**3. Health management and leadership competencies**

The terms 'competency' and 'competence' are often used interchangeably and inconsistently in health management and leadership literature. However, both terms are distinct concepts. Competency refers to the knowledge, skills, and attitudes which health leaders require for effective performance in roles [10, 50, 51], and can be improved with training and development interventions [51]. Knowledge has been described as a demonstration of the awareness or understanding of the concepts, theories, guidelines, or principles required to successfully perform a task [52–54]. Skill, on the other hand, refers to the possession of the capacity to successfully carry out physical or cognitive tasks to achieve a specific outcome [54], while an attitude refers to "a relatively enduring organisation of beliefs, feelings, and behavioural tendencies towards socially significant objects, groups, events or symbols "([55] p. 150). Certain competencies are considered as crucial for successful performance of organisations; such competencies are known as 'core competencies', a concept first advocated by Prahalad and Hamel [56]. Core competencies have also been described as common competencies which overlap and complement one another and are shared by health managers in a wide range of positions and settings [5]. Although the concept of core competencies engenders understanding and collaboration among individuals, it has been criticised for not taking into consideration the specific needs of each manager in line with his or her dominant management or leadership role [5]. Thus, in addition to identifying core competencies, it may also be useful to identify specific competencies required by certain individuals or members of a professional body for effective performance [5].

a leader varies, depending on the prevailing circumstance or situation [41–44]. According to Smirich and Morgan [45], leadership is a product of interaction between the situation, the leader, and the followers. Other theories which have their roots in contingency theory include transactional and transformational leadership theories, which were introduced by Burns in 1978 [36]. Transactional leaders are associated with contingency rewards (exchange of rewards for compliance) and management by exception (either actively or passively) [27, 36]; they emphasise legitimate power and respect for rules and tradition [46]. In view of the practices associated with transactional leadership, some authors have connected this leadership style with management functions [42, 43, 47, 48]. In contrast, transformational leadership motivates and inspires followers to rise above their personal interest for the sake of the organisation; it empowers employees to participate in the process of transforming the organisation and initiate major changes and reforms [27, 34]. One important outcome of transformational leadership is 'empowerment', which entails sharing of leadership process between the leader and the followers [34, 42]. This feature is consistent with the original idea of Burns that leader-

ship may be exhibited by anyone in the organisation in any type of position [42].

workforces for successful performance in roles.

86 Leadership

**3. Health management and leadership competencies**

Closely related to the notion of 'shared leadership' is a concept known as 'distributed leadership'. As stated earlier, distributed leadership focuses on how actors engage in tasks that are 'stretched' or distributed across the organisation [35]; it sees leadership activities as a situated and social process at the intersection of leaders, followers, and the situation [49]. In practice, leaders from both health management and clinical backgrounds are expected to demonstrate leadership theories as they (the theories) underlie the basis of the knowledge, skills, and attitudes (that is competencies, see below) required by the health management and leadership

The terms 'competency' and 'competence' are often used interchangeably and inconsistently in health management and leadership literature. However, both terms are distinct concepts. Competency refers to the knowledge, skills, and attitudes which health leaders require for effective performance in roles [10, 50, 51], and can be improved with training and development interventions [51]. Knowledge has been described as a demonstration of the awareness or understanding of the concepts, theories, guidelines, or principles required to successfully perform a task [52–54]. Skill, on the other hand, refers to the possession of the capacity to successfully carry out physical or cognitive tasks to achieve a specific outcome [54], while an attitude refers to "a relatively enduring organisation of beliefs, feelings, and behavioural tendencies towards socially significant objects, groups, events or symbols "([55] p. 150). Certain competencies are considered as crucial for successful performance of organisations; such competencies are known as 'core competencies', a concept first advocated by Prahalad and Hamel [56]. Core competencies have also been described as common competencies which overlap and complement one another and are shared by health managers in a wide range of positions and settings [5]. Although the concept of core competencies engenders understanding and collaboration among individuals, it has been criticised for not taking into consideration the Competence is the ability to consistently produce the outcomes (of behaviour) required for effective achievement of organisational goals [57]. In other words, a competent health manager or leader possesses the requisite knowledge, skills and attitudes that enable him or her to manage or lead effectively. The term 'proficiency', or 'competence level', refers to the level of expertise for a particular competency. A 'competency model' is a framework which contains competency statements in which essential knowledge, skills and attitudes desirable for specific roles are described [57], or a collection of competencies required for successful performance [58]. A 'competence model', on the other hand, refers to a framework which describes the process and work outputs required to achieve the set goals of specific roles [57].

