Why it matters 

Strong leadership and management is essential in building health systems that are responsive to population needs. In low and middle-income countries, where health systems are often characterised by scarce resources and high burdens of disease, these skills are particularly needed.

However, current approaches to leadership and management development do not equip emerging leaders with the competencies (knowledge, behaviour, skills, attitudes and values) required for effective leadership and management.

It is not just high-level managers who need these competencies, but actors at all levels of the health system - including those responsible for managing primary health care facilities and district services.

What we did 

Convening experts in health leadership training 

In 2015 we held a workshop in Cape Town that brought together experts in leadership training in the public health sector from low, middle and high income countries. The workshop report, offers practical strategies for training institutions and governments to improve the sustainability of leadership training programmes in the public health sector. 

In 2018, in a workshop we reviewed existing experience with leadership development interventions and produced a short overview report in collaboration with the Collaboration for Health Policy and Systems Analysis in Africa (CHEPSAA).

Research on leadership development approaches 

Through the learning sites research collaborations, we investigated how the leadership practices of mid-level managers influence health system resilience in Kenya and South Africa. In this work, researchers studied the effects of tailormade leadership development activities which were initiated in the learning sites and aimed to strengthen ‘soft skills’ among leaders. 

• In Mitchell’s Plain, Cape Town, interventions aimed to support relational and distributed leadership. These interventions targeted primary health care facility managers and district-level managers, and were implemented in their workplaces. They sought to support individuals and  teams, in part through instituting changes in workplace routines, such as meetings, that enable shared reflection and problem solving. 
   
• In Sedibeng, a leadership intervention was developed to strengthen routine practices of leadership amongst  senior district managers and facility managers. The first phase of the intervention involved the senior managers to support leadership and to facilitate effective team functioning. The intervention then targeted facility managers at the sub-district level on leadership and management skills, focussing on personal competencies such as self-awareness and interpersonal competencies. 
   
• In Kilifi, Kenya, management teams participated in a one-week course on Complex Health Systems where they were challenged to explore how to effectively and sustainably strengthen “intangible software” of the health system and build soft skills for leading and managing.

What we found 

• Health system context constrains leadership
  Across settings, the health systems context often encourages negative leadership practices: management and leadership functions at the district and facility level are often constrained by bureaucratic demands and onerous monitoring and accountability requirements to higher bureaucratic levels.
   
• Leadership practices influence staff motivation and team work, with consequences for patient care
  Across settings, there are examples of leaders whose own practice encourages and enables team work, supporting staff to work together to address challenges. This team work both supports their motivation and enables good patient care.
   
• Leadership practices that enable are foundeon respectful communication, encourage teams, and support reflective practice 
  In addition, they encourage shared learning through collective problem-solving and decision-making, which leads to staff that feels valued and enhances trust. 

Implications for policy and practice

1. New forms of leadership are required within health systems that encourage teamwork and relationships, enable staff to tackle problems collectively and spread motivation and positive staff attitudes. 
    
2. Leadership development programmes should not solely focus on training individuals but should instead engage teams within workplaces, seeking to develop  experiential skills and tacit knowledge through workplace based activities. 
    
3. Within health systems, is important to develop an organizational context that sustains new leadership practices. This requires both a critical mass of people with new leadership skills and structures of governance that spread decision-making power and encourage multiple forms of accountability.
    
4. A key focus of research inquiry around health leadership development must be to understand how programme design enables system change in a particular context. Flexible design, qualitative research is most appropriate for research that seeks to support leadership development.

What we changed 

The learning site in Mitchells Plain, Cape Town, South Africa, has led to new insights with regards to the importance of effective leadership in supporting staff to deliver health services under challenging conditions.   These insights have fed into discussions with senior managers at the Western Cape Provincial Health department, influencing the framing and orientation of the current Western Cape Strategic Plan (Healthcare 2030) and the provincial Leadership Development Strategy (April 2016) .

The learning site work has also been fed into national debates through discussions with others involved in leadership development and through engagement with the processes of planning for an Academy for Leadership and Management in Health Care. Finally, through supporting the development of new leadership teaching curricula and models in the University of Cape Town and elsewhere this work has had wider effects as well.