Czabanowska K, Cichowska Myrup A, Aleksandrova O. Women leadership for public health: The added value and needs of women driving public health system reform in Ukraine (Case study). SEEJPH 2018, posted:20 September 2018. DOI 10.4119/UNIBI/SEEJPH-2018-200 1 CASE STUDY Women leadership for public health: The added value and needs of women driving public health system reform in Ukraine Katarzyna Czabanowska1,2, Anna Cichowska Myrup3, Olga Aleksandrova4 1 Department of International Health, CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands; 2 Institute of Public Health, Faculty of Health Sciences, Jagiellonian University, Krakow, Poland. 3 Division of Health Systems and Public Health, World Health Organization Regional Office for Europe, Copenhagen, Denmark. 4 World Health Organization Country Office, Kyiv, Ukraine. Corresponding author: Katarzyna Czabanowska, Maastricht University; Address: Duboisdomein 30, 6229 GT Maastricht, The Netherlands; Telephone: +31433881592; Email: kasia.czabanowska@maastrichtuniversity.nl Czabanowska K, Cichowska Myrup A, Aleksandrova O. Women leadership for public health: The added value and needs of women driving public health system reform in Ukraine (Case study). SEEJPH 2018, posted:20 September 2018. DOI 10.4119/UNIBI/SEEJPH-2018-200 2 Abstract The Ukrainian health care system is undergoing reforms. Although women constitute a driving force in the Ukrainian health system transformation, their economic and decision- making participation remains extremely low. The existence of barriers such as: work/life balance, gender bias, stereotypes, lack of confidence, lack of mentoring, and lack of adequate networking and equal access to opportunities prevent women from reaching high leadership positions. With the aim to empower the current and future female public health leaders, the Ministry of Health of Ukraine and WHO held a seminar entitled “Women’s Leadership in Public Health” in Kyiv on 16-18 May 2017. The seminar was based on the assumption that contemporary public health demands require a more inclusive and less hierarchical style of leadership – focused on developing and working with stakeholder networks. Such a leadership style is more effective in achieving public health goals. The international, interdisciplinary and inter-professional faculty engaged in the interactive meaning making around such topics as: the self-assessment of leadership competencies, public health leadership, leadership theories, system thinking, dealing with interests, power and stakeholders, barriers to women leadership and methods to address them, special leadership tools for women empowerment and leading change, communication and impact. Strengthening health systems for better health was the red thread throughout the whole seminar. Keywords: leadership, public health, Ukraine, women. Conflict of interest: None. Acknowledgements: The authors would like to acknowledge the contributions and participation in the course and its development of: Taru Koivisto, Ministry of of Social Affairs and Health, Finland, Valia Kalaitzi, Mendor Publishers, Greece, Aasa Nihlen, WHO, Denmark, Dr. Olena Hankivsky, Institute for Intersectionality Research and Policy at Simon Fraser University, Canada. The support and commitment of Dr Oksana Syvak, the Former Deputy Minister of Health in Ukraine, Dr. Marthe Everard, WHO Representative and Head of Country Office to Ukraine, Oleksandr Martynenko, Project Officer, WHO Country office in Ukraine, Polina Adamovych, Technical Assistant, WHO Country Office in Ukraine, is highly appreciated. Funding: The seminar was supported by the Swiss Agency for Development and Cooperation. Czabanowska K, Cichowska Myrup A, Aleksandrova O. Women leadership for public health: The added value and needs of women driving public health system reform in Ukraine (Case study). SEEJPH 2018, posted:20 September 2018. DOI 10.4119/UNIBI/SEEJPH-2018-200 3 Introduction The Ukrainian health care system is undergoing through reforms. One of the main objectives of the new reforms is the shift towards a policy of strengthening and maintaining health and preventing diseases through the life-course. Women constitute a driving force in the Ukrainian health system transformation however, according to the Global Gender Gap Report by the World Economic Forum (1), Ukraine ranks 64th in terms of women’s income level, 22ndin terms of women’s education and 34thon economic participation and opportunities. Women's participation in decision-making remains extremely low. Women hold only 12% of seats in the parliament and make 11% of the Cabinet of Ministers. The European Parliament stated that gender mainstreaming constitutes an essential factor for the achievement of a sustainable and inclusive society (2) and smart, sustainable and inclusive growth require higher gender equality scores (3). The United Nations (UN) included gender equality and the empowerment of women in its sustainable development goals (SGDs) (Goal No 5) for the 2030 Agenda. Both Global Gender Gap Report (1) and EU Progress Report (2012) (4) examine barriers existing in relation to women leadership such as work/life balance, gender bias and stereotypes, lack of confidence, lack of mentoring, and lack of adequate networking and equal access