New Leadership for Global Health

(Illustration by Neil Webb) 

In just a few decades, the international community has witnessed a string of successes in the field of global health. Polio cases have declined 99 percent in the past 25 years due to expanded vaccine access. In the same period, child mortality rates have been halved. Thanks to antiretrovirals, an HIV diagnosis today is no longer a death sentence.

But focusing exclusively on these successes masks some vexing failures. Although effective treatments exist, neglected tropical diseases still affect more than one billion people annually, and tuberculosis alone claimed 1.5 million lives in 2018. Only two years after the end of the West Africa Ebola epidemic, which claimed more than 11,000 lives by 2016, public health authorities were once again faced with a sprawling Ebola epidemic in the Democratic Republic of Congo. The new coronavirus, responsible for COVID-19, has already killed more people than the previous respiratory epidemics SARS and MERS combined.

Why, despite often having affordable and effective treatments available, do we still struggle to address these and other diseases? Development agencies and global health researchers commonly focus on financing shortages while arguing that the solution lies in finding more money. While more funding and new technologies are certainly important, they represent only part of the solution.

We contend that not enough attention is placed on one critical blind spot of the global health community: the practice of leadership. Specifically, the Adaptive Leadership Framework (ALF), a tool developed and widely used to address a diverse range of persistent social problems, can help catalyze progress in global health. It offers a nontraditional conceptualization of leadership that will help the global health community to better characterize the challenges it faces and to craft solutions to address them.

Adaptive Leadership

The Adaptive Leadership Framework (ALF) was developed by Ronald Heifetz and Marty Linsky more than 30 years ago at the Harvard Kennedy School. It draws upon theories from psychology, system dynamics, and the humanities to propose a set of theories, tools, and tactics for addressing complex problems that require managing multiple stakeholders and adapting to fluid situations. 

Heifetz and Linsky define adaptive leadership as the act of mobilizing people to tackle complex challenges that cannot be solved solely by applying technical tools such as a new law, technology, or program. This type of leadership requires stakeholders to accept shared responsibility for learning, innovating, and continuously adapting in order to make progress. By focusing on the problem to be solved and its root causes, the ALF allows us to examine how the actions of individuals and organizations contribute to the problem itself and to potential solutions.

Two core components of the framework are particularly useful for global health: identifying adaptive challenges and distinguishing between leadership and authority.

Technical vs. adaptive challenges | In order to understand and address a social challenge, we distinguish between its adaptive and technical parts. Whereas technical problems are usually concrete in nature and easily identifiable, adaptive problems are themselves difficult to define, and their solutions are unclear. Making progress solving adaptive problems requires an arduous process of collective learning on behalf of multiple stakeholders.

Many contemporary global health issues contain both technical and adaptive components. For example, the recent Ebola crisis in the Democratic Republic of Congo, in which more than 2,200 people died, was a complex situation with many adaptive challenges framed by the public health community and the media as purely technical. Most international media outlets focused on the development of new treatments and a new vaccine. By contrast, there was much less attention given to adaptive components of this crisis. The burial of bodies according to local traditions increases the risk of contamination of family members. The underreporting of cases to health authorities, attacks on health workers by local communities, and the difficulty of coordinating within the World Health Organization (WHO) and between WHO and other stakeholders also complicated efforts. WHO country officers often have strong ties to local governments and may be reluctant to raise the alarm about a potential epidemic sooner, because of the economic repercussions of WHO issuing a Public Health Emergency of International Concern (PHEIC)—a legal designation WHO may choose to assign to extraordinary events that constitute a public health risk through the international spread of disease and may require a coordinated international response. While using this mechanism can help draw resources and attention to the epidemic, it can also amplify its consequences.

Distinguishing between adaptive and technical problems is critical because actions that rely primarily on technical solutions to solve adaptive problems almost always fail, no matter what field we are discussing. This helps explain why, despite the existence of technical expertise, the global health community consistently falls short of solving persistent global health issues, such as preventing the emergence and spread of new outbreaks like Ebola and COVID-19.

