1. Establish a great sense of urgency

Kotter argues that urgency is critical. This is not easy—the dearth of ‘sport for health’ programmes across national sporting federations and international organisations underscores his point. Success requires ‘change champions’, and to this extent FIFA President Sepp Blatter deserves tremendous credit.

Blatter's leadership has been remarkable for moving health from irrelevance to pre-eminence in a major sport.2 Blatter and the Chair of the FIFA Medical Assessment and Research Centre (F-MARC), Professor Jiri Dvorak, supported by Dr Michel D'Hooghe, Chair of FIFA Medical Committee, convened national sporting organisation leaders together with a sports medicine lead from almost 200 countries to the first Football for Health conference (Zurich, 2009). That is how FIFA/F-MARC conveyed a sense of urgency. The meeting was not a talk-fest, but carefully structured to obtain buy-in for the concept of having active ‘medical commissions’ in each country. One goal for FIFA.

2. A powerful guiding coalition with expertise and relationships

Kotter tells us that ‘nothing much worthwhile happens’ without a critical mass willing to encourage others to engage in change.1 It takes a coalition to create transformational change such as the concept of Football for Health (which is outlined below).

FIFA's health efforts stem back to the FIFA Board acting cohesively (ie, as a team) to support F-MARC,2 which brings together international groups of experts in football medicine to support both professional and recreational football players. F-MARC is critical to the Football for Health programme because it is the core of the guiding coalition that supports the health of players. This has many advantages over a ‘medical director’ acting alone.

Furthermore, F-MARC is represented on the executive committee of FIFA by Dr Michel D'Hooghe, who skilfully explains and promotes medical matters at this critical political platform. This is most unusual among international sporting organisations. Kotter notes, ‘in the most successful cases (of change), the coalition is always pretty powerful—in terms of titles, information and expertise and relationships.’ Score: FIFA 2–0.

3. Creating a clear vision that includes concrete execution strategies

FIFA's Football for Health vision meets Kotter's criterion for transformational change because it's a ‘sticky’ message3—it is simple and somewhat unexpected. The first phase of FIFA's health commitment focused on Medicine for Football—ensuring that players the world over obtained appropriate medical care for their injuries. (Think of providing quality medical care in Livingston, Guatemala, rather than Liverpool, England.)

Preventing injuries was not a transformational message, however, and FIFA went further, developing a programme that addressed the needs of non-professional football players. Football for Health encourages everyone to play football as a way to prevent or reduce risk factors for disease. The model is ambitious, extending the worthy call of achieving fewer musculoskeletal injuries for professional football players.

Football for Health was a compelling vision to help people achieve fitness goals, but Blatter and Dvorak didn't stop there. Through their leadership, FIFA also developed a programme for Africa: The 11 for Health. The programme uses 11 simple messages (table 1) to educate African youth through football, helping them to become more aware of disease and its prevention. F-MARC has captured the message in four steps (table 2): two goals here. Score: FIFA 4–0.

4. It takes 10 times as much communication as you think

FIFA developed and delivered the Football medicine manual—now in its second print edition in seven languages. Even more importantly, it's available on DVD. This product helps developing nations understand how football could make their citizens healthier, and thus better contributors to society.

FIFA's 11 for Health programme is visionary, because it extends health messages beyond those needed for football alone.4 Also, the communication programme is generously supported by the FIFA marketing division—the productions are attractive and professional. Prominent footballers, cooperating as they would in a team, extol the importance of critical behaviours that are essential to transform health.

This impressive awareness campaign includes large posters for clubrooms, plastic-covered cards attached to a lanyard for coaches to wear at practice, a promotional DVD, and free video on the FIFA website. Many other popular websites provide links to the 11+ videos.

True engagement has been built through FIFA's meetings with its medical commissions in every continent and in many many countries. For example, the government of Mauritius is considering implementing the programme in all primary schools starting in 2011. The South African minister of health, Dr Aaron Motsoaledi, expressed support for the programme as an effective means of improving public health. He has called for a meeting of African leaders to discuss the programme's wide-scale adoption across the continent. Score: two more goals makes it 6–0 for FIFA at the halfway point of the Kotter Cup.