to opportunities. The recent publication of the World Bank on Gender Assessment in Ukraine (5) pointed out clear misbalances such as: male domination at the top managerial positions, political representation and decision making, persistent ‘glass ceiling’ in access to chief executive positions in public administration, stereotypes - traditional roles of men and women, lower wages and devaluated social prestige often associated with female economic activity, vulnerability at the labour market and poverty risks, prevalent part-time employment, unequal income opportunities, limited access to business activities and financial resource, public tolerance to spousal violence, gender-based violence and trafficking to name a few. With the aim to empower and support the development of current and future female leaders who drive public health reform, the Ministry of Health of Ukraine held a seminar entitled “Women’s Leadership in Public Health” in Kyiv on 16-18 May 2017. It organized the seminar with technical support from WHO, contributions from the Association of Schools of Public Health in the European Region (ASPHER) and Maastricht University, the Netherlands, and financial support from the Swiss Agency for Development and Cooperation. The seminar was delivered in the context of the implementation of the WHO European Action Plan to Strengthen Public Health Services and Capacities and the WHO Strategy on women’s health and well-being in the WHO European Region. The seminar contributed directly to the implementation of the SDGs by developing a workforce with 21st century public health competencies. The seminar Concept, mission, objectives and content The seminar was based on the assumption that contemporary public health demands a more inclusive, less hierarchical style of leadership – focused on developing and working with stakeholder networks to be effective in achieving public health goals (6,7). Public health leaders “must be the transcendent, collaborative “servant leaders” (8) able to: articulate shared values, acknowledge the unfamiliarity, ambiguity, and paradox, combine administrative excellence with a strong sense of professional commitment (8), show passion, drive and perseverance in leading for change. The concept of the seminar was linked to the Merizow’s Transformative Learning Theory (9), according to which learning is “…the process by which we transform our taken-for-granted Czabanowska K, Cichowska Myrup A, Aleksandrova O. Women leadership for public health: The added value and needs of women driving public health system reform in Ukraine (Case study). SEEJPH 2018, posted:20 September 2018. DOI 10.4119/UNIBI/SEEJPH-2018-200 4 frames of reference (meaning perspectives, habits of mind, mind sets) to make them more inclusive, open, emotionally capable of change, and reflective so that they may generate beliefs and opinions that will prove more true or justified to guide action.” (9). The seminar was competency-based, structured around modern leadership theories especially suited to develop women leaders, reflecting real life experiences of role-models. It included the topics identified through research and local needs analysis. The seminar was supported by the executive coaching provided to the participants with the objective to develop, enhance and build personal leadership attributes for the successful career and growth in health care environment and develop the ability to set individual career goals to the benefit of population heath outcomes. The main topics included: self-assessment of leadership competencies, public health leadership and leadership theories, system thinking, dealing with interests, power and stakeholders, barriers to women leadership and methods to address them, special leadership tools for women empowerment and leading change, communication and impact. Strengthening health systems for better health was the red thread throughout the whole seminar. The content was presented during the two and a half day training which included interactive lectures, discussions, group work and experiential learning. The core of the programme was reinforced with the leadership development life stories from female health professional leaders Trainers and participants Five lecturers and trainers came from various professional fields: policy, academia, public health practice, government and business. They also came from different countries to assure variety of perspectives and experience. They represented: the Netherlands, Greece, Sweden, Finland, Canada and Ukraine. The lead trainer was responsible for the design, main content, cohesion and coaching whereas other trainers presented specific topics and illustrations from their public health practice as well as their leadership development stories. All presenters engaged in the discussion with the participants. The consecutive high quality professional translation was provided which allowed for good communication and satisfaction from the learning and teaching experience. There were 22 participating women leaders who were carefully selected by the Ministry of Health in Ukraine based on their role or potential new position in relation to the introduction of public health reforms. The women came from different regions of Ukraine and represented