Leadership vs. authority | The ALF also proposes a nonconventional way of understanding the source of leadership needed to make progress on adaptive issues. While leadership is commonly conflated with notions of authority, power, and charisma, adaptive leadership, by contrast, is an activity or practice that does not depend solely on one’s position of authority. Rather, the task of exercising leadership involves sharing the burden of responsibility for solving a problem with all those who are affected by it.

For example, during the recent Ebola epidemic, the international community struggled to get local communities to adopt international best practices with regard to safe burials. Rather than looking to external authority figures for answers, adaptive leadership asks: How can local people be mobilized to face this adaptive issue and identify their own solutions that both respect the traditions and religious beliefs of the community and protect it from the virus? Community-based participatory research, an approach that emphasizes the inclusion of community members as full partners throughout the research process, can help identify adaptive problems and design adaptive solutions.

The ALF can also help identify leadership and authority challenges between and within organizations. The politics between WHO and other international stakeholders is clearly rife with adaptive challenges. After the 2014 Ebola outbreak in West Africa, world leaders and health experts criticized WHO for the ways in which it handled the epidemic—particularly for its reluctance to declare it a PHEIC, a hesitation that likely led to an increased number of deaths. As a consequence of WHO’s inaction, the international community failed to handle the crisis in a timely manner. This scandal illustrates how the global health community sometimes abdicates responsibility for leadership to actors with formal authority. Instead, the ALF suggests a different approach in which all actors in the global health community are empowered to exercise leadership to mobilize collective action, regardless of any designation of formal authority.  

Actors with formal authority, such as WHO, obviously play an essential role in addressing complex problems. However, the ALF suggests that WHO should exercise leadership by sharing responsibility for generating solutions with all stakeholders rather than by allowing others to avoid responsibility. In contrast to the 2014 Ebola case, the response to COVID-19 appears markedly different. WHO swiftly recognized the threat and declared a PHEIC, and called on countries to prepare themselves for the imminent spread of the disease across the globe.

Finding Balance

The global health community typically focuses on technical approaches to global health problems. To make greater progress, we need to redefine our ideas about the leadership required to address them.

Adaptive leadership starts with observations by conscientious stakeholders, including those with and without formal authority, about the adaptive problems and authority dynamics of a system. This diagnosis phase is followed by an action phase designed to focus all stakeholders’ attention on the adaptive challenges that must be addressed to make progress on the problem. For example, in the context of the current COVID-19 pandemic, individuals may exercise leadership by developing voluntary containment measures, such as social distancing or self-quarantine without relying on formal authorities to tell them to do so. Formal authorities can facilitate this individual response by providing the right messaging and managing the public’s fear and expectations.

Adaptive work inevitably generates resistance because it requires stakeholders to confront their own role in creating problems and to adapt or evolve in order to make lasting change. People naturally seek to avoid this difficult work. Thus, acts of leadership often involve making stakeholders feel uncomfortable enough about the status quo to motivate change, but not so uncomfortable that the process erupts into chaos. Finding this balance is the great challenge of exercising adaptive leadership, and it is especially relevant for those seeking to move national governments into taking timely action in this high-stakes era of global pandemics.

The ALF has the potential to help the global health community rethink the lens through which we view our most pressing challenges. As we identify the underlying adaptive work and redefine leadership as an activity shared across the entire spectrum of stakeholders, the locus of responsibility shifts away from traditional actors in positions of authority (i.e., WHO, heads of state, bilateral donors) and toward all individuals and communities affected by a problem, including those with no formal authority. These tools are important for the kind of leadership needed to mobilize people across all social and political strata to collectively generate the learning needed to make real and lasting change in global health.

Read more stories by Ashveena Gajeelee, Claire Chaumont & Jeff Glenn.