Competencies for Transformational Leadership in Public Health—An International Delphi Consensus Study

Objectives: This Delphi study intended to develop competencies for transformational leadership in public health, including behavioral descriptions (descriptors) tailored to individuals and their contexts. Methods: The study involved five rounds, including online “e-Delphi” consultations and real-time online workshops with experts from diverse sectors. Relevant competencies were identified through a literature review, and experts rated, ranked, rephrased, and proposed descriptors. The study followed the Guidance on Conducting and REporting DElphi Studies (CREDES) and the COmpeteNcy FramEwoRk Development in Health Professions (CONFERD-HP) reporting guidelines. Results: Our framework comprises ten competencies for transformational public health leadership (each with its descriptors) within four categories, and also describes a four-stage model for developing relevant competencies tailored to different contexts. Conclusion: Educators responsible for curriculum design, particularly those aiming to align curricula with local goals, making leadership education context-specific and -sensitive, may benefit from the proposed framework. Additionally, it can help strengthen links between education and workforce sectors, address competency gaps, and potentially reduce the out-migration of graduates in the health professions.


Doing
Empathy Sensing others' feelings and perspectives, and taking an active interest in their concerns. (1)

Doing
Influence Influence others to achieve high standards of performance and accountability (3) Doing Influence Works across sectors in local, national and international organizational structures (2) Doing Influence Builds, maintains and effectively uses strategic alliances, coalitions, professional networks and partnerships to plan, generate evidence and implement programmes and services that share common goals and priorities to improve the health and well-being of populations (

Doing Teamwork
Communicates with respect when representing professional opinions and encourages other team members, including community memb ers and patients, to express their opinions and contribute to decision-making

Doing
Convinces others in an honest, respectful and sensitive manner in order to get them to go along with one's objectives.It can also be the desire to have a specific impact or effect on others (Influencing) Doing Fosters an environment that will encourage professional and personal growth and the transfer of knowledge to future talent (Developing talent) (5) Doing Works to build and maintain friendly, trustworthy and open internal and external relationships and networks with people who are, or might become, important actors in achieving strategic-related goals (Strategic Networking)

Being
Emotional self-awareness Recognizing one's emotions and their effects Being Emotional self-awareness Demonstrates emotional intelligence with awareness of how one's own beliefs, values and behaviours affect one's own decision-making and the reactions of others (2) Being/Doing Emotional self-awareness Critically reviews and evaluates own practices in relation to public health principles, including critical self -reflection Ensures that the change is aligned and integrated with all interdependent systems and processes (4) Doing Implement strategic planning processes (3) Knowing Uses conscious process thinking to design the change as a full stream process (4) Doing Models and promotes the emerging mind set and way of being to the organization (4) Knowing Perceiving themes or patterns in seemingly random items, events, or (1) Knowing Understands the interdependence, integration and competition among health-care sectors and various actors who have interests in public health issues (2) Knowing Understands the principles of systems thinking and can apply them within systematic enquiry to analyse, model and improve public health organizations and services at different strategic levels Knowing Identifies, connects and manages relationships with stakeholders in interdisciplinary and intersectoral projects to improve p ublic health services and achieve public health goals

Knowing
Evaluates partnerships and addresses barriers to successful collaboration to improve public health services (2) Knowing Creates and sustains conditions for success for the change, especially the continuous generation of new information (4) Knowing/Doing Understands and applies effective techniques for working with boards and governance structures, including regulatory, professional and accreditation agencies (2) Knowing/Doing Effectively applies knowledge of organizational systems, theories and behaviour to set priorities for, align and deploy all relevant resources towards clear strategic goals and objectives (2)

Doing
Is proactive in designing and monitoring quality standards and applies quality improvement methods and tools to identify internal and external facilitators and barriers that may affect the delivery of the Knowing 93 Is able to respectfully communicate ideas and information (often technical) in writing to ensure that information and messages are understood and have the desired impact (Drafting Skills) (5) 94 Is able to effectively adapt to a variety of situations, individuals or groups.It is based on the ability to understand and appreciate different and opposing perspectives on an issue, to adapt an approach as the requirements of a situation change, and to change or easily accept changes in one's own organisational or job requirements (Flexible Thinking) Knowing 95 Understands human, financial, and operational resource issues to make decisions aimed at building and planning efficient project workflows, and at improving overall organisational performance (Managing Resources) Knowing/Doing 96 Working together effectively with interdependent goals and common values and norms to foster a collaborative environment and drive teams in the same direction (Teamwork and Team Leadership) Knowing 97 Is able to understand internal/external clients' (e.g.Committees, working groups, country representatives, etc.,) needs and concerns in the short to long-term and to provide sound recommendations and/or solutions (Client Focus) Knowing 98 Is able to hear accurately and understand unspoken, partly expressed thoughts, feelings and concerns of others (including cro ss-cultural sensitivity) (5) 99 Is able to keep one's emotions under control and restrain negative actions when faced with opposition or hostility from others or when working under stress (Diplomatic Sensitivity) Knowing 100 Works towards win-win outcomes.At lower levels, this competency assumes an understanding of one's counterparts and how to respond to them duri ng negotiations.At the higher levels, the competency reflects a focus to achieve value-added results.(Negotiating) Knowing 101 Understands the power relationships within the Organisation and with other organisations (including formal rules and structures, decision-making processes and influencers) (Organisational Knowledge) (5) (5) Competency Framework 5   In case you are interested please find below the steps we have taken to analyse the data:

Expert panel participants
Step 1 Listing of all competencies and ranking according to the degree of agreement (threshold 85%).

Example comment on category KNOWING: «(…) The obvious is knowing one's field exceptionally well (subject competence). Also, knowing what you don't know, and knowing how to identify talent to fill your own competency gaps (e.g., technology, social media).»
Example comment on C38: A transformational leader will do this out of instinct» « to transform may be to obstruct/change power relations and then someone loses and it is not a win win at all»

Example comment on C37: «One can have cultural awareness but must also act on that awareness and demonstrate it (…) Being alone is not enough [one] also need to act on in «DOING») Example comment on C01: «Knowing cannot be disconnected to Doing and Being is socially and culturally constructed» Example comment on category KNOWING: «(…) most competencies are in the domain of DOING & BEING. BEING competencies are of higher hierarchy, they include already the lower KNOWING competencies.» Box S7 Newsletter Round 2: Delphi Study on competencies for transformational leadership
Newsletter Delphi Round 2

Dear Expert,
The second Delphi round is completed and we have spent the last weeks analysing your valuable feedback to now come up with an adapted list of competencies.

