But let’s get to business now. I knew about Orcas shows in some places in the world, and like many other people I was astonished at what these animals were capable of. Yet, what really intrigued me was how such dangerous, ferocious and huge animals could be trained. Again in search for an answer, I found a book called Whale Done! by Ken Blanchard that demystified my questions about training Orcas. Reading the book was a particularly wonderful experience because it not only answered my question on what it took to train such animals but also drew a connection between some of these training principles and human motivation, something I had always been interested in. This blog is inspired by the book ‘Whale Done!’ and suggests useful lessons we can learn from the training of Orcas, even if I know that human beings and Orcas are not entirely comparable (fortunately, perhaps).

Often lack of financing and political commitment are pointed out as important reasons for the failure of health systems to achieve desired outcomes. However, there is very little focus on so called ‘software components’ in a health system such as better understanding of employees who work for organizations, or the importance of individual and organizational values such as trust and how it influences individual as well as collective organizational behavior, systems and practices. In the public health literature, publications related to Organizational Culture (OC) are still somewhat limited. However, from organizational theory, we know that a conducive OC is very important for the success of an organization and implications of a dysfunctional OC are reflected at various levels: (1) at individual level: lack of motivation, poor job satisfaction and organizational commitment; (2) at dyad and team levels: lack of trust resulting in less team effort and cohesiveness; (3) at organizational level: low work productivity and higher turnover rates, reduced community and client satisfaction. The importance of understanding and having a conducive OC in the public health system is particularly important if you know that many state health departments and health organizations in India do not lay enough emphasis on the need to have a conducive OC. Often such issues are just taken for granted.

The health systems and environments in which such systems operate are quite complex. This complex nature is largely due to the human factor: human beings are involved in virtually every aspect of interactions in health systems, be it as providers, community, funders etc. Health systems have been identified as inherently relational and many challenges for health systems are relationship and behaviour problems. Hence understanding employee motivation and various factors such as trust and OC that contribute to improved motivation is important.

But now what do killer whales have to do with all this?

Lessons of Orca training that apply to Human Motivation:

Trust building is a slow but crucial process. The first lesson that ‘Orcas’ teach us humans (and management teachers in particular) is that trust building is a slow but very crucial process. The trainers involved in training Orcas have to win the trust of them before they can expect them to do anything for them. This implies that Orcas first have to see that the trainers mean no harm to them and this takes time. The best from Orcas is seen when they completely lose their fears and the positive vibes between trainers and the whales are transferred to the audience. Building trust among humans or employees follows pretty much the same process, i-e. it tends to be a slow process and if harm is done at some point, trust can be easily destroyed. It takes more time to build trust than to destroy it, unfortunately.

Sadly, many organizations do not want to invest in building a culture where trust is purposively encouraged – they often take such issues for granted, with the consequences we know: it is often the lack of trust between peers, superiors-subordinates and teams that is reflected through lower job satisfaction and commitment, poor performance and hostile environments with very little emphasis on a culture of collaboration; confrontation is, instead, often the norm. Subordinates do not trust their superiors and vice versa and far too often individual performance is a resultant of fear and obligation rather than something that individuals themselves enjoy. I believe that when employees genuinely feel that their peers, subordinates and superiors mean no harm to them, trust is built and the positive vibes between employees and the organization will then be transferred to the community or patients. Therefore building trust in an organization is very important. When trust is there, we can expect magic to happen.

Research around trust in the area of health systems is gradually building and trust is increasingly being recognized as one of the most important aspects to gear health systems towards people centeredness.  Trust greatly influences human motivation, both professionally and in your daily life.

Reinforcing and accentuating positive behavior. One of the important lessons from the training of Orcas is that the right behavior needs to be encouraged and rewarded by trainers every time such animals demonstrate a desired behavior. Accentuating right behavior also means eliminating punishment, as the latter doesn’t work and can also be risky for the trainers who are training the most feared predators of the ocean. Positive reinforcement involves paying close and continuous attention to positive behavior rather than negative behavior. By focusing on positive behavior a desired behavior is more likely to be repeated.

Now enter the organizations we work for. Often, too much attention is being paid to negative behavior, with various forms of punishment such as scolding, reprimanding, spoiled appraisal reports, demotions etc. In my teaching and research experience, I have come across several cases where doctors working for government health departments may be transferred to very remote health facilities and other job-related benefits such as salaries and promotion avenues are affected. True, perhaps such punishments exist because their superiors think the average health system employee is not as ferocious as a killer whale, and so they think they can get away with it. But damage is still done. All these forms of punishment are evidence of a negative or even hostile culture in an organization where there is no trust amongst the employees.

