Orgill Marsha, Marchal Bruno, Harris Bronwyn, Gilson Lucy
Children's Institute, Department of Paediatrics and Child Health, University of Cape Town, Rondebosch 7700, South Africa.
Institute of Tropical Medicine, Antwerp 2000, Belgium.
Health Policy Plan. 2025 Jan 11;40(1):31-41. doi: 10.1093/heapol/czae099.
The need for leadership within district health systems is critical for the effective delivery of services and for inter-sectoral collaboration for health. Leadership capacity development (LCD) has not, however, been prioritized within health systems, and the systemic capacity (i.e. roles, structures and processes) that is needed to develop managers who can lead is not always in place. This paper aims to contribute to understanding how to build such capacity, considering a relevant bottom-up innovation. We observed, in the period 2013-15, the emergent implementation of this innovation (a 'Leadership Commission') in a South African health district. What started out as an effort to train individual leaders evolved into the development of systemic capacity for LCD. We adopted realist evaluation as the main methodological approach, as well as case study design, and we first developed a programme theory of the internally driven LCD initiative, through a round of interviews with senior managers. We then tested the programme theory drawing on 14 in-depth interviews and field notes of meetings and processes. Our analysis suggests that building systemic capacity for LCD requires leadership to be expressed as a strategic priority by those with positional authority and that bottom-up LCD requires institutional commitment through strengthening routine structures or creating new ones. The ability to leverage existing resources is another key element of systemic capacity. The mechanisms that enable bottom-up capacity development include tacit and experiential knowledge, sensemaking, systems thinking and trust between, and motivation of, those tasked with leading LCD. Leadership development is constrained by increased workloads for those involved as the prioritization of leadership becomes simply an additional task, and sustainability challenges are likely in the absence of additional resources for bottom-up innovation.
地区卫生系统中的领导力对于有效提供服务以及卫生领域的部门间合作至关重要。然而，领导力能力发展（LCD）在卫生系统中并未得到优先重视，培养能够发挥领导作用的管理者所需的系统能力（即角色、结构和流程）也并非总是具备。本文旨在通过考虑一项相关的自下而上的创新，为理解如何构建这种能力做出贡献。在2013 - 15年期间，我们观察了南非一个卫生区对这一创新举措（“领导力委员会”）的初步实施情况。最初旨在培训个体领导者的努力逐渐演变成了LCD系统能力的发展。我们采用现实主义评价作为主要方法，以及案例研究设计，首先通过与高级管理人员的一轮访谈，制定了内部驱动的LCD倡议的项目理论。然后，我们利用14次深入访谈以及会议和流程的实地记录对该项目理论进行了测试。我们的分析表明，构建LCD系统能力要求有职位权威的人将领导力作为战略重点来体现，并且自下而上的LCD需要通过加强常规结构或创建新结构来实现机构承诺。利用现有资源的能力是系统能力的另一个关键要素。实现自下而上能力发展的机制包括隐性和经验性知识、意义建构、系统思维以及负责领导LCD的人员之间的信任和积极性。领导力发展受到参与人员工作量增加的限制，因为将领导力作为优先事项仅仅变成了一项额外任务，而且在缺乏自下而上创新的额外资源的情况下，可能会面临可持续性挑战。