Thank you for your participation and all the constructive suggestions and comments!!
As we did after the first round, we have summarised frequently mentioned topics as 'Golden Nuggets' and added corresponding examples.Please find them below.Again, we ask for your understanding that we could not include all answers, although we considered them to be of great relevance.

Example comment on C05: "Is it 'strive for' or 'identifies' (more of a natural or learned/trained ability rather than an constant active search for it)."
Example comment on C09: "This competency tries to incorporate too many ideas.Further, "striving" implies some kind of activist or entrepreneurial approach.Slightly reformulated, this would be a very-to-extremely important competency." Example comment on C09: "It is not about challenging relationships but rather about engaging and addressing." Example in the comment and recommendation section: "Some of the competencies are more a code of conduct or guidelines -some of the competencies could be lumped together" Example in the comment and recommendation section: "Some of the wording has to be revised that they are at the advanced level demonstrate from example .... rather to judge ...advise ...

Nugget 2: Self-regulation is different from being emotional and operating from vulnerability.
Example comment on C05: Verb "demonstrate" was replaced since it is regarded as a higher level competency  Flexibility and Adaptability not always the "Gold standard", rather important to push for change  C04 was included in this competency since it was mentioned five times that C04 would be redundant and should rather be part of C01 C02:  It was mentioned five times that it would be required to separate the competency into different components C03:  The part external stakeholders was removed from the formulation since it was five times mentioned that this too resource-intensive and impossible.The competency was merged with competency C11.

C06: 
The part about emotions was removed since it was mentioned that recognizing emotions would not necessarily be related to self-care  Some TL would not practice self-care and would never burn out, it would rather be about being emotionally blunted.
C08:  Verb "demonstrates" was replaced since this wasn`t regarded as an advanced competency  The suggested reformulation was adopted since it has a clearer focus on challenging situations and change, which are core characteristics of transformations C10:  Building trust not necessarily in the interest of a common goal, therefore the word trust was removed C11:  "How" was mixed with competency itself, restriction to public health was removed.
C12:  Participative decision-making was regarded important but many comments referred to the fact that it would not always be possible to maintain trust f or everyone involved.
 "Through" was removed as it was mentioned that this would mix up the how with the competency itself.
C13:  Not limited to health, often mentioned, that the whole (system, ecology, climate change, etc.) need to be linked to it, Co-creation with all is not possible, there is always someone who doesn't like change. Too many aspects in one competency, TL don't build coalitions, rather initiates, monitors and measures, no co-creation alone.

C14: 
The word paragon was removed as it was twice not well-understood by the participants.


Transparency was removed as it was mentioned that this may not be possible and that it would be problematic to link it to the other concepts. It would rather be about having a clear strategy, acting with integrity and being ethical, what leads to trust.
Explanation for inclusion/exclusion (competencies below the threshold 80%):  C04: part of C01, therefore C04 was removed in its original formulation.Adopting to all situations and being overall flexibl e was not regarded as a must. C09: regarded as too complicated, therefore it was split into two parts.Challenging interdependencies was rejected, rather should they be challen ged  C05: was regarded as an intuitive/unconscious competency, something that TL do out of instinct.The original formulation was removed.It was suggested to link it to the competency on systems thinking (C02)  C15: Not understood well as a competency (four times).It was suggested to include into the competency on systems thinking (C02)  C07: Removed in its original formulation since many commented that they would not understand the competency formulation.Self-regulation was regarded as important but not linked to vulnerability (four times mentioned).Suggested reformulations were merged with C06 Adaptations after Delphi Round 3 (Consensus WS)

C01:
 Remains at it is, no major comments.

C02: 
No major comments during workshop. Suggestion of a research group member was adopted.

C03: 
No major comments during workshop. Suggestion of a research group member was adopted.

C04: 
No major comments during workshop. Suggestion of a research group member was adopted.

C05: 
No major comments during workshop. Suggestion of a research group member was adopted.

C06: 
No major comments during workshop. instead of collaborative the term "diverse" was set, since collaborative is part of C09 (Practices participatory leadership)

C07: 
No major comments during workshop. Suggestion of a research group member to simply sentence was adopted.

C08:
 Comment of one panelist to consolidate two into one (C08/C12)  The two competencies were merged.


One of the competencies is now seen as the descriptor of the other.

C09: 
No major comments from the group. Suggestion of a research group member was adopted.

C10: 
No major comments from the group. Suggestion of a research group member was adopted.
C11:  Suggestions for rephrasing of one of the research group members  Comment of one panellist that Nourishing D&I is enough in itself.
 Suggestion of research group member and panellist were adopted.

C12: 
No major comments from the group.
C13:  Comment of one panellist that it would be the most ambiguous of all, word context needs to be considered.


Comment of one panellist that it would need to be defined within the public health context.


Comment of one panellist that this relates to human relations.


Comment of one panellist Leadership can challenge unequal distribution of power, but not power itself.
 Comments of panellist were adopted.
C14:  Comment of two panellists that it would be difficult because of the word entrepreneurial.


Comment of one panellist that the relation to public health should be made in the operationalisation Suggestion of panellists was adopted.To "adapt" considered an inappropriate term for leaders, as it would be too passive.


There are more conditions for achieving shared goals than just adapting to the needs of the eco-system.Similarly, adapting to the needs of the eco-system is a condition serving more than just achieving shared goals.


The adaption is also necessary for being able to implement change that sticks C02: 


Entrepreneurial would be more related to economics and focusses on the present and a narrow paradigm linked with some western values (capitalism, neoliberalism).

