Leading public health: A competency framework (book review)

What are the competencies of effective public health leaders? I have had the opportunity to participate in several health leadership fellowships (UCSF/California HealthCare Foundation, NACCHO, and Kresge Foundation). All of them have been great! I have learned a tremendous amount. Leadership training curricula start by identifying desired competencies (knowledge, skills, and abilities) for the participants.

As part of my project in the Kresge Foundation fellowship (Emerging Leaders in Public Health) I discovered, and highly recommend, the book by James Begun and Jan Malcolm: Leading Public Health---A Competency Framework (Springer, 2014). Leadership development is a lifelong, continuous improvement endeavor, and this book has become my competency road map. There are 25 competencies clustered into five sets, which I will summarize here.

Begun & Malcolm define public health leadership as the practice of mobilizing people, organizations, and communities to effectively tackle tough public health challenges.

An overview

Here is useful way to categorize leadership:

1. How to be
2. What to know
3. What to do

How to be---public health values and character traits

“[O]ur framework separates values, traits, knowledge, and competencies. … [W]e call out specific values (beliefs about what ought to be) and traits (patterns of personal characteristics) that are particularly helpful to developing public health leadership.”

Public health values: From Begun and Malcolm: “Personal values are broad preferences concerning appropriate courses of action or outcomes. They represent a person’s sense of right and wrong or what ought to be. They are strongly affected by what we learn from parents, teachers, religious traditions, and peers, as well as life experiences. While deeply ingrained, we can examine and redefine personal values. Indeed, we often carry them subconsciously, unless circumstances allow us or force us to examine or test them.”

• Social justice
• Reliance on evidence
• Interdependence
• Respect
• Community self-determination
• Requisite role of government
• Transparency

Character traits: From Begun and Malcolm: “[Character] traits … are distinguishing features of the behavioral and mental characteristics that make us unique. Traits are fairly hard-wired and may be harder to change than values—at least they would be hard to change in an authentic manner …”

• Integrity
• Initiative
• Empathy
• Comfort with ambiguity
• Passion
• Courage
• Persistence

From Begun and Malcolm: “[O]ur framework separates values, traits, knowledge, and competencies. ... [W]e call out specific values (beliefs about what ought to be) and traits (patterns of personal characteristics) that are particularly helpful to developing public health leadership.”

What to know—knowledge areas

1. Public health science
2. Understanding people
3. Understanding complex systems
4. Changing people, organizations, and communities

What to do—five competency sets

1. Invigorate bold(er) pursuit of population health
2. Engage diverse others in public health initiatives
3. Effectively wield power to increase the influence and impact of public health
4. Prepare for surprise in public health work
5. Drive for execution and continuous improvement in public health

Here are some details (mostly definitions)

How to be---public health values and character traits

Public health values

• Social justice: Acceptance of health as a universal, fundamental human right for all, and a strong commitment to correcting patterns of systematic disadvantage to population subgroups
• Reliance on evidence: Requirement that evidence informs and challenges decision making, accompanied by a healthy skepticism about existing practices, mindsets, and outcomes; helps mitigate groupthink among like-minded public health practitioners
• Interdependence: Recognition of the need to work with and in collaboration with diverse individuals and communities rather than independent pursuits; enhanced by the impact of social determinants on population health
• Respect: At the personal level, a way of regarding another individual that denotes the individual is important; manifested in soliciting input from the individual, listening, and doing so in a way that is sensitive to the individual’s culture and individuality
• Community self-determination: Respect for the right and ability of communities to define their own issues and interventions; serve as a coalition builder rather than the agenda-setter
• Requisite role of government: Belief in the value of public service and the role of government action to protect the public’s health
• Transparency: Public and other stakeholders have the right to information; develops trust and promotes constructive politics

