Leadership in Health Services

ISSN: 1751-1879

Article publication date: 27 April 2012



(2012), "Editorial", Leadership in Health Services, Vol. 25 No. 2. https://doi.org/10.1108/lhs.2012.21125baa.001



Emerald Group Publishing Limited

Copyright © 2012, Emerald Group Publishing Limited


Article Type: Editorial From: Leadership in Health Services, Volume 25, Issue 2

It is always good to start an issue with a viewpoint. In this case, our viewpoint is provided by Dr Victor Maddalena’s of Memorial University, Newfoundland, who has written about the importance of project management in health management. Intended for students or novice leaders, his viewpoint starts by discussing strategic planning – an essential focus for any seasoned leader – and the importance of establishing key priorities and advancing the mission and aims of the organization and then the implementation of project management skills and procedures to advance the plan.

In my experience, every student of leadership learns in the classroom about the importance of vision. It is always a curriculum item. However, in practice, in today’s ever-changing real world, visions can get all too easily lost in the complex environment of budget shortages and difficult business and political climates. It does not matter where you are on the planet, the health environment is always on someone’s agenda. Someone always wants to do it cheaper, more effectively, faster, and/or differently. This is surely a good thing. How else would we be able to learn from each other if we did not share this type of information or our opinions with each other? Fortunately, social and electronic media make this type of sharing so easy. But at the same time, the plethora of knowledge makes it even more important to really know how to implement projects. How can we use them to better test our ideas, and build our visions, particularly in these unstable political and economic climates?

This is why we, as editors, chose to lead with this simple piece by Dr Maddalena. As overwhelmed by change as we are, it is very easy to forget the basics. Where does change start? It starts with us, and how we implement it through the projects in our workplaces. It can never be business as usual, because business, particularly health business, is not usual. As the viewpoint reminds us, every plan can be easily derailed by the unexpected. But reminding us of the basics can help us to have a better understanding of how and where to start in our daily business of leading in organizations. In my mind, a project is like a brick – a building block in our effort to make our healthcare workplaces more relevant to our changing world. For this reason, Dr Maddalena’s piece offers timely advice.

Healthcare roles are changing. Not only is there the technical difficulty of how to manage projects, there is the ongoing dilemma of competing loyalties, particularly for middle managers. Dr Eric Carlstrom writes from Sweden about how the role of middle managers in health care is caught in a dilemma of conflicting loyalties, particularly as a result of ongoing fiscal constraints. His article, entitled “Middle managers on the slide” (surely a nice use of metaphor?), focuses on how cost savings influence the position of middle managers caught between the pressures of advocacy and governance. His research is based on interviews with 25 Swedish middle managers from public health care organisations. His findings suggest that, as we can imagine, their loyalty is contested between the competing pressures inherent in their in-between role. As middle managers, their roles are based on the traditional tenets within “care itself”. However, because of the tenuous economic climate of the institution itself, they all too often have to take on what Carlstrom calls “advanced management tasks”, around achieving cost savings, reducing personnel, making people redundant, and even closing operations. Thus, he suggests, middle managers are all too often sliding out of their traditional role and entering the middle ground between management and operations.

These implications are important for our general consideration of the training required for middle managers. Although Carlstrom’s research is limited to Sweden, his findings surely have a more generalised application. Middle managers, all too often recruited to their positions because of their health care expertise, need to understand both business and leadership. The prerequisites of project management that Maddalena discusses are essential. In this world of increasing role ambiguity and loyalty testing, however, technical skills are not enough. They also need to learn about management control, conflict management, and the role of leadership in today’s modern healthcare environment so that our managers are more adept at acting in ambiguity and can slide more easily within the conflicting demands of their positions.

Dr Kerstin Nilsson also writes about roles and change in Sweden in her paper “Learning leadership through practice”. The paper concerns the role of health care managers, specifically about the 4,000 head nurses, and 1,300 head physicians employed by Swedish county councils These individuals are expected to handle a multitude of different roles, including those involving structural, technical and business concerns within their institutions, provide “holistic” and patient-centred care, and at the same time be responsible to develop staff competencies and build leadership. Despite these responsibilities, no formal leadership qualifications are required for their role. Using a qualitative research approach, based on critical incident technique, this paper reports on healthcare managers’ experience of learning leadership through practice.