Terminology
In the context of this research project, we start from a holistic competency model.According to Van Loo and Semeijn (6) competencies are defined as "composites of individual attributes such as knowledge, skills, and attitudinal or personal aspects that represent context-bound productivity.This definition was chosen to be suitable for the context of this study as it builds on the following three assumptions: first, the competency model is based on a holistic understanding, since it is a collection of personal attributes or characteristics.Secondly, the reference to performance means that competencies are something that is actually and consistent ly applied, which is important for measurability in the context of competency surveys.Thirdly, competencies are always to be seen in relation to a specific context, i.e., their expression or application varies according to the given circumstances and setting.
Transformational leadership is about the assumption that everything and everyone in the universe is interconnected and part of continuous change.In this study, transformational leadership is defined as a "combination of practical skills such as modelling the way, inspiring a shared vision, challenging the process, enabling others to act and encouraging the heart to jointly bring re ality to a higher level" (adapted from Kouzes & Posner ( 7)).Further, transformational leadership is to be seen as an individual competency development process.A stage model was designed to represent transformational leadership as a developmental process.Different stages reflect the level of experience within one competency (see Figure 3).
Competencies can be studied from different perspectives.Different viewpoints have different definitions and classification systems of competencies.This has implications on how competencies are measured as this is closely linked to the definitions, the leaning theories behind as well as the classifications.Van Loo and Semeijn (6) assign competencies to three different perspectives to generate a comprehensive picture on how to operationalise and describe the meaning of competencies: The educational perspecti ve, the labour market perspective and the organisational/human resource perspective.The educational perspective argues that not only knowledge, skills and attitudes should be considered but also the learning behaviour.This perspective is therefore a rather dynamic concept.Nevertheless, performance criteria are often used today to describe competencies.The labour market perspective is traditionally very strongly oriented towards specific qualifications, which focus less on the individual and more on a specif ic work context with its respective and characteristic requirements.In addition, skills are very often mentioned in this area, which is traditionally used as a form of operationalizing productivity.The competency concept applied to the organisational/ human re source perspective is strongly oriented towards organisational goals.Cognitive learning as well as social learning are given importance.
Cognitive learning is reflected in acquired knowledge, skills, and attitudes whereas social learning refers to agreement and satisfaction.Within the human resource perspective, competencies are directly linked to the individual, thus competencies are something dynamic rather than static.What constitutes and defines a competency is extremely contextual and subjective.The s ector or professional field a person belongs to determines the type of competencies that are considered important.This does not necessarily have to be justified by the type of work performed.Rather, competencies can be weighted differently because they reflect different value patterns and experiences.