5. Empowering others to act on the vision: snowball effect

In FIFA's case, the Football for Health Program, which includes the 11 for Health message, has been shared in person with national federation physicians through intensive meeting programmes at national, continental and international meetings. The innovation has been to bring political leaders and sports medicine teams to the same table. This sounds straightforward, but it rarely happens. Doctors are generally not part of the power structure of sports organisations.

One way that FIFA and F-MARC have empowered others to act on the vision is by accrediting a global network of FIFA Centres of Excellence, with at least one hub in each continent to serve local football communities. The Centres of Excellence leverage the data and resources available at F-MARC headquarters in Zurich to partner local policy makers and funders to improve health locally. The Centres of Excellence also provide a foundation for a communication channel for FIFA with its grass-roots constituency. Thus the 11 for Health engages players nation by nation.

Empowering requires positive steps such as building networks, but Kotter emphasises that change leaders must also have the courage to remove anyone who is like an ‘elephant that appears to be blocking the path’.1 In the first half of transformational change, such as what FIFA was attempting to do, there is not time to eliminate all obstacles. That said, those who are most resistant to change, particularly if they are more visible leaders, ‘must be confronted and removed…both to empower others and to maintain the credibility of the change effort as a whole’.1 In FIFA's case, the senior managers were on board from the start, providing no major obstacles to goal. Score: 7–0.

6. Planning for and creating short-term wins

Kotter's principle of creating the ‘win’ sits well in the sporting setting. Public health change takes time, but FIFA can already point to at least six success stories: (1) implementing ‘The 11’ exercise programme nationwide in Switzerland reduced football injuries and proved cost-saving for the national insurance company5; (2) in New Zealand, every dollar invested to disseminate ‘The 11’ resulted in a $NZ4 saving on injury costs for the Accident Compensation Corporation; (3) early success in Khayelitsha, a South African informal settlement, is reported in this issue of BJSM (see page 546); (4) FIFA's F-MARC team has been part of the guiding coalition of the research and policy leadership at both completed World Congresses of Injury Prevention and features prominently on the programme for the 2011 event in Monaco (http://www.ioc-preventionconference.org/); (5) academic rigour is reflected in F-MARC's over 150 peer-reviewed publications in a diverse range of sports medicine journals under the leadership of Professor Dvorak and epidemiologist Dr Astrid Junge since 2000; and (6) the extensive user-friendly resource materials discussed in previous sections above clearly count as wins as well. Two goals: score FIFA: 9–0.

7. Don't let up!

Kotter emphasises that leaders of successful efforts use the credibility afforded by short-term wins to tackle even bigger problems, rather than suggesting that the win is already in hand.1 Extending Medicine for Football (effective injury treatment and prevention) to the more ambitious Football for Health, and now the even more ambitious 11 for Health. The latter, which clearly qualifies as a ‘Big Hairy Audacious Goal’ (BHAG, pronounced BEE-hag)6 7 aims to promote social change through physical activity by contributing to general education within the framework of ‘One Goal, Education for All’. FIFA is the largest organisation we know of that aims to leverage ‘elite sport’ to promote social change. Score is now FIFA 10–0.

We are aware that organisations such as the Oslo Sports Trauma Research Centre and the University of Cape Town's Research Unit for Exercise and Sports Medicine have also succeeded in peer-reviewed national competitions to gain funding to achieve similar goals.8,–,11 We look forward to including stories and examples from other groups on the BJSM blog (http://blogs.bmj.com/bjsm/) to add to this theme—global efforts linking sport to health and social change.

8. Anchor the changes in the institution's culture!

When education simply happens in remote and impoverished communities, when young girls know they will have the same opportunities as boys, when people consider inequities unthinkable, the Football for Health movement will be institutionalised.

Kotter emphasised that this requires more than one generation of leadership. He noted, ‘one bad succession decision can undermine a decade of hard work.’ The successor must also be a champion of change—transformation can be undone within a year or two when the choice of successor is inappropriate. Score: FIFA 11–0.