Character traits

• Integrity: Honesty, truthfulness, and consistent action in accord with one’s values; key to credibility and strength in the face of attack
• Initiative: Drive to change; willingness to take charge and take risks when necessary
• Empathy: Interest in and ability to relate to people
• Comfort with ambiguity: Comfort with lack of clear boundaries and hierarchy in work settings
• Passion: Deep commitment to values of public health, profession of public health, and service
• Courage: Willingness to take unpopular stands on high-visibility issues and to push harder, to insist more vigorously, more effectively, and over a longer period of time
• Persistence: Patience with long-term cultural, social, and multi-generational change

What to know---knowledge areas (a) and key characteristics (b)

a) Knowledge areas

• Public health science
• Analytic / assessment
• Basic public health sciences (biostatistics, epidemiology, environmental health, health policy and management, social and behavioral sciences)
• Cultural competency
• Communication
• Community dimensions of practice
• Financial planning and management
• Leadership and systems thinking
• Policy development / Program planning
• Understanding people
• Motivation
• Social and emotional intelligence
• Understanding complex systems
• Systems thinking
• Focusing on complex adaptive systems
• Changing people, organizations, and communities
• Change management
• Culture of innovation
• Positive deviance

b) Key characteristics of public health knowledge

• Evidence-based
• Correlates with an emphasis on science and scientific research
• Uses evidence as a key weapon in tackling public health challenges in political arenas
• Grows largely through the accumulation of scientific evidence-based
• Empowers societal influence of public health leaders and the field
• Dynamic
• Changes frequently, particularly knowledge connected to scientific disciplines
• Invites an attitude of learning by public health leaders
• Demands the push for new evidence where it is needed
• Requires leaders’ openness to change their minds where compelling evidence is identified
• Prevention-focused
• Directs most public health knowledge toward preventing the emergence of health problems
• Compels focus on addressing the root causes of health problems to prevent them
• Enables a “return-on-investment” mindset that reflects the shard belief in the value of prevention
• Transdisciplinary
• Driven by problems rather than traditional boundaries of scientific disciplines
• Welcomes acceptance of relevant information from other fields and disciplines, as well as their potential limitations
• Encourages cross-sector collaboration within and outside clinical and scientific fields
• Value-laden
• Characterized by strongly political nature of field due to value conflict inherent in most population health issues
• Raises questions about the allocation of public resources relative to government regulation and intervention, legal and ethical concerns, and political influences
• Requires political debate over both the means and ends for improving population health

What to do---five competency sets (25 competencies)

1. Invigorate bold(er) pursuit of population health
1. Critically assess the current state of your program or organization
2. Articulate a more compelling agenda
3. Enlist others in the vision and invigorate them to drive toward it
4. Pursue the vision with rigor and flexibility
5. Marshal the needed resources
2. Engage diverse others in public health initiatives
1. Assess local conditions, in ways relevant and credible to the local stakeholders
2. Search widely for the right partners
3. Apply a social determinants perspective to planning
4. Take time to build relationships, teamwork, and common understanding
5. Clarify roles and governance
3. Effectively wield power to increase the influence and impact of public health
1. Understand and strategically use both positional authority and informal influence
2. Analyze a given public health problem and proposed solution in “campaign” terms
3. Build coalitions of core supporters, new partners, and issue-specific allies
4. Deal effectively with opponents
5. Be strategically agile
4. Prepare for surprise in public health work
1. Promote resilience in individuals and communities
2. Develop and critique an emergency response plan
3. Communicate effectively during surprises
4. Execute an emergency response plan with flexibility and learning
5. Learn and improve after surprises
5. Drive for execution and continuous improvement in public health programs and organizations
1. Build accountability into public health teams, programs, and organizations
2. Establish metrics, set targets, monitor progress, and take action
3. Proactively demonstrate financial stewardship of public health funds
4. Employ the methods and tools of quality improvement
5. Encourage innovation and risk-taking

Summary

Leading Public Health provides 25 competencies associated with effective public health leadership. The authors reviewed the appropriate literature, and provide further readings and inspiring case stories. This book succinctly summarizes the challenges faced by public health leaders (many of their examples resonated with my personal experience). If you want to become a more effective public health leader, or if you want to learn what public health leaders do (or should be doing), I highly recommend this book!