Box S9 Draft Operationalization of competencies (descriptors)
C01: Adapts according to the needs of the eco-system  I apply principles to guide change and feel competent to initiate change processes. I consider alternative options and new approaches and I am always willing for negotiations. I'm attentive and watchful to external realities. I handle challenges with change. I'm taking the initiative to change the way things are  I give others the chance to create new approaches and take the initiative. I constantly analyse the changing nature, key factors and resources that shape global health (8) (7) C02: Inspires others to commit to common goals. I apply tools and techniques to develop a common strategy. I initiate and structure goal-setting processes. I regularly use techniques to identify and pursue common goals over the long-term. I prospect and describe an image of the future to engage the minds and hearts of others and to anticipate what is possible. I trust my abilities to make extraordinary things happen. I clearly envision and belief in the goals, outcome, etc. before starting any project. I connect my visions and the future to experiences to understand the themes that led me to where I am. I engage others in a dialogue about the future by showing them how they will be served in the long-term. I generatively listen to my constituents (their hopes, dreams, and aspirations to be aware of what is meaningful and valuable to them and to identify opportunities for them).(7) (9) (2) C03 Empowers others to build upon their competencies and wisdom. I support my constituents in dealing with change and I am aware of their need for security and steadiness. I express my trust and genuine belief in the capacity of my constituents to build their confidence in their abilities and their trust in me. I ensure the availability of professional development opportunities for the organization (e.g., training, mentoring, peer advising, coaching). I consult the opinions and ideas of my constituents to update and question my own perspective and offer a chance to do things differently.
 I coach my constituents step-by-step including constructive feedback, probing questions and active teaching to promote gradual progress. I assess my constituents' capacities and try to liberate their visions to perform in the context of the challenges they face. I sense my constituents' development needs in a given position and plan learning to bolster their abilities. I make it safe for others to try, fail, and learn from experiences and turn them into learning experiments. I facilitate a "can-do" attitude and increase self-determination by creating opportunities for people to accomplish a task. I motivate performance by supporting meaningful assignments and by creating possibilities to exercise choice and latitude. I assist others in positioning themselves and stating why they do what they do and what is important to them.
(1, 5) (10) C04 Practices participatory and inclusive leadership. I foster accountability and responsibility by delegating authority, sharing power and involving my constituents in decisions. I create a spirit of community by acknowledging values and victories and by celebrating individual and team accomplishments. I'm striving try to build trust and psychological safety by paying attention to my tone of voice, posture, gestures, and facial expressions. I give my constituents the chance to explore better ways of doing things and to move forward and embrace the initiative. I provide challenging assignments together with support and sufficient resources to accomplish them. I promote group morale and productivity by providing clear directions and priorities to my constituents. I instruct, coach and guide others to harmonise their actions with the shared values. I establish challenging targets for my constituents' scope of responsibility.
(5) (11) C05 Creates synergies and fosters a collaborative environment. I recognise achievements by giving personal, precise and visible feedback. I regularly meet with small groups and "walk the halls and plant floors". I sense others' feelings and perspectives, and taking an active interest in their concerns. I organise teamwork and coordinate interdisciplinary teams to synergise complementary skills. I identify and respond to underlying attitudes or behaviour patterns such as cultural norms and personality differences. I actively foster a diverse and tolerant environment that values singularities as well as common grounds. I value the diversity of my constituencies and at the same time, I build on the establishment of shared values. I communicate the shared values of my constituents and enable them to talk about their values wi th others. I facilitate the discussion and resolution of conflicts or disagreement. I analyse my environment for information enabling me to develop better communication strategies. I purposefully react to frustrations trying to negotiate and resolve disagreements. I promote and participate in socially and culturally sensitive multidisciplinary teams.Feedback EvaSys, (5, 8) (1) C06 Proactively manages partnerships with diverse stakeholders. I constantly get people and organizations interacting towards cooperative goals and promote a sense of mutual dependence and respect. I am looking for opportunities for interdisciplinary and intersectoral exchange among stakeholders and across continents. I set up and utilise networks, multi-stakeholder meetings to seek information of strategic importance. I conduct, coordinate, mediate and/or moderate high-level fora and events, at national, sub regional or regional levels. I establish formal agreements (e.g., MOUs, bilateral agreements) at various levels and promote transnational, intersectoral initiatives to overcome inequities, implement effective interventions and monitor the success of collaborations. I advise stakeholders and give feedback in terms of ideas, concerns or problems they are facing. I improve communication processes by building trust and psychological safety. I make an effort to hear and respond to a group's emotional currents and power relationships and anticipate other's reactions. I adapt my negotiation style to the respective context (e.g., competing, cooperative, avoiding, compromise, accommodating). I communicate complex issues clearly and credibly with widely varied audiences. I attempt to understand the values of others and to establish values that can be shared by all. (5, 8) (1) (10) (11) C07 Personifies optimism and perseverance to build resilience in challenging times. I ask for clarification if I feel that I have not understood something. I consider problems as constructions dependent on time and situation that arise due to its problematic description, explanation and assessment. I operate with the confidence that behaviour is situational and contextual and therefore not constant. I value having others question or challenge my approaches. I see challenges and disappointments as learning opportunities to generate small wins and am curious about the uncertainties that life holds. I constantly try to demonstrate a positive and engaging behaviour seeing the positive aspects of things and the future. I have an awareness of my emotions and apply techniques to balance disturbing emotions and impulses. I embrace opportunities for learning and constantly become involved and engaged to what's happening. I preserve an objective attitude within negotiations and a non-emotional distance from interpersonal conflicts.(5) (1) C08 Aspires to act with integrity. I openly disclose things I stand for, I value, I want, I hope for and I am willing (not willing) to do and thus give up control and show vulnerability. I apply self-regulation techniques to operate authentically. I continuously try to personify a connection between action and the values I stand for. I am aware of my core values and guiding principles and beliefs by examining experiences to make choices and decisions.
 I formulate the values that guide my decisions, priorities and actions and I am mindful of my choice of words. I strive to improve my emotional intelligence (through training, mentoring and feedback from others). I regularly reflect my own beliefs, values and behaviours and the ways in which these can impact both my decision making and the response to others. I clarify my vision (What drives me?What do I care about?Why do I want to accomplish certain things?) I attempt to give constructive and precise feedback based on facts and behavioural patterns observed, containing individualised suggestions for improvement. I get personally involved and demonstrate with my behavior what is desired, expected and what will be rewarded (e.g., by attending meetings and events, visit stakeholders, make presentations, visiting my constituents at their desks to say hello). I demonstrate cultural sensitivity and incorporate ethical standards of practice (e.g., Public Health Code of Ethics) into all interactions. I use ethical principles to critically review the development and implementation of policies and activities.(8) (5) (11) (10) (11) Feedback EvaSys Round 4 C09 Acts effectively in complex and multifaceted systems. I engage in change initiatives at a micro (individual), meso (group), macro (institutional) as well as the global level . Encourages others to see the positive outcome of doing things differently. I try to make connections across seemingly unrelated questions, problems or ideas. I promote a comprehensive, strategic perspective and at the same time focus on the crucial details . I use a variety of analyses and experiences to draw conclusions. I use my depth-expertise in how to facilitate and manage change at a micro (individual), meso (group), macro (institutional) as well as the global level. I actively seek and identify emerging development opportunities and take the initiative to change the way things are done. I experiment with many ideas and divide larger problems into small, manageable actions. I'm willing to do things that have never been done before and actively put myself in new situations. I continuously change my perspective to assess and promote global responsibility in terms of local actions as well as to understand the local impact of global events. I reprioritise and restructure regularly to increase my constituents' responsiveness to internal and external demands. I try to overcome habitual patterns of thinking and welcome opportunities to step out of my comfort zone/ by actively looking for new ways of doing things and by perceiving themes or patterns in seemingly random items, events, or phenomena.(5,8) (1) C10 Pursues strategic approaches for value-based, innovative solutions. I synthesize information and ideas from multiple sources and disciplines to design and implement of programs, policies, and systems.(11)  I assess cultural, ethical, environmental, and political influences on the feasibility and sustainability of activities. I actively involve my constituents in a dialogue/discussion about values and make them reflect on core val ues. I ensure that people comply with agreed values and norms. I evaluate the performance and impact of actions and strategies. I assess risks, benefits and unforeseen consequences of our professional work. I direct organisational decision-making and planning based on internal and external research. I develop professional plans that include lifelong learning, mentoring and strategies for continuous professional development  I apply quality improvement methods. I attempt to stay up to date with changing trends and stay sensitive to changing external circumstances.

Core Competencies for Transformational Leadership Self-assessment tool
This self-evaluation tool is the result of five rounds of an expert informed Delphi process.The Competency Framework including competencies, categories and descriptors were systematically developed using quantitative and qualitative analytical methods.
The self-assessment tool is designed to support you in reflecting on your personal development status.It should also help you to identify areas for further development. Procedure: 1. Read the competency and its descriptors.2. Next to each descriptor, you will find a scale, please choose a rating that best reflects how often this behaviour applies to you. 3. Now add up the values in each column and write the value at the bottom of the competency.4. Reflect on how you have rated yourself.If you have mostly light green scores within a competency area, this could be a competency you would like to develop further.If you have almost exclusively dark green ratings, this could be a sign that certain strengths and skills are being overused.It could be a behaviour that you rely on too much, which could have a negative impact on your overall performance.