Accentuating the positive also means that the Orcas need to be rewarded and appreciated for every little positive behavior they display “in between” – i.e. on the journey towards the “final” desired behavior by the trainers. Another important aspect of accentuating the positive behavior is not paying too much attention to (occasional) negative behavior and redirecting the negative behavior towards positive behavior. However, it may take a long time before one can observe the desired behavior, i-e- jumping out of the water, carrying trainers on their shoulders etc; so every little progress must be rewarded with appreciation and other rewards such as feeding the Orcas as well as rubbing and patting them.

Moving to self-motivation: When the Orcas have trust in their trainers, are adequately rewarded and genuinely appreciated and loved, these creatures love to perform (are self-motivated) and their stellar performance is reflected during the performance shows. Just like Orcas, most humans love to work and perform as it is a natural part of their lives. People are intrinsically motivated and they accept responsibility under favorable conditions – i.e. if organizations show trust in them, and they receive personal rewards (monetary and non- monetary). Hence if a conducive culture of trust, recognition and love is created in organizations (I am aware I begin to sound a bit like Sai Baba here ) then people may like to perform and be motivated without the lure for or pressure of external factors and forces.

Health organizations and systems need to put more emphasis on analyzing OC and more importantly on creating a conducive culture where people are sufficiently self-motivated. Creating a conducive culture requires the health organizations to pay close attention to processes rather than only focusing on the outcomes. Results matter, but the journey also does. The need for health organizations to create and reinforce positive values such as trust is important as it could have great potential to transform the way typical healthcare organizations function – from a culture characterized by lack of trust and responsibility, poor team work and collaboration, and a blaming culture, to a culture where achievement is emphasized and functional values such as trust, mutual help, responsibility and autonomy are emphasized, facilitated and encouraged.  Most importantly a positive focus on values such as trust and respect for employees can help build a culture where organizations have an employee-centric approach, employees are self-motivated and the development of Human Resources remains a key agenda for the organization.

A “Whale Done Approach” can really help build trust in organizations so that people will lose their fear and positive vibes between health organizations/ systems and the employees will be transferred to the community.

If that happens, perhaps it’s time to call the health system a “Free Willy” health system…

In last week’s New Leaders for Health (NL4H) Pre-Forum in Manila, four Emerging Voices alumni – three from Class 2014 (Renzo Guinto, Nasreen Jessani, Bhaskar Purohit) and one from Class 2012 (Beverly Ho) – participated in a panel entitled “Emerging Voices for Global Health: The Future of Health Systems Research.” The panel aimed to not only introduce the Emerging Voices for Global Health (EV4GH) program to young health researchers and innovators, but also to showcase the experiences of Emerging Voices (EV) alumni post-training and their visions for the future of health systems research across the world. We asked the four alumni to summarize in ten points the key messages that arose from their exciting ‘Manila conversation’ – and below are their answers:

1. Novel and innovative opportunities such as EV4GH help prepare the new generation of health system researchers for greater impact locally and globally. Many of the ‘soft skills’ essential to success in global health systems research are not taught inside the classroom – they require innovative approaches that allow peer-learning and ‘learning-by-doing’ modalities for example. The impact of EVs goes beyond conferences – for instance, because EVs were prepared on how to better package their research findings for evidence to policy translation, Bhaskar’s research on role-related stress among health workers in India and Bev’s study on health insurance coverage and healthcare utilization in the Philippines have been considered in policy development by government agencies and decision-makers. On the other hand, Renzo’s paper on migrant inclusion in universal health coverage in Southeast Asia has been cited several times by other researchers in articles and presentations. Clearly, programs such as EV4GH both enhance traditional presentation skills (i.e. posters and lectures) and develop contemporary public outreach skills (writing blogs and op-eds), among others. More capacity-building programs that are both innovative and impact-oriented are therefore encouraged to complement traditional education in schools of public health.

2. Posters should be in no way treated as inferior to oral presentations. Posters are essential and effective ways of communicating research to the scientific community. Often however, researchers are guilty of copying and pasting bits and pieces of their manuscripts into the poster, and of not seeking help even for seemingly minor aspects such as font, color, layout, and photos. During the EV4GH program, we alumni have witnessed how our posters dramatically evolved and transformed from Day One to poster session day. In fact, during the Third Global Symposium on Health Systems Research held in Cape Town last year, EV4GH 2014 alumni won in the poster competition in 2 out of 3 days – up against tenured researchers some of who had been creating posters for over 30 years! The EV4GH program enhanced our skills in creating powerful scientific posters for conferences – not just for the prizes as demonstrated earlier, but also for capturing the attention of interested colleagues and target audience. For instance, Renzo recalls how he got connected with fellow Southeast Asian researchers as well as enthusiasts in migrant health who visited his poster in Cape Town. Nasreen’s poster on the use of social network analysis (SNA) to identify key knowledge brokers in linking research to policy led to requests for her to conduct workshops on SNA at the ResUpMeetUp symposium in Kenya and the NL4H Pre-Forum in the Philippines.