This analysis in part demonstrates the power of learning about leadership through the narration of personal stories, although Nilsson never actually talks about personal stories. She does, however, refer to “recorded narrations” from the managers which tell how they have to lead reorganization, perform developmental work, and be involved in conflicts. As they describe it, these become a platform for learning that brings about important insights in the form of personal development, and increased awareness of interpersonal leadership qualities, and strategies. In particular, Nilsson emphasises the importance of conflict situations as an important basis for learning outcomes.

Personally, I believe the importance of this paper is the power that reflection, and sharing with others has in the development of personal growth. An important question for me is how to build workplaces that can provide people with the opportunity to have these reflective and learning narratives with each other outside of a research study? Nilsson’s paper also provides insight into the power of conflict from something all too often considered undesirable, to a powerful tool for personal development. Overall this research reminded me about the power of building work cultures that encourage people to talk with each other about their on the job experiences as a means of building personal and organisational learning.

Finally, we have two very different types of papers, one examining an innovative market driven business model of a Saigon Eye Hospital in Ho Chi Minh City, Vietnam by Tuan Luu. The other, written by Sinimole K.R., involves the evaluation of the efficiency of national health systems in 180 countries making up the membership of the World Health Organisation.

I first learned of what is possible in market-driven healthcare systems through the work of C.K. Prahalad, and his wonderful little book called The Fortune at the Bottom of the Pyramid (Prahalad, 2004). In this book Prahalad uses the concept of microfinance to show how the very poor, usually ignored as targeted consumers in the traditional market economy we live in today, are in fact a potential engine for global prosperity and entrepreneurship. All we have to do is to think about them differently and see them as partners in new economic models within the capitalistic system we live in. To this end, his description of the Aravind Eyecare system, headquartered in Madurai, India is an amazing insight into what is possible in giving people the gift of sight. The Aravind surgical teams boast an outcome rate that is the best in the world. It is a private model, likely impossible to replicate in the Western world, yet it throws so much of what we know of the delivery of this particular kind of health care on its head.

Luu’s paper describes – at least to my mind – a similar model of eye care operating in Ho Chi Minh City. His paper is based on the analysis of data from the case research provided by the hospital. He describes this eye hospital as innovative for a number of reasons – including the visionary level-five leadership style of the founder and CEO, Dr Thai Thanh Nam, the market driven model it is founded on, the human resource processes it has developed which allow for major cost reductions, and the brand it has succeeded in building. Market driven as the paper reminds us, is based on Dr Philip Kotler’s definition of the creation of a need that does not exist before. In this case, the largest marketing segment in Vietnam is the poor – that category of people which will define future markets and provide potential for entrepreneurial directions, as long as visionary people are willing to think and act outside of the tenets of traditional market research.

I believe the power of this kind of paper is not only the research it is founded on, but also the demonstration of how much we can learn from competing models of health care delivery. We do not have to be stuck with what we have and know. There are alternative models if we are prepared to learn about them, dare to act, and challenge our mutual status quos. Luu concludes his paper by telling us that this is an exploratory study, although he notes that it has much to offer in advancing our understanding of how leadership behaviours can advance clinical outcomes. In a world that cries out for more effective leadership, we have much to learn from the kind of model this author describes.

Sinimole K.R.’s paper by contrast researches a much bigger picture. Using a methodology called data envelopment analysis, the paper models and measures the efficiency of National Health Care Systems from countries making up the World Health Organization (WHO). The results are surprising. Using WHO data from 2008, the findings are that 45 of the 180 countries in total are efficient. The authors indicate that many of these countries are poor, with low input values (i.e. low expenditures on health and low density of health personnel per 10,000 in population), yet have some impressive output values where almost 90 per cent of children are covered by immunisation schemes. The authors also note the relative inefficiency of more highly developed countries such as the USA in terms of very high inputs of money and manpower yet with similar outcomes to countries where health investment is much lower.

This paper will be of much interest to researchers who want to learn more about the relative health outcomes between different countries. The methodology also provides a pathway into further research for the assessment of global comparative healthcare performance. However, as the authors warn, the volume of data available for these research purposes has increased considerably, even since 2008, and can easily lead to data overload. It is important to synthesise meaningfully, or the message will get lost in the sheer size of the material available.

This issue provides more global news about healthcare initiatives in the news and views section contributed by my co-editor Jo Lamb-White. Once again, thank you to all our contributors and readers for your ongoing support. We trust that you will find this issue to be of value in your ongoing health service leadership considerations.


Prahalad, C.K. (2004), The Fortune at the Bottom of the Pyramid, Wharton School of Business, Philadelphia, PA

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