a range of organisations which are vital in the change process including the Ministry of Health of Ukraine, Public Health Centre of the Ministry of Health of Ukraine, regional Health Centres and hospitals, non-governmental organizations, and the like. Evaluation method In order to gather the feedback from the participants we used a short open-ended questionnaire addressing the following dimensions: usefulness of the seminar for the public health reform and for personal development, satisfaction with the content, form and instructors, the highlights of the course and areas for improvement, further needs concerning a follow-up on women leadership in public health training and specific areas which the participants would like to cover. We also gave space for personal reflections about the course. 14 out of 22 participants filled in the questionnaires and five shared their observations face- to-face with the course leader with a help of a professional interpreter. The atmosphere was open and relaxed, building on trust and opinion sharing. The evaluation was carried out after the course and before the individual coaching sessions. The feedback on coaching was Czabanowska K, Cichowska Myrup A, Aleksandrova O. Women leadership for public health: The added value and needs of women driving public health system reform in Ukraine (Case study). SEEJPH 2018, posted:20 September 2018. DOI 10.4119/UNIBI/SEEJPH-2018-200 5 obtained in a follow-up conversation after the coaching sessions. The evaluation forms were filled in Ukrainian language. The anonymity of responses was assured. The collected data was translated into English, analysed and synthesized according to the leading questions. Next conventional content analysis was used (10) to develop categories and arrange the data around them. The five categories include: opinions about the course, aspects of special value, satisfaction with the trainer, areas for improvement and further training needs. Feedback from the participants Opinions about the course It was the first seminar about the leadership in public Health for women. All the respondents were “100% positive” and found the seminar of high quality, extremely useful both form and content wise. It was very interesting, helpful, informative, comprehensive and consistent. The participants felt that “…Three days passed with one breath”. New theories and different leadership tools that can be used at work in the field of public health combined with the leader experience of the participants helped them structure all previously gained knowledge. The participating women leaders had a unique opportunity to do self-assessment and self- appraise their leadership qualities which help them reveal the strong and weaker sides and discuss the ways to improve them as well as see themselves from the leadership prospective. They also valued learning about Emotional Intelligence and how to manage emotions “…I have a desire to invite the psychologist to work with us at the hospital...”. This helped them also understand why the authoritarian style is not the best approach especially when you work in an interdisciplinary team or if you are newly appointed to lead a department. The participants stated that owing to this training they realized that the inner power of women is able to move or change things which may seem unchangeable. They especially valued familiarity and open communication with other women leaders and professional trainers who provided useful information and tips for troubleshooting the situational problems and barriers. Moreover, the experience of getting to know the colleagues from other regions who are inspired, fulfilled, beautiful women striving to use their skills as well as spiritual and cultural values for the general development of the country was very powerful. The presence, facilitation and sharing of experience of the international faculty was greatly appreciated. “…it showed the openness of the world towards my country Ukraine from a different perspective”. Aspects of special value The participants especially valued some specific aspects of the training. These included: the scientific evidence on which the public health leadership course for women was based, realizing the added value of women power in leading people regardless of age and position, systematically presented content, examples from personal lives of trainers and coaches which allowed for making comparisons with their own life experiences, possibility to improve oneself, importance of developing the vision and understanding what kind of a leader you want to be. “The value for me personally is that I realized my personal complexes, my claims toward myself which I have in my thoughts that I shouldn’t have”. The new theories of leadership, practical exercises on system thinking using a ”red ribbon” (a role play illustrating system thinking using a red ribbon to connect the elements of a system) and “thinking hats” (the de Bono “six thinking hats”) technique provided the information that a woman-leader needs at work. “When I return to work, I will try to put into practice all gained knowledge and skills and will put special attention to my personal