Other terms commonly associated with competency are 'capability' and 'capacity'. Capability refers to the process which allows individuals to demonstrate or express the required competencies on their jobs; it is the ease with which the required competencies can be accessed, deployed, or applied by individuals [59]. Capacity, on the other hand, refers to the power or ability of individuals to hold or possess the required competencies at a level considered sufficient for a role [59].

As pointed out earlier, several studies have been conducted on health management and leadership. The majority of these focused on identification and/or assessment of essential competencies required by health managers and leaders for effective performance in management and leadership roles. The focus on competencies has been informed by the need to develop strong and competent health management and leadership workforces, given the pivotal roles of leaders from health management and clinical backgrounds in driving changes and leading development in health care organisations. This much has also been recognised by the World Health Organisation, which has advocated the need to strengthen management and leadership capabilities at all levels of the health system [60, 61]. Different approaches are being used to identify and assess essential competencies required by health management and leadership workforces. These approaches include literature review, position description analysis, the Delphi technique, surveys, interview of job incumbents and focus groups. The optimal approach recommended for identification and assessment of competencies involves the use of multiple methods to improve the credibility of findings [54, 62].

A major point of contention in health management and leadership is whether competencies are similar across countries and organisational contexts, or are contextually sensitive. While some authors have argued that certain 'core' competencies are applicable to most health contexts [5, 11], others have advocated for more contextually compatible competencies based on the premise that competencies may be influenced by contextual factors such as demographic characteristics of personnel, as well as the size, culture and needs of organisations [12, 22, 63, 64]. Notwithstanding the argument, certain domains of competencies have been identified across several studies as important for health management and leadership roles, regardless of the contexts in which those roles are performed. These domains include communication, interpersonal relationships, business skills, knowledge of the health care environment, professionalism, and leadership [5, 10, 11, 65]. A close look at these domains of competencies shows that some, including communication, interpersonal relationships, professionalism and leadership, are people and relationship centred. This is not surprising, given the fact that health care organisations are comprised of human systems where people of diverse backgrounds interact with one another for successful management of the health care system [66], and provision of safe, effective, and high-quality patient care [67, 68].

can be targeted at strengthening the collective capabilities of the entire management and leadership workforce to achieve 'leadership development' [78]. A more common approach, however, is to focus training and professional development on expanding the capacity of individual managers and leaders to be effective in management or leadership roles [77].

The Concept of Leadership in the Health Care Sector http://dx.doi.org/10.5772/intechopen.76133 89

Notwithstanding the crucial place of training and professional development in health management and leadership, evidence of the impact of such development interventions on competence and performance is limited and contentious. While some authors have stated that the evidence linking competency-based training to improved competence and performance remains inconclusive [79–81], others have posited that a positive relationship exists between training and improvement in competence and performance outcomes [22, 82]. Thus, in addition to identifying requisite competencies and corresponding training or professional development opportunities, health care organisations and researchers should put in place appropriate mechanisms to assess the effects of such development interventions on individ-

ual competence and, mediated by competent leadership, organisational performance.

of leadership development is worth exploring in health care organisations.

**5. Conclusions**

Although the competency-based approach has much to offer related to development of leadership capabilities, it has, however, been criticised for focusing mainly on developing specific behaviours considered as essential for successful performance in roles, while ignoring the internal processes which underlie those behaviours [83]. Such internal processes include emotions, mindsets and personal life experiences which significantly impact the behaviours exhibited by leaders [83]. Thus, an approach to leadership development, which focuses on leaders as complete individuals (as against the current practice of concentrating on specific behaviours), has been advocated to ensure holistic leadership development [83]. This model

The health care sector is complex, characterised by constant changes and reforms. Strong and competent management and leadership workforces are thus required to navigate the sector through the complex web of interacting factors and lead reforms for effective and efficient health care delivery. An added challenge to leadership development is that leadership is spread across health management and clinical workforces; while some clinical leaders may work in management roles, for others leadership is exercised from a clinical position. The need for competent management and leadership workforces has fuelled an upsurge in interest in health management and leadership, as reflected in the large number of studies examining the concept across different countries since the turn of the century. A notable trend in health management and leadership literature is the increasing focus on identification and assessment of essential competencies required by leaders from both health management and clinical backgrounds for effective performance in leadership roles. The purpose of competency identification and assessment in most cases is to inform the development of competency frameworks which are used to assess performance, identify gaps in proficiency and target appropriate training and development opportunities. However, evidence for the impacts of

Although certain competencies may be common to most health contexts, in practice they are likely to be demonstrated differently, depending on certain factors such as management levels and sectors [5, 11, 14, 21]. In other words, while some competencies may be similar across most health contexts, the competence level (proficiency) required to demonstrate them will vary from one management level or organisational setting to another. Thus, in addition to identifying the essential competencies required by health management and leadership workforces generally, the health care sector should also focus on the competencies required by specific groups and organisations.
