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THE FIVE LEVELS OF LEADERSHIP

A leader is a person who inspires others to action and guides their undertakings. These others can
be members of a team employees of an agency, or head of groups that had formed a coalition, an
alliance, or a partnership, for example. In other words, leaders in public health, as in other arenas,
operate on different levels. The major difficulty in conceptualizing what leadership is relates to the
fact that we live in an ever-changing world that demands that leaders adapt to this changes in a
continuous way. Each day leaders face new technical challenges for which solutions need to be
found. These challenges require more than the usual solutions tied to an authoritative position or
to the standard operating procedures of an organization in community. All we need to do is look
at the events of September 11, 2001, to see that the world has changed. Heifetz and Linsky pointed
out that these adaptive challenges require solutions that are innovative, perhaps experimental, and
create new forms of adjustment. Adaptive change may require a change in attitude, values, and
behavior, or a new interpretation of events.
Sometimes this new perspective may involve trying to see the situation from the perspective of
others. I have suggested to students that simply changing their seats from one class session to
another will give them a new perspective of me as teacher. I recently saw this effect in a
management training program. The trainees were asked to develop a new public health program
during the first six months of the training. During the second six months, the trainees task was to
develop a business plan for their new program. They reported that the business plan project gave
them a whole new perspective on their project and the feasibility of making the project work.
Heifetz and Linsky have added a variation on this technique, which they named the balcony
exercise. If you are at a dance, you tend to concentrate on dancing with your partner. If you go to
the balcony between dances, you get a different view of the proceedings.
It is also important to understand what entices people into leadership roles. Over the last 20 years,
there has been a strong belief that leadership can be taught. Many public heath leadership programs
have come into being with the goal of training public health professionals to be better leaders with
the belief that leadership is one of the key dimensions in building a stronger public health system.
Parks has stated that there are important explanations of why people want to be leaders. She calls
these explanations hungers and discusses five of them as follows :
1. Hunger to contribute and make society better
2. Hunger to be in an authority position
3. Hunger to implement and explore systems issues
4. Hunger to show others how to adapt to change
5. Hunger to demonstrate moral courage in behalf of the common good
This chapter first discusses the abilities that public health leaders need any level, including the
personal level (i.e., when dealing with another individual one on one), then goes on to consider the
particular abilities and strategies that they put to use in heading a team, heading an agency, working
within a community collaboration activity, or guiding their profession toward improvement. As
we proceed, it is important to remember that each of the five level of leadership provides a
foundation for the next level of leadership. It is almost like going up a flight of stairs on which we
need to go up the first stair before going to the second stair. Skipping a stair might trip us up.

Personal Leadership Development

This section considers some of the prerequisites for being an effective public health leader at any
level. These prerequisites include a commitment to social justice, an understanding of democracy,
an understanding of the political process, communication skills, mentoring skills, decision-making
skill, and the ability to balance work and life outside work.

Values
Public health leaders, to be fully effective, must be committed to the values that characterize public
health, especially social justice. However, they need to be careful not to be done. Furthermore,
social justice is a broad concept and encompasses a range of different issues. The predominant
social justice issue of concern to almost all public health leaders is equity in access to care. On the
other hand, no consensus exists that, for instance, there should be a radical redistribution of wealth
in the society at large.
A commitment to a value such as equity in access to care entails a willingness to challenge the
political status quo and act as an advocate for the public health agenda. Leaders are supporters of
organizational and community values and should be on the front lines in attempts to make public
health practices and policies conform to these values.

