Abstract
Clinical leadership is recognized as a crucial element in health system strengthening and health policy globally yet it has received relatively little attention in low and middle income countries (LMICs). Moreover, analyses of clinical leadership tend to focus on senior-level individual leaders, overlooking a wider constellation of middle-level leaders delivering health care in practice in a way affected by their health care context. Using the theoretical lens of ‘distributed leadership’, this article examines how middle-level leadership is practised and affected by context in Kenyan county hospitals, providing insights relevant to health care in other LMICs. The article is based on empirical qualitative case studies of clinical departmental leadership in two Kenyan public hospitals, drawing on data gathered through ethnographic observation, interviews and focus groups. We inductively and iteratively coded, analysed and theorized our findings. We found the distributed leadership lens useful for the purpose of analysing middle-level leadership in Kenyan hospitals, although clinical departmental leadership was understood locally in more individualized terms. Our distributed lens revealed medical and nursing leadership occurring in parallel and how only doctors in leadership roles were able to directly influence behaviour among their medical colleagues, using inter-personal skills, power and professional expertize. Finally, we found that Kenyan hospital contexts were characterized by cultures, norms and structures that constrained the way leadership was practiced. We make a theoretical contribution by demonstrating the utility of using distributed leadership as a lens for analysing leadership in LIMC health care contexts, revealing how context, power and inter-professional relationships moderate individual leaders’ ability to bring about change. Our findings, have important implications for how leadership is conceptualized and the way leadership development and training are provided in LMICs health systems.
Highlights
Leadership plays a key role in improving care quality, performance and outcomes in health systems globally (WHO, 2008, Gilson and Daire, 2011, Alliance for health policy and systems, 2016) and having doctors and nurses in leadership roles has been found to be important in driving health service improvement (Ferlie and Shortell, 2001, Ham, 2003, Fitzgerald et al, 2013, McGivern et al, 2015)
By focusing on county hospitals in one low and middle income countries 7 (LMICs), we show how distributed leadership provides a useful lens for understanding clinical leadership and, in doing so, provide lessons for others analysing leadership in other LMIC health care contexts
We found clinical departmental leadership was heavily affected by taken-for-granted individualised concepts of leadership, top-down authority and medical professional dominance, reflecting other research on leadership in Kenyan health care (Nzinga et al, 2009), other LMIC
Summary
Leadership plays a key role in improving care quality, performance and outcomes in health systems globally (WHO, 2008, Gilson and Daire, 2011, Alliance for health policy and systems, 2016) and having doctors and nurses in leadership roles has been found to be important in driving health service improvement (Ferlie and Shortell, 2001, Ham, 2003, Fitzgerald et al, 2013, McGivern et al, 2015). Researchers have shown that leadership in health care usually involves multiple leaders from different professional groups, at the top and middle-levels of organisations, whose actions are enabled and constrained by their organisational contexts (Denis et al, 2001, Currie and Lockett, 2011, Denis et al, 2012, Fulop and Mark, 2013, Ferlie et al, 2013, Nzinga et al., 2013, Daire and Gilson, 2014, Fitzgerald et al, 2013) Addressing this oversight, we the use lens of ‘distributed leadership’ (Gronn, 2002) to examine the messy day-to-day practice of middlelevel leadership in Kenyan district hospitals
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