In developing countries, millions of people are gaining access to formal health care for the first time. In industrialized countries, aging populations and chronic, lifestyle-related conditions are adding to demand for health care. Such increases in volume would put strain on any organization. But the challenges are even greater for health systems, which are extraordinarily complex and must coordinate and account for many people, products, services, and resources every day—and the stakes can be life or death. Combined with increasing pressure to improve outcomes, enhance quality of care, and reduce costs, the need to strengthen health systems has become dire.
Great challenges require great leadership, and indeed health systems now require a culture that continually develops new leaders. The World Health Organization includes leadership and governance as one of the six building blocks of health systems. And in a recent McKinsey survey of 40 senior health leaders from around the globe, more than 90 percent cited leadership development as one of their top five strategic priorities. However, in most health systems, leadership and management skills are underdeveloped, and turnover in pivotal positions is high. For example, the worldwide average tenure for a minister of health is only three or four years. Most existing initiatives are not filling these gaps: our survey revealed that 64 percent of leadership programs are considered ineffective.
We set out to identify how health systems could use programs for leadership and management development to improve performance and drive widespread change. As part of our research, we analyzed leadership-development efforts in more than 20 countries, explored the approaches of more than 30 providers of leadership and management training, and examined best practices from successful transformations in both the public and private sectors. The results were staggering. For example, effective leadership programs in municipalities in Brazil have reduced infant mortality by as much as 50 percent; another program in sub-Saharan Africa reduced waiting times in clinics by more than 30 percent and ambulance response times by 70 percent—and it did so within six weeks.
We presented these and other success stories, as well as our initial findings on leadership-development best practices, to more than 40 ministers of health and senior health-systems officials in Geneva in May 2011. In a paper we presented at that meeting, we discuss four principles that should guide health systems’ leadership-development efforts:
- Make leadership development the backbone of health-system reform, not just a complement to it. By grooming current leaders to achieve specific service-delivery objectives and to overcome organizational challenges, leadership programs serve as a powerful engine for reform efforts.
- Create a master plan for leadership development; do not rely on a scattershot approach. To optimize resources and maximize impact, systems must ensure that development programs are well coordinated, reach the right leaders, and build the right skills.
- Strengthen who leaders are, not just what they do. Although many leadership programs build participants’ management skills or technical knowledge, they rarely do enough to help participants deepen their self-awareness (including how they identify and use their core strengths, respond to crises, delegate, and handle conflict); these programs also often fail to provide participants with tools to better motivate, renew, and manage themselves and their time.
- Put existing senior system leaders at the center of leadership development, not on the sidelines. Senior leaders should not only clearly set the direction and communicate an inspiring message, but also visibly model new behavior and actively involve themselves with the front line.
Our paper delineates several recommended actions for each of these four principles and includes a set of seven questions to answer when designing a leadership-development program.
 The other five building blocks, according to the WHO, are good service delivery; a well-performing workforce; a well-functioning health-information system; equitable access to essential medical products, vaccines, and technologies; and adequate financing. For more on these building blocks, see Everybody’s business: Strengthening health systems to improve health outcomes, World Health Organization, Geneva, Switzerland, 2007.
 Jo Ivey Boufford and Francis Omaswa, Strong ministries for strong health systems, African Centre for Global Health and Social Transformation and New York Academy of Medicine, with support from the Rockefeller Foundation, January 2010.