Politics and Governance

Public health leaders need to understand the political system of the location in which their activities
take place. In this country, they need to understand how the American version of democracy works
at the local, state, and national levels and how to influence the political process. As an example,
the
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Public health leaders are often the heads of public health departments or agencies and thus need
agency-level leadership skill as well. Their duties as agency heads include such things as mission
and vision statement development, fund raising, job performance evaluation, and role modeling.
At the agency level, leaders also see systems thinking in action. It its the big picture that guides
our work.
Public health is obviously community oriented, and so public health leaders need to be able to play
a major role in the community, by acting as advocates on public health issues and building
coalitions to deal with such issues. They thus need advocacy skill and coalition-building skills,
among others. At the community level, we can see the passion and commitment of our partners.
Finally, public health leaders, like other public health practitioners, have an obligation to try
improve the field of public health, by becoming involved, for instance, in professional
organizations such as the APHA, NACCHO, ASTHU, and NALBOH. Many leaders have told me
that he networking that occurs at the national level is important and help leaders to sustain then
strong beliefs that public health can make a difference. Fighting our battles legislatively becomes
easier when we work with our public health colleagues. Professional friendships often become
lifelong.

Discussion Questions
1. What is the difference between politics and governance?
2. What is the relationship between communication and empowerment?
3. What are several of the main barriers preventing public health leaders from being as
effective as they could be?
4. What is one way public health leaders can deal with the increasing cultural diversity in the
public health workforce?
5. What are some of the main reasons for creating and using teams?
6. What are the main agency-related responsibilities of public health leaders?
7. What are the main community-related responsibilities of public health leaders?
8. How can partnership differ from other types of collaborative relationships?
9. How can public health leaders further the interest of public health profession?
Exercise 6-1 : The Drawbacks and Benefits of Professional Diversity
Purpose : to explore how professional diversity affects public health decision making
Key concepts : decision making, diversity professionalism
Procedure: there has been an increase in teen gang violence in Midcity over the last 10 years. The
mayor and the city council have asked the Midcity Department of Health to develop a plan to
address this public health problem. The class should divide into teams to discuss the problem. Each
team will have a designated leader from a different profession (e.g., physician, nurse, social
science, environment health specialist, or business expert). In addition to discussing the issue at
hand, which should be done for half an hour, each team should reserve 5 to 10 minutes to examine
how the professional background of the leader influenced the process and the outcome of the
discussion. Each team will then report its conclusions and observations to the class as a whole.
Exercise 6-2 : leadership and Team Building
Purpose : to explore leadership behavior in team situations
Key concepts : team building, leadership in teams, leadership style
Procedure : using the Mallory personality typology, each group member, using the worksheet,
should classify him- or herself as one personality type or as a combination of types and analyze
the degree to which he or she possesses the characteristics associated with all four types. The group
should then break into teams and discuss the results of the self-evaluations, focusing on issues that
are critical to team development, such as team communication, discussion facilitation, consensus
development, priority setting, and conflict resolution.
Table 6-5 worksheet for team building
Utilizing the personality typology for leaders, classify yourself relative to the percentage of each
type that you may have. Fill out the worksheet and discuss it with your team development.
1. Name

2. Personality Type % of this type

Dominant
Influencer
Balancer
Loyalist
3. Previous outstanding achievements in team activity, if applicable
4. Previous problems in team activity, if applicable
5. Outstanding achievements in overall job performance
6. Problems in job performance
7. How you act under pressure
8. How you react to a lack of structure
9. Ability to get along with others
10. Potential future position in agency
11. Current extracurricular activities requiring teamwork
Exercise 6-3 : a community in crisis
Purpose : to explore the role public health leaders play in dealing with a natural disaster
Key concepts: collaboration, community crisis, strategic planning
Procedure: in February, California in hit by storm after storm. The town of Crisona is flooded for
a two-week period, the entire town is evacuated, and eventually mudslides begin to occur in the
surrounding hills.
The class should divide into teams of 6 to 10 members. In each team, half the members are assigned
to play the role of Crisona City Council members, including the role of the mayor and of the
Crisona department of Public Health. The remaining team members are to act as community
leaders, These leaders and the head of the Department of Public Health testify about the disaster
and offer suggestions for addressing it. The city council listens to the testimony and then works
with the community leaders to develop a strategy for dealing with the crisis. The whole team
should develop a one-page consensus statement outlining a strategy for responding to the crisis.