Competency 1
Adapts according to the needs of the eco-system Very little Some of the time Many times Always 1.I apply principles to guide change and feel competent to initiate change processes.2. I constantly analyse the changing nature, key factors and resources that shape global health.3. I'm attentive and watchful to external realities.4. I consider alternative options and new approaches and I am always willing for negotiations.5.I handle challenges with change and flexibility.6.I recognise new aspects and align my observations on the basis of experience, which enables me to grasp processes easily.7. I give others the chance to create new approaches and take the initiative.8.I immerse myself in the context and try to get the best out of it.9. I feel comfortable to step back in full confidence that my team will continue in an autonomous, target-driven and situational way.TOTAL

Competency 2
Inspires others to commit to common goals Very little Some of the time Many times Always 1.I regularly apply participative leadership techniques (e.g., Art of Hosting, Transformational scenario planning, Experimentation) with my team and/or external partners.2. I initiate and structure goal-setting processes.3. I clearly envision the goals, outcome, etc. before starting any project.4. I actively participate in the career planning and development of my team to ensure that personal goals are clearly defined.5.I ensure that goals are understood collectively.6.I connect my visions and the future to personal experiences to understand the themes that led me to where I am. 7. I try to empathise with the reasons for different behaviours of my employees.8.I project an image of the future to inspire others to envision what is possible and how their own interests will be served at the same time.9.I generatively listen to my constituents (their hopes, dreams, and aspirations to be aware of what is meaningful and valuable to them and to make them aware of opportunities).TOTAL

Competency 3
Empowers others to fully capture and build upon their competencies and wisdom Very little Some of the time Many times Always 1.I ensure the availability of professional development opportunities for the organization (e.g., training, mentoring, peer advising, coaching).2. I facilitate a "can-do" attitude and increase selfdetermination by creating opportunities for people to accomplish a task.3. I motivate performance by giving meaningful assignments and by creating possibilities to exercise choice and latitude.4. I assess my constituents' capacities and try to liberate their visions to perform in the context of the challenges they face.5.I consult the opinions and ideas of my constituents to update and question my own perspective and offer a chance to do things differently.6.I support my constituents in implementing their ideas even if it does not fully align with the way I would do things.7. I support my constituents in dealing with change and I am aware of their need for security and steadiness.8.I support others to be authentic in the way they act (e.g., positioning themselves, stating what is important to them).9.I encourage my constituents to build their confidence in their abilities and their trust in me.10.I make it safe for others to try, fail, and learn from experiences.11.I coach my constituents step-by-step including constructive feedback, probing questions and active teaching to promote gradual progress.TOTAL

Competency 4
Practices participatory and inclusive leadership Very little Some of the time Many times Always 1.I appreciate to work with people of different backgrounds including socio-economic status, different nationalities, different sex/gender, etc. 2. I invite constituents to co-create work processes and projects, from ideation to evaluation of the implementation.3. I promote group morale and productivity by providing clear directions and priorities to my constituents.4. I provide challenging assignments and targets for my constituent's scope of responsibility together with support and sufficient resources to accomplish them. 5.I create a spirit of community by acknowledging values and victories and by celebrating individual and team accomplishments.6.I give my constituents the chance to explore better ways of doing things and to move forward and embrace the initiative.7. I foster accountability and responsibility by delegating authority, sharing power and involving my constituents in decisions.8.I am striving to build trust and psychological safety by paying attention to my tone of voice, posture, gestures, and facial expressions.9.I feel comfortable working with people that do not share my own values to try and build a consensus.I strive to ensure that the structure of my team, as well as our activities, reflect the composition and needs of the communities we aim to serve.TOTAL

Competency 5
Creates synergies and fosters a collaborative environment Very little Some of the time Many times Always 1.I recognise achievements by giving personal, precise and supportive feedback.2. I sense others' feelings and perspectives, and take an active interest in their concerns.3. I identify and respond to underlying attitudes or behaviour patterns (e.g.cultural norms, personal preferences and differences).4. I support my constituents in dealing with change and I am aware of their need for security and steadiness. 5.I facilitate the discussion and resolution of conflicts or disagreement.6.I analyse my environment for information enabling me to develop better communication strategies.7. I purposefully react to frustrations trying to negotiate and resolve disagreements.8.I regularly walk the halls and workspaces to chat and have informal conversations.9.I actively foster a diverse and tolerant environment that values singularities as well as common grounds.10.I value the diversity of my constituencies and at the same time, I build on the establishment of shared values.11.I communicate the shared values of my constituents and enable them to talk about their values with others.12.I organise teamwork and coordinate interdisciplinary teams to synergise complementary skills.13.I promote and participate in socially and culturally sensitive multidisciplinary teams.14.I encourage academia and/or international agencies to take the lead in organizing multisectoral workshops (public & private sectors, civil society, bilateral agencies, donors) to address any given multifactorial problem (e.g.health, environment, poverty) analyse potential risk factors and underlying determinants and develop jointly a methodology using e.g.logframe to define process and impact indicators which cut across sectors.Publish the findings.15.I encourage utilization of the workshop findings and recommendations to move them forward (e.g pilot projects).TOTAL

Competency 6
Proactively manages partnerships with diverse actors Very little Some of the time Many times Always 1.I attempt to understand the values of others and to identify values that can be shared by all.
2. I explore any potential conflict of interests with any given partner before setting up a partnership.3. I research and listen to each of the partners interests.4. I engage partners in every step of the process, initially in informal settings to build trust and camaraderie before moving on to settings that are more formal.
5. I advise constituents and give feedback in terms of ideas, concerns or problems they are facing.6.I try to communicate complex issues clearly and credibly with widely varied audiences.7. I try to be fully aware of any possible cultural sensitivities that might jeopardize the partnership and prepare to handle these.8.I constantly try to encourage people and organizations interacting towards cooperative goals and promote a sense of mutual dependence and respect.9.I make an effort to hear and respond to a group's emotional currents and power relationships and anticipate other's reactions.10.I adapt my negotiation style to the respective context (e.g.competing, cooperative, avoiding, compromise, accommodating).11.I am looking for opportunities for interdisciplinary and intersectoral exchange among actors and across continents.12.I conduct, coordinate, mediate and/or moderate highlevel fora and events, at national, sub regional or regional levels.13.I establish formal agreements (e.g.MOUs, bilateral agreements) at various levels and promote transnational, intersectoral initiatives to overcome inequities, implement effective interventions and monitor the success of collaborations.14.I encourage consensus building to decide on the best possible partnership's management body/entity (with special care on conflict of interest issue).TOTAL

