**4. Leadership development in the health care sector**

One of the main goals of competency identification and assessment in health care organisations is to facilitate the development of competency or competence frameworks which are applicable to specific organisations or groups of individuals. Competence-based systems serve as useful means of identifying gaps in proficiency to inform appropriate training, education, or professional development to improve individual competence and organisational performance [69]. The basis for the use of training and professional development to improve health management and leadership competence is found in the evidence that human behaviour can be developed in adulthood [70], and that individuals can change their behaviour, moods and self-images through training [71] and education [72].

The importance of improving the competence in health leadership in both management and clinical workforces has been widely emphasised [10, 11, 22, 39, 60, 61, 73]. In the health care sector, approaches and priorities may differ for health management and clinical leadership development. In the light of this, different training and professional development strategies are currently being used to address identified gaps in proficiencies, develop new competencies and improve existing ones. Such strategies include formal training and professional development in the form of structured academic programmes [74], and informal training approaches such as coaching, mentoring, role modelling, work-based or contextual learning and experiential learning [74, 75]. Both training approaches have been recognised as important in strengthening the capabilities of the management and leadership workforce [75, 76], especially in complex systems like health [74]. In health care organisations, competency-based training or professional development can be directed at improving the capabilities of individual managers or leaders for effective performance in roles, a concept known as 'leader development' [77]. On the other hand, such training or professional development interventions 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].

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

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 of leadership development is worth exploring in health care organisations.