3. It is important to distinguish advisors from mentors. Oftentimes, we come across well-established and impressive professionals who are willing to provide advice but have neither the time nor the inclination to provide constant support to aspiring early careerists. During the panel discussion, we urged participants to look for people who have a stake in their success: those who are willing to walk the path with them and willing to coach them along the way. The best mentors may not necessarily be the ones occupying the highest posts, but they are the ones who may be willing to dedicate time, the proclivity and the passion to guide the next generation.

4. Be strategic in using professional networking sites such as LinkedIn. Our generation is blessed with online networking platforms that can help emerging researchers identify and reach out to professionals locally or globally who could serve as mentors and/or collaborators. There are several mid- to advanced-career professionals engaged in relevant health research activities who have also traversed the same path as these young students, and may be interested to serve as mentors to young people whom they have same interests or can identify with. For example, during the panel, Renzo shared that through LinkedIn, he was able to meet Professor Phua Kai Hong of the National University of Singapore, who later provided invaluable inputs for Renzo’s paper on migrant health coverage in Southeast Asia. To top it off, Prof. Phua accepted the invitation to be the keynote speaker for the NL4H Pre-Forum!

5. Never commit the folly of underestimating your peers. In our pursuit for linking with those more experienced than ourselves, we forget the value of social and intellectual capital inherent in our own networks composed of fellow emerging leaders. Leveraging peers to test our ideas, practice our presentations, and critique our papers is an important part of not only enhancing our skills but also nurturing our networks. We encouraged participants to benefit from the strengths and experiences of their friends and colleagues, and to invoke principles of peer learning and feedback. Furthermore, a bit of healthy competition within our networks may drive more creativity and innovation, as long as at the end of the day, we remember that we are united under common goals of improving health and achieving health equity, no matter how diverse our backgrounds and skills may be.

6. Building capacity in institutions is critical. During the panel, we were asked by a technical staff from a government agency if we EV4GH alumni are available to work as consultants to support the creation of posters, presentations, and communication strategies both for the health research and policy community as well as the general public. First, we clarified that it is important to make a distinction between public health communication (whose aim is to modify behaviors, inform about health threats, etc.) and communicating research to decision-makers and fellow researchers – nonetheless, both forms of communication may follow similar principles. However, while the request was flattering, we emphasized the importance of institutional capacity building so that there will be no need for external consultants to perform these routine yet essential tasks. What would be perhaps worth exploring is replicating some of the EV4GH methods of training and coaching for these organizations. In this vein, multiple employees would benefit from enhanced research communication skills, a system of embedded capacity strengthening could be instituted, and a culture of effective knowledge translation could be fostered.

7. Emerging voices should demand for strengthening of national health research systems. In relation to our thoughts about institutional capacity-building, the vitality of local health research also boils down to strong health research systems that ensure long-term professional development, provide incentives for the conduct of effective and relevant research, ensure sustainable funding support and other resources, among others. There was huge enthusiasm among the attendees in the room for research; however, there was also enormous concern about low salaries, ‘contractualization’ of research positions, lack of mentors and role models, limited opportunities for postgraduate training opportunities, and in general the uncertainty of their future research careers. We urged the young leaders to proactively advocate for reforms specifically in the Philippine health research system, so by the time they have graduated, they can be guaranteed fulfilling opportunities in their journey in health research.

8. Be creative in finding resources for health research and innovation. One participant asked a very practical question – how did EV4GH panelists fund their research projects? Nasreen’s study was funded partly through a grant by DfID Future Health Systems Project, partly through awards and partly through work-study; Bev and Renzo’s research used data they collected as part of their paid work, and Bhaskar’s project was funded through his home research institution – in short, there is no single funding source for research. However, while financial resources may be limited, there is a need for new leaders to look at innovative mechanisms and novel sources for research funding, such as by tying research with social enterprise. We also encouraged the attendees to maximize online platforms such as Asia which regularly publishes funding opportunities for research projects. Finally, as demonstrated by Renzo’s research paper, one can conduct, for instance, desk reviews with collaborators from overseas even without meeting them face-to-face, thanks to e-mail and Skype (Note: His paper was published even before he has met in person two of his co-authors!).