Competency 7
Personifies optimism to build resilience and perseverance in challenging times Very little Some of the time Many times Always 1.I constantly try to demonstrate a positive attitude by practicing a solution-oriented approach.2. I embrace opportunities for learning and constantly become involved and engaged to what is happening.3. I approach problems as potential for growth and scope for experience in a specific context.4. I see challenges and disappointments as learning opportunities to generate small wins. 5.I am curious about the uncertainties that life holds.6.I have an awareness of my emotions and apply techniques to balance disturbing emotions and impulses.7. I perceive the emotions of others and then reflect on how and whether I will respond to them.8.I value having others question or challenge my approaches.9.I preserve an objective attitude within negotiations and a non-emotional distance from interpersonal conflicts.10.I feel competent to assess the behaviour of my team in relation to the context and the situation.TOTAL

Competency 8
Acts with integrity Very little Some of the time Many times Always 1.I ask for clarification if I feel that I have not understood something.2. I adhere to honest and verifiable research methods in connection with research projects (proposal, implementation and evaluation) and follow generally accepted scientific norms and standards.(New) 3. I communicate research results with a special focus on adherence to rules, regulations, and guidelines.4. I formulate the values that guide my decisions, priorities and actions and I am mindful of my choice of words. 5.I apply self-regulation techniques (e.g.meditation, distraction, imagination, physical activity) to ensure that I operate in an authentic way.6.I am aware of my core values and guiding principles and beliefs by examining experiences to make choices and decisions.7. I attempt to give constructive and precise feedback based on facts and behavioural patterns observed, containing individualised suggestions for improvement.8.I openly disclose things I stand for, I value, I want, I hope for and I am willing (not willing) to do. 9.I continuously try to personify a connection between action and the values I stand for.10.I demonstrate cultural sensitivity and incorporate context specific ethical principles (e.g., Public Health Code of Ethics) into all interactions (including the development and implementation of policies and activities).11.I get personally involved and demonstrate with my behavior what is desired, expected and what will be rewarded (e.g. by attending meetings and events, visit actors, make presentations, visiting my constituents at their desks to see how they are, how they are feeling, to listen, to give support, etc. 12.I strive to improve my emotional intelligence (through training, mentoring and feedback from others).13.I regularly reflect my own beliefs, values and behaviours and the ways in which these can impact both my decision making and the response to others (What drives me?What do I care about?Why do I want to accomplish certain things?)TOTAL Competency 9 Operates effectively within and across complex and multifaceted systems Very little Some of the time Many times Always 1.I (pro-)actively facilitate and engage in change initiatives at a micro (individual), meso (group), macro (institutional) as well as the global level.2. I encourage others to see the positive outcome of doing things differently.3. I promote a comprehensive, strategic perspective and at the same time focus on the crucial details. 4. I use a variety of analyses and experiences to draw conclusions.5.I actively seek and identify emerging development opportunities and take the initiative to change the way things are done.6.I experiment with many ideas and divide larger problems into small, manageable actions.7. I am willing to do things that have never been done before and actively put myself in new situations.8.I continuously change my perspective to assess and promote global responsibility in terms of local actions as well as to understand the local impact of global events.9.I reprioritise and restructure regularly to increase my constituents' responsiveness to internal and external demands.10.I try to overcome habitual patterns of thinking and welcome opportunities to step out of my comfort zone/ by actively looking for new ways of doing things and by perceiving themes or patterns in seemingly random items, events, or phenomena.
11.I encourage other to make connections across seemingly unrelated questions, problems or ideas to develop comprehensive solutions.TOTAL

Competency 10
Pursues strategic approaches for value-based, innovative solutions Very little Some of the time Many times Always 1.I synthesize information and ideas from multiple sources and disciplines to design and implement of programs, policies, and systems.2. I assess cultural, ethical, environmental, and political influences on the feasibility and sustainability of activities.3. I actively involve my constituents in a dialogue/discussion about values and encourage them to reflect on core values.4. I encourage others to comply with agreed values and norms. 5.I evaluate the performance and impact of actions and strategies.6.I assess and balance risks, benefits and unforeseen consequences of our professional work.7. I direct organisational decision-making and planning based on shared and transparent criteria.8.I develop professional plans that include lifelong learning, mentoring and strategies for continuous professional development.9.I apply quality improvement methods including process, product and people-based improvements (New).10.I attempt to stay up to date with changing trends and stay sensitive to changing external circumstances.TOTAL

Personal development plan (1) Choose one development need that you have identified for yourself (you can repeat the exercise after the course for other areas). Summarise the most important aspects of this in key points (WHAT). (2) Justify your choice (WHY).
(3) Start at the end to describe the specific activities.In other words, what is the overall goal or desired new behaviour, what will be in place, what will you have achieved at the end.Think about all the activities that are necessary for you to perform thi s behaviour.As a tip, the activities can be broadly categorised as experience, engagement and education (HOW).(4) Take the 'Personal Strengths and Resources' worksheet that you have already completed in preparation.Think about which personal resources and strengths are particularly useful for your undertaking (WHICH).(5) In addition, think about the timing (WHEN), the location (WHERE), and possible stakeholders/groups of people (WHO) in your environment who can be both supportive and impeding.
information and responsibility effectively at different organizational levels to gain political commitment, policy support and social acceptance for a health goal or programme (2) Doing Influence Communicates facts and evidence effectively within the context of translating science and evidence into practice and policy for various actors in the system and populations of concern to increase the effectiveness of responses to risks, threats and damages to health (2) Doing Influence Communicates health messages (including risks to health) effectively (both in writing and verbally) through a range of modern media and social marketing to lay, professional, academic and political audiences (2) Doing Catalyzes people's commitment and highest contribution to the change (toward shared goals.Creating group synergy in pursuing collective goals. flexibility and adaptability in the process of working with others, emphasizing achieving goals as opposed to rigidly adhering to traditional and commonly used work methods (2) Doing Teamwork Effectively leads interdisciplinary teams to work in a coordinated manner in various areas of public health practice (2) Doing Teamwork Develop teams for implementing health initiatives

Figure
Figure S1 Initial version of the Competency Framework for Transformational Leadership (left) compared to the final version (right) following the consensus workshop Online Consensus Workshop on 19 October 2021 from 12:00pm-3:00pm (GMT+2) you are welcome to do so by Friday 15 October.The programme and dial-in details (zoom link) will be shared with all participants in advance.I am looking forward to an exciting discussion!:-) Barbara On behalf of the research team ***

