The best reward

Allow me to paraphrase an old Taoist saying: " The best leaders are those the people hardly know exist. The mark of a successful leader is when the team says WE DID IT!"

I have always believed a leader is only as strong as his/ her team. My work has consistently given the opportunity to build the capacity of my team and others involved in my work. The effort you put in to building a team's capacity is directly proportional to the quality output. Now, what is all this talk about leadership, you may ask? Strengthening health systems has a lot to do with leadership. Building the capacity of workforce and the system requires leadership qualities. That is why I sought a doctorate in public health leadership after my medical degree. I am firm believer that leadership is essential to build and strengthen health systems.

So, what is the exact relationship between leadership and health systems strengthening (HSS)? Allow me to give an example. HSS requires a commitment and buy-in from various stake holders, government and non-government players included. Anyone heard of "From silos to systems"? Strong leadership qualities are an absolute necessity in securing these commitments and buy-in. A successful leader will engage all the players and bring them together to build a strong health system. That is what I have always done in my line of work...engage, secure commitments, and obtain buy-in. It is the first and crucial step towards building/ strengthening a health system.

My work in Liberia is a testament to successful leadership. I can proudly say I was responsible for conceptualizing, operationalizing, and initiating the first and only comprehensive HSS/ capacity building framework for a post-conflict country. It would not be possible without the commitment and support from various stakeholders and my staff. Starting from the Liberian Ministry of Health to international donors like USAID and various NGOs, everyone played a role. I am proud to have created and implemented a framework that facilitated the stakeholders to come together and rebuild Liberia.

Besides stakeholder buy-in, a successful leader is also appreciated by his/ her team. It has been almost six months since I left Liberia and I continue to receive messages from my staff and colleagues about the impact I made in their career. The best message is one I received from an ex-staffer which read "Thank you for all that you have done. WE are now able to work towards rebuilding and strengthening our health system". I capitalized the word "we" to emphasize the mark of a successful leader. The message brought a tear to my eye. I am glad the ex-staffer said "we". I never want things to fall apart after I leave, and I am glad my ex-team is following up and making things happen after my departure. I take pride in them and I am blessed to have had the opportunity to build their capacity, which enables them to continue with the work I started.

A latest message from an ex-colleague in Liberia made me think about leadership today. She wrote "good to know that you are working in Kenya. I know you will help people in Kenya like you helped my career". Am I a successful leader? I may not fit the stereotype of a traditional leader, but I possess some leadership qualities. I will, however, say with certainty that I will continue to build the capacity of people and health systems in order to prove myself as a successful leader in my line of work.

While I appreciate every opportunity I have been given, I am particularly appreciative of the fact that my teams always say "WE DID IT!". The sense of camaraderie among the team members and the stakeholder buy-in will continue to be the best reward of my career.

Onwards and upwards!

What does it mean to build capacity and strengthen a health system??

The one question I have been trying to get answered, since I've been here. I may finally have an answer by the end of this month. I have to warn my friends reading this post: it is going to be all about work, no personal or fun stuff here.

Plato once said "the beginning is the most important part". I always believe the beginning of a project sets a tone for what's to come. One of the preliminary and major tasks of building capacity in health systems is to "define" what building capacity means for the recipient. Some call it developing a "vision". Whatever terminology you may prefer, the common understanding is that the recipient should be able to "define/ envision" what building capacity means for them.

My priority task, since I've arrived in Monrovia, has been to help/ guide/ persuade the Ministry of Health come up with an idea of what building capacity means for them. Why is this important? I'll give you another quote (I am full of these quotes today). To paraphrase what H. James Harrington wrote in Business Process Improvement:

"In order to strengthen/ change a system you have to control it;
in order to control a system you have to understand it;
in order to understand a system you have to measure it"

In my quest to strengthen/ change the health system in Liberia, I realize the need to measure it. Measurement requires definition. That is why I need the ministry to define building capacity and strengthening the health system. I could do it myself (I am thoroughly capable and competent), but I am not here to tell people what to do. I am not a dictator (although, in my spare time, I pretend to be one wearing a ridiculous crown). I am here to help, enable, and advise. So I proposed a few definitions and helped facilitate a discussion. We are making progress in coming up with a common vision.

Few days ago I delivered a talk to the senior leadership at the Ministry. It was well received, they were engaged in the discussion, and the best outcome - they agreed to finalize the vision for capacity building very soon. I am happy about this development. Now that I am gathering stakeholder participation and support - a vital component of strengthening a system - I am focusing on stakeholders at both central and county/ district level. The central ministry has heard (and got on board) with my strategy to build their capacity and strengthen the system, now it is the county and district health departments to get on board. In order to accomplish this buy-in, I will be traveling to the counties - Lofa, Nimba, and Bong - next week. I will present my strategy, introduce the instruments, and seek feedback.

The framework I am following to strengthen Liberian health system and build capacity is the WHO framework. It describes six building blocks that form the basis of a health system. Building Block 6 - Leadership and Governance - is the one that interests me the most. I strongly believe leadership capacity is the one that guides the other five building blocks. Allow me to share a diagram from the WHO framework

Six building blocks of a health system

As you can see, all building blocks work in unison towards creating/ strengthening a health system, but leadership is the one that guides other building blocks.

I believe we need strong leadership and a capacity to govern fairly in order to have a viable health system. Leadership is something that is lacking in the health system here. There are a few people at the central ministry who understand the importance of leadership and see the big picture, like Deputy Health Minister Yah Zolia, but leadership at county and district level is severely lacking. One of my objectives in building capacity for the ministry is to build their leadership capacity. I will be conducting an assessment of current leadership in the ministry - both at the central and county level - to identify issues that plague leadership. This assessment will help us develop a strategy to build leadership capacity.

Of course leadership is only one of the six building blocks of a health system. There are five other blocks for me to focus...and they will all receive due attention. I am using resources from WHO and CDC to create assessment tools for the Liberian ministry. These tools have been adapted and tested in other countries. I have first hand experience with these tools, having adapted and implemented them to health systems in Israel and India. I do not have to tell you that post-conflict systems are a completely different ball game. There are developed systems (US and most of Europe), emerging systems (India), and then there are post-conflict systems. There are not many frameworks/ instruments that have been developed specifically for post-conflict health systems, and that puts the burden on people like me to adapt existing frameworks to post-conflict settings. I like the burden because I like a good challenge. In the beginning I thought it feels like going back to the drawing board, but I have come to realize it is not even that. It is more like understanding that I need a board and pencils to draw, then embarking on a journey to procure the board and pencils before I begin drawing on a board. That's the level of  system in a post-conflict setting. Needless to say, it is challenging but extremely rewarding.

I have a lot of work ahead. We will start assessing baseline capacity next month and that will lead us to developing a capacity building and health system strengthening strategy. Analyzing the data and developing a strategy will take 2-3 months. We intend to start implementing our activities in June. I see a poetic sense of beginning because June is also the rainy season. To me, rain has always symbolized the beginning of a new adventure. It will be perfect for our adventure to begin in June.

I promise the next post will be not as dry as this one. I will add more personal and fun stuff, perhaps some pictures, for my friends.