Think Big. Start Small. Act Now.
From Egypt to Afghanistan—A South-to-South Leadership Development Exchange

In May 2005, 15 Afghan doctors visited Upper Egypt's Aswan region, where health staff are continuing the leadership development begun with Management Sciences for Health under the USAID-funded cooperative agreement, Management and Leadership Program (M&L), from 2002-2003. Because they perceived fundamental similarities between the two regions, Afghan visitors reported that the techniques they witnessed in the traditional Islamic setting of Aswan could also work in the health sector of Afghanistan, which currently faces significant challenges. In Aswan, leadership facilitators say: "Think big. Start small. Act now." This concept resonated with the Afghan visitors. With his country's specific challenges in mind, one Afghan doctor explained, "We will start in one place within a province, and like when dropping a stone in a pond, the ripples will spread to the rest of the country."

All health systems need managers that lead—those that inspire people to face challenges and work together to achieve results. Such leaders are needed at all levels of any health system. This is a guiding belief of the M&L Program, which works with health organizations in both the public and private sectors around the world to encourage and guide leadership development. The M&L Program strives not only to promote leadership within the health sector, but also to ensure that any leadership approach is appropriate, desired, and self-sustaining. M&L is also guided by the belief that leadership development becomes a valued and permanent part of people's lives only when it is driven by local interests; the M&L Program aims to promote leaders today who will teach leaders tomorrow.

One M&L activity promoted just such a transfer recently, when provincial managers from Afghanistan's Ministry of Public Health visited a locally owned leadership development program in Egypt's Aswan region. M&L worked with health staff in Aswan from 2002-2003 to develop leadership at the front lines of the local health system. That leadership development program is now maintained by Egyptian staff, who are eager to impart their successful process. They want to reach out to other health managers looking for efficient ways to improve services not just with capital investments, but with an investment in human resources that promotes strong leaders who are ready to address health challenges effectively. An investment in leadership development, according to the health staff in Aswan, yields benefits that are long-term and tangible.

Aswan's vision

Not long ago, health clinics in the impoverished Aswan region faced numerous difficulties. The region had dismal health statistics and the population was dissatisfied with the level of care available. Overcome by seemingly insurmountable challenges, health staff in Aswan lacked motivation to deal with the problems they encountered on a daily basis.

Aswan doctor Morsy Mansour attended an M&L presentation on the Leadership Development Program (LDP), which enables front line health care workers to "own" the processes that improve health delivery services. He came out of the LDP presentation believing that the approach might be an appropriate way to address the Aswan health sector's significant organizational challenges. Under the LDP, health staff themselves conceive of solutions to challenges they encounter in their workplace, and with this ownership they increase their commitment to improving services.

In 2002, MSH and the Egypt Ministry of Health and Population began a pilot Leadership Development Program in three different districts of the Aswan region. Less than a year later, Aswan's discouraging situation had changed dramatically. By promoting leadership and engaging all staff in the process of improvement, health unit teams in Aswan were working more effectively than ever to improve service results. All teams that participated improved their family planning and maternal/child health service indicators. News of their dramatic results quickly spread throughout the region. Now, three years later, there are more than 100 teams using LDP leadership methods in Aswan, and health indicator improvements have continued.

When program funding and assistance from the M&L Program ended in June 2003, Aswan district teams continued the leadership process they had begun, though now without additional funding or technical support. To date, the teams have developed 36 facilitators—nurses, doctors, and other health workers—to champion additional LDP teams throughout the region. The original 10 LDP teams have grown to over 100. Dr. Monsour is now the Director of the Leadership Development Program in Egypt, and is working with the teams to expand the program to the whole Aswan region by the end of 2005. The program is now entirely led and supported by local facilitators and district managers, and all resources to support the program come from local health units. Recently, Aswan facilitators have been called to three other regions of Egypt to help health staff there develop similar leadership programs.

Aswan LDP teams report improvements in family planning, infection control, vaccination coverage, and patient visits. Dr. Barakat Sayeed, General Director for Health for the Aswan Governorate, offers his appreciation and support for the results: "Now there are leaders throughout the governorate!"

South to South

USAID Chief Technical Officer (CTO) Susan Wright visited Aswan's LDP teams in January 2005. She was impressed by the teams' enthusiasm and commitment to their program, as well as the improvements in health indicators that have accompanied team activities. Believing that the low-resource, self-sustaining LDP model could be developed in other countries, she shared her experiences in Egypt with colleagues at USAID. Jim Griffin, CTO for the REACH Project in Afghanistan, recommended that a group of Afghans travel to Egypt to learn about how a low-resource, rural leadership program at the district and health unit levels was improving health results.

The team of fifteen physicians from Afghanistan representing eight provinces arrived in Egypt in May 2005, for a tour of the Leadership Development Program. In Aswan, the Afghan group met with health unit teams and community members to hear about how the LDP teams had improved health indicators in the area. The Afghan visitors were amazed by the similarities between the Faris village they visited in Aswan and their native Afghanistan. "The culture of the village is the same as our villages in our country," one Afghan doctor remarked. "We saw people from a traditional culture using and supporting modern maternal and child health practices."

The Afghan doctors were impressed by the level of participation of all health staff, praising the leadership program's democratic nature. One Aswan health unit clerk left a particularly good impression on the Afghan doctors with a presentation in which he analyzed the problems of his health unit, demonstrated his team's planning chart, and illustrated his personal accountability for overcoming obstacles. The other presentation that stood out for the Afghan doctors was that made by a female lab technician, fully covered in Nikab, with only her eyes showing. She spoke about Muslim female leadership in the health sector in Aswan, and how the LDP's leadership process had enabled her personally to practice the principles of her religion through her work in the health sector. The technician's presentation sparked a discussion among the Afghan doctors and their Aswan counterparts on the distinction between commitment and compliance in both religion and the workplace—the consensus was that the technician's choice about her work was a commitment freely made, based on her beliefs.

Through this south-to-south exchange of learning and experience, Aswan LDP teams were able to convey the key elements of the leadership development program to the visiting Afghan professionals and demonstrate LDP tools and principles in practice. The Afghan group reported they were able to feel the credibility of the LDP process by witnessing it firsthand in Aswan.

The interaction of the Aswan and Afghan teams was highly beneficial. Because they perceived fundamental similarities between the two regions, Afghan visitors reported that the techniques they witnessed in the traditional Islamic setting of Aswan could work in the health sector of Afghanistan, which currently faces significant challenges. "We will bring strong leadership to the health system in Afghanistan," the Afghan doctors reported at the end of their visit, clearly enthused by what they had seen of the LDP and hopeful about its application in their own country. With Afghanistan's specific challenges in mind, one Afghan doctor explained, "We learned not to be heart broken about the conditions in our country. That we can, using our own resources, mobilize our people to improve the health system—this is what we learned from the people in Aswan."