-governmental charities and faith-based organizations. Public health was falling short in meeting the health needs of people.Private nursing homes and hospitals mushroomed in response to the unmet health needs of people. Informal care givers (quacks, rural medical practitioners, pharmacy aides etc.,) emerged in villages as doctors flocked to towns and cities. Corporate hospitals made entry with economic liberalization that began in the early ‘90s. Pharmacies, labs, clinics started branching out of hospitals as standalone entities. More recently, the entry of online digital platforms is paving the way for online and at home services, drastically improving access to healthcare services in the process.
Medicine emerged to relieve physical and mental suffering and treating illnesses. With the emergence of disease prevention and positive health, the concepts of health promotion and care provision came into being. While medicine was focused on personal health, public health came into existence to address population health. This includes promoting reproductive health, preventing communicable and non-communicable diseases, accidents, and injuries, addressing mental health, elder care, tackling epidemics & pandemics,responding to natural calamities, war & strife, and mass migrations, providing access to safe drinking water, clean air, hygienic surroundings, safe roads, healthy food, discouraging unhealthy habits like tobacco and alcohol consumption, and encouraging physical fitness. This shows a clear demarcation between ‘healthcare provider system’ that takes care of personal health and ‘public health system’ that takes care of population health.
In the beginning, people used to pay for the services of a doctor in kind. With the advent of public hospitals, people started having access to free medical services. Industrial revolution and two world wars resulted in an explosion of medical technology with attendant rise in health expenses. Economic devastation caused by the two world wars begot the need for financial risk pooling, resulting in the birth of the Bismarck and Beveridgemodels of health financing. The former, originating in Germany, was based on labor contributory social health insurance model. The latter, founded in United Kingdom as the National Health System, was based on tax-funded public health insurance model. Thus, began the bifurcation of health system into ‘Provider System’ and ‘Payer System’.
In India, the Employee State Insurance Corporation (ESIC) and subsequently the Central Government Health Scheme (CGHS) were founded on the social health insurance modelpost-independence. The Rajiv Arogyashree Scheme, introduced by the erstwhile state of Andhra Pradesh, ushered in tax-funded public health insurance in 2007 with the main objective of preventing catastrophic expenses involved in tertiary hospital care. The Rastriya Swasth Bhima Yojana (RSBY) was introduced subsequently as contributory health insurance to provide health protection for secondary care to poor people and informal labor. Private health insurance was introduced in the nineties with economic liberalization. RSBY has been transformed into the Pradhan Mantri Jan AaarogyaYojana, a much larger tax-funded public health insurance program designed to cover 100 million poor families.
The above narrative provides an understanding of how medicine has evolved into a complex, adaptive health system and how it further got demarcated into various subsystems. Social systems, in general, evolve around people. In a democratic governance system, communities elect persons to legislative bodies to represent their needs. These elected representatives, in turn, elect their leader to lead them in serving the people who elect them. These legislative bodies, consisting of legislators, lay down laws, envision the future, formulate and approve policies, designate leaders and managerial teams to implement these policies, provide human and material resources needed for successful implementation, assign responsibilities to public or autonomous bodies to accredit and regulate other constituents of the health systems, engage private players, communicate various policies and strategies across and outside the health system, manage 360 degree relations with various stakeholders at global, national, and subnational levels, and continuously monitor and evaluate performance of the entire health systems. Hence, leaders who govern health systems should be knowledgeable about the complexities of the health systems. They should understand the core functions of health systems as enumerated aboveand should have skills to provide leadership and stewardship of the entire system for it to be effective and efficient.
The BhagwadGita is amongst the most comprehensive treatises on leadership – both of personal and people leadership. Tao Te Ching, the sixth century Chinese treatise by Lao Tzu, is another exposition of personal leadership. Gautam Buddha focused on theeight fold pathway to personal leadership. Plato introduced philosophical underpinnings of ideal forms of governance and leadership in his book, The Republic. He introduced the idea of the philosopher-king. The great epicsof Mahabharata and Ramayana outline many characteristics of leadership and good governance. Janaka, the father of Sita, is depicted as Rajarshi (rishi= philosopher and raja=king). The Gita speaks of non-attachment in action (nishkama karma) and equanimity in adversity (stitaprajnata). Buddha founded ‘Vipassana’ as a technique in ‘mindful awareness’ and ‘experiential wisdom’. Patanjali’s Yoga helps one in developing stability through posture and concentration through meditation.Lao Tzu alludes to the understanding of complex natural systems and aligning oneself with it. Personal leadership that builds a noble character is one of the defining qualities of a leader. Just as planets revolve around the sun due to gravity, a character based on morals, ethics, knowledge and wisdom gives it the gravitas that attracts others to follow the leader.
‘Know thyself’ is the basis of personal leadership. Similarly, knowing the system that you are assigned to lead, is be the basis for effective leadership. Hence, knowing the core purposeof a health system is foundationalto understanding it. Understanding how the health system is organized in its structure and functions is akin to understanding the anatomy and physiology of the human body. Similar to how pathologies afflict the human body, health systems can be afflicted by inherited defects of a corrupt culture, undernourishment due to inadequate supply of needed resources (financial, human, and material), fragile immunity in the face of unexpected crises, fragmentation due to information silos, inequity due to unfair financing, and an unregulated private sector due to poor stewardship.
Some core competencies are needed for effective leadership. The include assessing the performance of health systems and diagnosing the root causes for its malfunction, designing policies and strategies to realize the vision, building teams to effectively implement the plans, providing needed resources, effectively communicating to various stakeholders, building relationships and the ability to visualize the future. Given the criticality of professions involved in leading and managing complex health systems, there is a need to groom these professionals in health systems management through standardized educational courses, and to incorporate these modules in medical professional education. This will help in building the capacity of in-service personnel in leadership and management roles both at induction and on an ongoing basis.
DrKrishna Reddy Nallamalla
Regional Director (South Asia), ACCESS Health International