Figure S3 Questionnaire Round 1 Figure S4 Questionnaire Round 2 Figure S5 Questionnaire Round 3 Figure S6 Questionnaire Round 4
Figure S3 Questionnaire Round 1 identify patterns across situations that are not obviously related, and to identify key or underlying issues in co mplex situations (Analytical Thinking) (5) Knowing 92 Is able to generate results by assuming responsibility for one's performance and the correctness of one's interventio ns, and recognising opportunities and acting efficiently at the appropriate moment and within the given deadlines (Achievement Focus)

Table S3 :
Key attributes of Expert Panel participants across all Delphi rounds

transformational leadership Newsletter Delphi Round 1 Dear Experts, A few weeks have passed since the first Delphi round. Since then, we have been working intensively on the data analysis. We have been overwhelmed by the richness and wealth of feedback we have received. Thank you so much! :-) Before the second questionnaire round starts from 01-15 September 2021, we would like to share with you a first newsletter in which we have summarised topics that were mentioned repeatedly as 'Golden Nuggets' and provided examples. We ask for your understanding that we could not include all answers, although we considered them to be of great relevance
. The selection of the examples and presentation of the content was made on the basis of the frequency in which a particular topic was mentioned.
 Voluntary work -currently chair two Boards of Directors; also do volunteer teaching and project work in Costa Rica, where I spent 6 months a year. Control programme  Health 4. Analysis of expert feedback Box S6 Newsletter Round 1: Delphi Study on competencies for

Nugget 2: «Transformational» is about the way one acts on knowledge in a specific context.
Example TL experience of one of the participants (C09): »In my organisation at my university my head of school has changed the chairing of our school admin meetings that occur once a month.Now instead of the Head of school chairing it rotates, what makes it transformationalis that it includes ALL staff, also admin staff, not only academics.What evidence have I of it being transformational?Everyone has been impressed that all staff can do this.Also last month the person doing it was a post grad coordinator (note in here these people may not have a tertiary degree) and he asked the Head of School why he chose to run the meetings that way.This was a demonstration of a change in usual hierarchical relationships.A junior less educated member of staff asked the most senior person about his motivation for choices he made in leading the school in a public forum.»

Nugget 4: Transformation requires embracing diverse realities and their interplay in different contexts.
engage with social entrepreneurs and social innovators how to apply participatory leadership methodologies (see Art of Hosting Community) -to co-create and innovate».Example comment on C05: «(…) Sometimes you may not need all the interdependent systems.You may need a few depending on the task being implemented.»Nugget5:Communicationandrelationshipbuildingarethe scaffolding.However, this is not about win-win situations, but about transformation itself.Comment on category KNOWING: «(…) [TL] understand the power relations that are at play (…) within own group (race, class, gender, nationality etc.) and applies this knowledge in how you lead.To have a political and economic analysis of the area your work is focused on and to use this in the way you direct your work.»Comment on category KNOWING: »Understanding differences in cultural practices and gender needs of staff in the organization.»ExamplecommentonC08:«Respectdifferences in the audience, an academic is different to the lay public or (…) even politicians.It would be a mistake to confuse these different stakeholders as customised, communication strategies are needed.»ExamplecommentonC22:«(…)The effective leader might have others help them (…)Example on C20: (…) the leader leads and the team does the work.Their is the risk of micromanagement and missing on delegation.»Examplecomment on 07: «A transformational leader (…) understand the role of technology, communications, and data/information in producing excellent research and ensuring that decisionmakers at all levels have access to accurate information.The transformational leader might not be able to do this work themselves, but (…) ensures that someone on the team can.»Example comment on category KNOWING: «[Promotes] professional growth and equity.Knowledge of tools to assess, measure and quantify employee inputs so as to adequately assess employee competence and fit for promotions.(…)Akey roles of a TL is to create more outstanding professionals and one of the key driving factors in that role will be an effective and transparent reward system that actually rewards competence and creates healthy competition.»Examplecomment on category KNOWING: «[TL] use technical knowledge to intellectually stimulate others to perform».Nugget 6:

There is no recipe for transformational leadership, merely the ability to act from an authentic inner place.
Example on categroy KNOWING: (…) «[TL is about attitude], transformational leaders care about the state of things and feel entitled and responsible to change it.Otherwise, they won't get to do anything» Example comment on C05: (…) Not possible to limit process thinking to conscious.(…)a lot may be unconscious, likely being influenced by one's previous experiences, attitudes and cultural concepts.Example comment on Category KNOWING: «Perhaps emotional intelligence which involves sensitivity to others' feelings and reactions, and should help to guide our work.For example, a young Muslim student sits behind her screen for her Zoom classes with a hijab, black background and surrounded by a gloomy atmosphere.She doesn't speak unless drawn out by the professors, and when she does, her answers are excellent.If the professors were not emotionally intelligent, they would give her a very low mark on class participation, which would be emotionally and culturally insensitive.»

