Our stickiest social problems often persist for decades and sometimes centuries – even in the face of compelling evidence and widespread support for change. Consider the United States’ inability to put in place sensible gun controls, or our collective inability to take the action needed to prevent further climate change. 

But sometimes glimmers of change start to emerge. And before we have fully realised, the boulder is crashing down the mountainside, reshaping the landscape. Think of the Indian Independence Movement in the 1940s, the establishment of universal healthcare in Europe after the Second World War, or the American Civil Rights Movement in the 1960s. 

Health leaders are grappling with these types of complex problems, trying to find ways to inch the boulder forward. Take the shift from treatment to prevention in health, or the even bigger shift from healthcare towards population health. Professionals, from doctors to researchers, largely agree on the case for change. Yet, for the moment at least, the system remains impervious to change, ploughing funding into late-stage health services. 

In his article, Jonathon Gray argues that we have conflated leadership with management in healthcare, equipping our leaders with the technical skills to manage established services, but without the full range of skills to lead transformative change. Ben Collins argues that a fundamental neglected skill is cultivating the freedom of imagination to find creative new responses to complex problems, rather than recycling solutions that have already failed.

But to push the boulder forward, health leaders also need to be able to contend strategically with questions of power. Health leaders may wield a degree of institutional power. But in highly contested domains of change, power dynamics within institutions, health fields, and society at large stymie efforts to shift the status quo. 

Achieving any major change requires an intentional strategy to shift the balance of power. Yet, in my view, health leaders often see power as fixed, determined by their position within the institutional hierarchy, their formal accountabilities, the size of their budgets and their institutional boundaries. If leaders perceive this stock of power to be insufficient for the task in hand, a sense of learned helplessness sets in. ‘I’d love to make the change, but I’m prevented by others’.

The leaders of successful social movements – say the Indian Independence Movement or the American Civil Rights Movement – understood however that power is not fixed but is a dynamic relationship. In many cases, these leaders wielded little if any formal institutional power. But necessity is the mother of invention. These leaders understood that power was not conferred by others but instead the product of a set of strategic choices that they could make. 

Political theorist Steven Lukes argues that power has three dimensions: visible, hidden and invisible. Visible power is the formal exercise of decision-making authority: voting in elections or making decisions within an organisation. Hidden power encompasses the systems and structures that shape how decisions are made: who gets a vote or a seat at the committee meeting, who sets the agenda and decides which votes will take place. Invisible power includes the beliefs and assumptions about how the world works that are often embedded into our institutions, professions and societal structures and shape how we understand the world. 

If health leaders are genuinely committed to achieving transformative change, they will need to attend to each of these types of power. When leaders start doing this, they may find that they have more influence over these three domains of power than they initially realised. Leaders make myriad choices that shape power each day, from deciding whether voluntary sector organisations or service users sit in your board meetings to deciding how much of their time is spent shaping people’s understanding of the problems and potential solutions in healthcare. Leaders can decide how much they want to invest in working with others to develop their motivations and capabilities to lead change. 

Leaders will need to do more than simply winning supporters to their cause. Grassroots organising and collective actions have always been fundamental to change. But much of that organising has failed to deliver the desired impact. 

To gain traction, leaders must make the investments in people necessary to turn supporters into agents of change, people who can act with lasting influence. In the world of social movements, a leader makes two strategic choices: first to engage others, and second to invest in their own leadership. 

In my experience, successful transformative leaders in health invest specifically in developing the skills of those around them, including young leaders, the voluntary sector and civil society so that everyone can engage actively in shaping health and healthcare. The Commonwealth Leadership Institute, and the Young Leaders’ fellowships, provide a new foundation for doing this.

Leading Across the Commonwealth and Beyond captures vital conversations between global health leaders and emerging voices. In this blog, we explore how to redefine how we lead with compassion, connectivity, and courage in an increasingly complex world.

Author

Hahrie Han

Hahrie is a political scientist at Johns Hopkins University and Director of the P3 Lab at the SNF Agora Institute. Her work focuses on social movements, civic engagement, and how communities mobilise to create social change. She is known for connecting theory with practice, partnering with grassroots organisations to strengthen their ability to organise and transform systems.

Declaration of Interests
No conflicts of interest to disclose