qualities”. http://context.reverso.net/%D0%BF%D0%B5%D1%80%D0%B5%D0%B2%D0%BE%D0%B4/%D0%B0%D0%BD%D0%B3%D0%BB%D0%B8%D0%B9%D1%81%D0%BA%D0%B8%D0%B9-%D1%80%D1%83%D1%81%D1%81%D0%BA%D0%B8%D0%B9/authoritarian http://context.reverso.net/%D0%BF%D0%B5%D1%80%D0%B5%D0%B2%D0%BE%D0%B4/%D0%B0%D0%BD%D0%B3%D0%BB%D0%B8%D0%B9%D1%81%D0%BA%D0%B8%D0%B9-%D1%80%D1%83%D1%81%D1%81%D0%BA%D0%B8%D0%B9/scientific+evidence Czabanowska K, Cichowska Myrup A, Aleksandrova O. Women leadership for public health: The added value and needs of women driving public health system reform in Ukraine (Case study). SEEJPH 2018, posted:20 September 2018. DOI 10.4119/UNIBI/SEEJPH-2018-200 6 Satisfaction with the trainers The participants were very satisfied with the speakers’ performance. The presenters and trainers were pleasant, open-minded, attracted their attention, very outspoken, showing excellent knowledge of the subject matter and professionalism, they served as examples or role-models. “I realized how to work on myself to become better and on what to work on concerning my personality.” The combination of women`s stories from real life or previous experience, attractive way of presenting the material, availability and genuine interest to answer the questions were inspirational. The trainers were open to dialogue and able to merge with the participants due to their high level of qualification, commitment to the job, high motivation, integrity and gratitude. Each speaker was an individuality holding their own position in the society and their own positive world view. Their honesty, openness and equal attention to all the participants greatly contributed to the satisfaction from the course. On the whole “….everything was good, time flew fast and the emotions were running high, it was generally hard to say goodbye to them. I love them. Good luck to them”. Areas for improvement Although everything was interesting and highly satisfactory, the participants identified some areas which might be improved in the future courses. They would generally welcome more time to get to know each other better, to have more possibility for discussions and communication with the speakers as well as time to solve some situational problems from their individual professional practice, using real-life examples and getting feedback on them from other colleagues. They would also appreciate more situational games, exercises and active group work like the ones with the “ribbon” and “hats” and have more space to delve into the emotional intelligence topic and more life stories or research on women leaders in medical sphere even if it means inviting more teachers. Further training needs There was a strong conviction that the course on women leadership in public health needs to be continued in the context of theoretical knowledge and extended practical application with mentoring and coaching. The participants would be interested in getting more acquainted with such topics as: emotional intelligence, communication and social marketing, theory of negotiations, general management and time management to become more efficient and effective, short, consistent personal coaching, how to develop as a future leader and practical application of women leadership in public health practice including the dress code and personal preparedness for a role as a woman leader, leading change in the organisation, how to create a successful and effective team for a new public health centre in the region. They would also like to learn and practice how to lead public health system transformation in Ukraine, how to collaborate with different sectors and stakeholders for the benefit of public health reform, how to use evidence for informed decision making, how to practically apply women leadership competences in specific public health practice and importantly how to reach a high level position “I have my personal need to get a high level job: just give me an opportunity and I will turn the world.” The list of needs is long which shows that there is a great need for such a training especially for women. The course on women leadership for public health in Ukraine was a small drop filling a huge niche which is open. The participating women would like to be informed and invited for similar events in the future. Some of them would like to be involved and collaborate with WHO in preparing future programmes to assure the inclusion of current and real issues of concern in Ukraine. Czabanowska K, Cichowska Myrup A, Aleksandrova O. Women leadership for public health: The added value and needs of women driving public health system reform in Ukraine (Case study). SEEJPH 2018, posted:20 September 2018. DOI 10.4119/UNIBI/SEEJPH-2018-200 7 Concluding remarks and recommendations The initiative proved to be empowering not only for the participants of the seminar but also for the trainers who were able to challenge their own frames of reference and show the added value of women leadership in times of transformation in the context of Ukrainian health care and public health reforms. The women leaders from different regions of Ukraine had a unique opportunity to build social capital around women leadership and develop their own professional public health network which, in order to be sustainable, needs further support and more focused and in-depth training. 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