transformational leader will never be able to please everyone / Transformation implies change and it isn't conflict free.
My problem here is that there are two questions -beyond a shadow of a doubt I think that recognising emotions is important if and when I let them interfere with my work.But is this related to self-care?I don't know that the two are really related.You can be a transformational leader and overwork and practise no self care and you can be very successful and you never burn out.Others may burn out.Also I have worked with transformational leaders who have achieved a lot and they are very thick skinned and I think do not recognise their own emotions or anyone else's .They are veryExample comment on C08: "(…) this may fall a bit within the purview of individuals' character which might be an asset you will want to look for as it is otherwise difficult to groom.Excellent human resources competencies would be a must.Example comment on C11: "I do think this is very idealistic and hard to achieve -there is always someone in a group who will find the leader insensitive, or will feel disrespected even if that was not the leaders intent.But this is certainly something to aim for."Example in the comment and recommendation section: "What is missing is a recognition that transformation is about change, and change is not always comfortable and it is not conflict free (…).
successful and it may be because they are emotionally blunted.I also suspect this is a gender issue.In my experience men spend less time feeling and worrying about how other people feel and woman do it too much."ExamplecommentonC07:"Iamnotconvincedthata leader should operate out of vulnerability.It may be that I am not aware of what operating out of vulnerability actually means."ExamplecommentonC07:"Operatesout of vulnerability could be open to misinterpretationperhaps operates authentically acknowledging vulnerability".Example comment on C07: "(…) self regulation is hugely important -BUT is it related to vulnerability?I don't think so.I have seen people who operate out of vulnerability who fail just because of that reason.I have also seen people who are seen to be very strong and invulnerable succeed, usually because they seem to be confident and sure of themselves and have no doubts or vulnerabilities.But I have also seen them succeed because they sometimes do very rarely demonstrate / know / expose a particular vulnerability.So I agree that self regulation is important but I would not link it to vulnerability."Example comment on C07: (…) I would not restrict it to operating out of vulnerability; it is important to engage with ones own vulnerability and establish authentic communication, but for some people operating out of it conflicts with their own way to handle issues in a healthy manner, not everyone engages with vulnerability in the same mannerExample comment on C07: "Checking the ego is important"Nugget 3: One's character is key for transformational leaders."(…)Bear in mind that a decision has to be made, even if a full consensus isn't possible."ExamplecommentonC12: "(…) just to point out if you are trying to force change there are always people/institutions with vested interests who will try to obstruct the transformation you seek to achieve.(…)youwork actively to see that some view points are not taken into account and those groups/people will not think that you have built trust, even though you may have with the majority.The idea that transformation/ change is devoid of conflict is naive and sometimes I feel these statements suggest that this is a wonderful process where everyone is taken care of and accounted for and considered and that is not that case.If you want greater equality then those with power have to give up something, if you want to change an organisation so that it is more efficient the lazy people or usual systems have to be chucked out or changed.(…)participatorydecision making is right but it can sometimes go with lack of trust at least for some.Example comment on C13:"Sometimes if you are looking to change something for the general good you can be in the minority -so you would never co-create with everyone -only particular stakeholders who have the same mission -sometimes some of the stakeholder you have to engage with are one you do not build a coalition with -you form a coalition with others against an obstructive stakeholder."

Transformational leadership cannot only focus on Public Health, it is about seeing the whole picture.
Example in the comment and recommendation section: "(…) You need to broaden the scope of scenarios beyond what we, honest individuals and leaders would like to see to scenarios which are much more complex and strained as a result of global warming, the pandemic and its brutal economic impact.Among the biggest challenges future public health leaders will face is how to change people's minds, perceptions, attitudes towards the impact of the global crisis, change corporate culture and address an ever increasing corruption phenomena." "I think we should not restrict ourselves to public health, there are other way more important topics such as climate and biodiversity collapse"

Nugget 6: Integrity, trust and acting ethically are above the importance of transparency.
) in transformational strategies it is important that you may not be 100% transparent all the time.(…) however (…) integrity is paramount.And it is very important to be ethical and super important that people groups feel they are treated the same.So trust is important.Linking all of this with transparency is problematic."Example in the comment and recommendation section: "I would say that however that integrity is super important.I have certainly followed and changed my practise / process when I have not agreed with a leader but I have found there is evidence or rational argument to support that change and that the person has integrity.But not just any integrity, but that is based on a value system that I support."

catalyst of intersectoral multi-stakeholder projects and programs"  "Applies principles of systems thinking within systematic enquiry to influence relationships with stakeholders in interdisciplinary and intersectoral projects and programmes."  "Applies principles of systems thinking to manage relationships with stakeholders in interdisciplinary and intersectoral projects and programmes."
To sense something is to know it -it is not about doing anything -to do you would have to put something into action with it and what makes this transformational is about how you act on that sense.And I think that it is context specific, so a good leader (transformational of otherwise) may have this sense but it is how they act on it that makes it a DOING thing and if it transformational or not will be context specific. "Creates opportunities for staff and partners to learn together by experimentation: co-creation, rapid prototyping and implementation, followed by adaptation (change is iterative)."  "…senses and respond to"  "Identifies development needs, including those that relate to roles, abilities, and responsibilities and strategizes on how to address them"  "determine development needs of internal stakeholders and supports capacity building on these" C10:  Includes a teaching component, (mentioned by two persons), requires active listening and trust, mindset of a leader  More than health initiatives, also include economic and social aspects  2 competencies in one "Develops leaders" and 2) "Develops teams".

up innovation labs for learning, stimulates experimentation"  "Fosters professional and personal growth within the team/next generation"
Context-specific, not always on all levels, relevance to community work depends on the nature of the organization and the role of the leader (two times)

capacity at the individual, organisational & community level for purposeful/mission driven change and innovation"  "Develops capacity at the individual, organisational and community level through multiples str ategies to achieve ongoing change and renewal."
 Just one aspect; 'manages people enabling them to deliver'; or, 'Provides clear expectations, well  defined responsibilities, and the means to deliver'  "

environment through trust and participatory leadership methodologies"
 no need to negate a behaviour when something is already confirmed  process to achieve goals is also important  Contradiction: one says this competency is not transformational, the other says this is clearly transformational  "Demonstrates practicality,

flexibility and adaptability in the process of working with others and continuously challenges established ways of working/status quo to stimulate creativity and innovation
" (in fact I think these are two separate competencies)  "

based practices (e.g. meditation) to review and evaluate own practices..., while paying attention to self-care"  "Critically reflects on own practices."  "Critically reviews and evaluates own practices in relation to public health principles" C28
: Aspect of "self-care" (three times mentioned), also an opposing voice that says that this is exactly the challenge and "conundrum"Too complex, operationalisation  Perseverance only if there is flexibility and adaptability C29:  Typical leadership skill, not really transformational  Stop after "actions"  Not helpful to suppress feelings  To reach out for (professional) help (mentioned two times) "Operating from vulnerability" as a key transformational leadership competency  Quantifying disruptive behaviours on TL is not scientifically measurable.Correlation cannot be ascertained. "Avails of mechanisms for self-regulation of....."  "Acts empathetically, is resilient and patient."

Table S5
Selection criteria for participation in the Delphi StudyClassification into one or more of the categories (educational perspective, labour market perspective, organisational/human resource perspective) Refusal to participate in the Delphi study Motivation and willingness to participate as well as to reconsider previous assessments in successive rounds Professional backgrounds and in-depth experiences linked to the topic area No response after a second reminder e-mail following the preliminary invitation