9. Building research and innovation programs, not projects. In the panel, Bev and Renzo raised their concerns regarding “projectization” of research particularly in the Philippines, which is also happening in many low- and middle-income countries. Most of the research projects are commissioned to individuals rather than institutions; therefore, there is the tendency to commission more projects, with smaller budgets per projects rather than larger multi-year contracts. There is also often the misconception that qualitative work is cheaper and can ‘replace’ more expensive quantitative nationally representative research studies. Such a lack of holistic approach leads to unusable work (or at least inconclusive, hence cannot be used to arrive at generalizations for policy-making), poor databases (because sample sizes are small, etc.) and lost opportunities for institutional research capacity building. Moreover, it is difficult to encourage promising researchers to build a long-term research career. Therefore, thinking of research in terms of programs instead of projects is beneficial in order to avoid fragmentation, ensure coherence among component research projects, and build long-term sustainability overall. While existing research programs and consortia in health systems are predominantly funded by organizations from high-income countries (such as RESYST, REBUILD, and Future Health Systems), countries which recently allocated significant amounts for health research such as the Philippines (at around 200 million Philippine pesos or 4.3 million USD per year) already have the initial resources to build long-term impact-oriented research programs that may eventually encourage other stakeholders such as the private sector to top these resources up with additional investments.

10. Health systems research and innovation is an exciting field for those who want to make a difference. Today, there is a worldwide recognition that in order to improve health outcomes and achieve health equity, strengthening health systems is the way to go. The emergence of networks such as Health Systems Global is a manifestation of this sea change in global health. What is exciting about health systems research is that it requires multiple disciplines and perspectives – this is the beauty of conferences such as the NL4H Pre-Forum in which students and young researchers and innovators from a wide range of disciplines and professions were gathered in a weekend conference. It was also raised that health systems do have a complex architecture and even fuzzy boundaries, thus opening new arenas for inquiry, and therefore there is always room for emerging researchers and innovators to explore, even experiment, and examine health systems beyond the traditional ‘six building blocks.’

For instance, Renzo expressed that his research interest is investigating the interface between health systems and the broader transitions in health such as climate change, migration, trade, and urbanization, among others. Bhaskar, on the other hand, took a unique perspective on human resources management by looking at the micro level, and emphasized that understanding roles and role-related stress experienced by health workers can be a useful framework to gain better insight into health workforce issues. Nasreen’s unique approach to understanding the flow of knowledge in health systems using SNA illuminated the complexity and multidirectionality of the various elements of a health system.

Conclusion: The ‘Emerged Voices’ should reach out to the ‘emerging’

During the session, it can be noted that the demand for enhanced skills in knowledge translation and research communication was clearly high – from students as well as from institutions. The value of tailored, timely, and context-specific research uptake mechanisms that promote a variety of voices was also clearly demonstrated. It is therefore important to strike while the iron is hot and start creating opportunities to meet this demand.

The EV4GH program also evoked much enthusiasm from the floor, with many participants wondering not on how they can apply for the next edition in Vancouver in 2016, but on how such a program can be replicated in their home countries. Hungry for innovative ways of training and capacity development, the participants challenged the panel to make the global Emerging Voices program one that is more local.

We therefore call upon all fellow EVs to become mentors and trainers, and to reach out to the young voices in their respective communities. Let us capitalize on the momentum by sharing our learnings and skills with peers and fellow colleagues. We can arrange brownbags in our institutions, panels at conferences (or even separate events such as the NL4H Pre-Forum), student groups, professional committees, deliberative dialogues… whatever it may be, let the knowledge gain power, let the skills gain traction. Create an EV legacy by being the mentors that those ahead of us, behind us and beside us all seek when it comes to being a resounding voice for better health for all.

Renzo Guinto, Nasreen Jessani, Bhaskhar Purohit and Beverly Ho

About the Authors/Panelists

Renzo Guinto (EV 2014) is the Campaigner of the Healthy Energy Initiative of Health Care Without Harm-Asia and director and co-founder of #Reimagine Global Health. He is a co-investigator at the Universal Health Care Study Group of the University of the Philippines Manila, and member of a WHO steering committee on social determinants of health and health professional education. He is also the chair of the New Leaders for Health Pre-Forum and of the ‘Health in Megacities’ track of the Global Forum on Research and Innovation for Health.

Nasreen Jessani (EV 2014) is a consultant in global public health policy and systems based in Johannesburg, South Africa. Her work spans health system strengthening through evidence-informed decision-making. She recently received her DrPH from the Johns Hopkins Bloomberg School of Public Health and is on the advisory board of Academy Health’s Translation and Dissemination Institute and a WHO Foodborne Diseases Burden Epidemiology Reference Group (FERG) task force on knowledge translation and policy.

Bhaskar Purohit (EV 2014) is an Assistant Professor at the Indian Institute of Public Health Gandhinagar, which is part of the Public Health Foundation of India. He received his MPH from the Harvard School of Public Health.

Beverly Ho (EV 2012) is a faculty at the Ateneo Loyola School’s Health Sciences Department. She co-founded the Fellowship of the Pump, a mentoring/support group for health professionals and medical students passionate about health systems. She also co-founded Alliance for Improving Health Outcomes, Inc. She recently received her MPH from the Harvard School of Public Health.