About the Author(s)


Magome A. Masike symbol
Department of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa

Health Professional Council of South Africa, Pretoria, South Africa

Ozayr Mahomed Email symbol
Department of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa

Citation


Masike MA, Mahomed O. Mapping healthcare leadership interventions and their performance in sub-Saharan Africa. J Public Health Africa. 2025;16(1), a754. https://doi.org/10.4102/jphia.v16i1.754

Review Article

Mapping healthcare leadership interventions and their performance in sub-Saharan Africa

Magome A. Masike, Ozayr Mahomed

Received: 12 Aug. 2024; Accepted: 13 Jan. 2025; Published: 10 Mar. 2025

Copyright: © 2025. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: Healthcare leadership development programmes (LDPs) are gaining recognition globally as enablers for competent leadership. Sub-Saharan Africa countries are also implementing healthcare leadership development initiatives.

Aim: This scoping review sought to map healthcare leadership interventions and their performance in sub-Saharan Africa.

Setting: Sub-Saharan Africa.

Method: A search of relevant articles was performed in PubMed, Semantic Scholar, and Academia, for articles written in English and published between 2003 and 2023. The Arksey and O’Malley framework was used to map the published studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews were used to report the results (PRISMA-ScR).

Results: One hundred and ten articles were retrieved. Twenty-eight articles were included in the review. Twenty-one per cent (n = 6) of the studies on LDPs were conducted in South Africa. Twenty-one per cent (n = 6) used the ‘case study’ design, 18% mixed-method (n = 5) and 14% (n = 4) used qualitative study designs. Twenty-three of the 46 countries in sub-Saharan Africa conducted LDPs. Four programmes are postgraduate university degrees with entry requirements, while two programmes do not have any formal entry requirements

Conclusion: Healthcare LDPs exist in sub-Saharan Africa. However, they are marketed as ‘healthcare leadership development’, while their content is management development.

Contribution: This article summarises the research on the state and contributions of the healthcare LDPs in sub-Saharan Africa. Development of all future healthcare LDPs must consider applicable policies and be based on curricula that are focused on healthcare leadership competency development across all functional areas in the healthcare service delivery value chain.

Keywords: leadership; management; health; health system; outcomes.

Introduction

Healthcare systems are widely acknowledged as ‘very complex’ to manage and lead.1,2 Healthcare leaders face multifaceted challenges, such as rising demands from informed patients, inadequate funding, inadequate workforce, and economic as well as ethical dilemmas.3 Adapting to an ever-changing healthcare environment, keeping up-to-date with the latest information, leading by example, being creative and innovative,4 and enabling a culture of communication, social exchange, creativity, and innovation are some of the necessary traits to lead the current healthcare environment into the future. Leaders in this environment will have strong communication skills and be scholars, health advocates, collaborators and professionals.5 The absence of positive leadership can result in a demotivated workforce, leading to poor health outcomes.6

The concepts of management and leadership are, at times, used interchangeably. Definitions of these concepts become critical to obviate misunderstandings when these are encountered in this text. Management involves planning, leading, organising and controlling organisational resources (human, financial, material). Leadership is a process whereby individuals can influence others to achieve or reach commonly desired outcomes.

Healthcare leadership development is complex and has received attention since the 1960s, given impetus by the Griffiths report in 1983.7 Thus, it has received significant and constant attention globally since then. The World Health Organization (WHO) is at the forefront of these developments and has encouraged countries, continents and economic blocs to customise healthcare leadership development to be context-informed.8 The healthcare sector started developing and implementing leadership development models and frameworks to influence and improve health system outcomes.

The often-cited healthcare leadership models and frameworks adopted and currently in implementation in different geographies across the world include the National Health Service’s (NHS) Leadership Model in the United Kingdom,9 the European Foundation for Quality Management (EFQM),10 the Canadian Health’s Lead Self, Engage Others, Achieve Results, Develop Coalitions and Systems Transformation (LEADS) Capability Framework,11 the Australia Health Leadership Framework,12 and others.

Healthcare leadership development in sub-Saharan Africa is also gaining attention, and conversations have commenced through conferences and country-specific research on this as one of the instruments that can be used to improve health system performance and outcomes.13

The challenges of the healthcare systems of countries in sub-Saharan Africa and/or Africa can be traced to the need for more, better or varied levels of healthcare leadership development initiatives in implementation on the continent. This has contributed to poor health outcomes in sub-Saharan Africa and has highlighted the need for healthcare leadership development interventions to improve health system performance and outcomes.

In contrast to the previous scoping review assessing interventions on what leadership capabilities are most important or how effective different leadership development models are,14 this study mapped out the available healthcare leadership interventions to determine the country and regions where they are in implementation on the continent to determine coverage, the curricula, the educational levels of the leadership development programmes (LDPs) in terms of the national qualification’s framework. ‘Good practices’ such as EFQM, NHS, Canadian LEADS and the Australian LEADS are used as a frame of reference when assessing the depth and breadth of the LDPs.

This scoping review sought to map healthcare leadership interventions implemented in sub-Saharan Africa, determine their performance where applicable and assess whether monitoring and evaluation, and performance management are included in the current LDPs.

Methods

This scoping literature review was performed according to the Arksey and O’Malley methodological framework15 to map the evidence from academic literature published over the last 20 years (2003–2023) on healthcare leadership development in sub-Saharan Africa. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) were used to report the results.16

The following questions formed the basis for the literature search:

  • Which healthcare LDPs were and are in implementation in sub-Saharan Africa?

The following lower-level questions flow from the first research question:

  • What is in the curriculum of the identified healthcare LDPs?
  • Who is the target population of the healthcare LDPs?
  • What is the impact of the identified healthcare leadership development on the health systems of countries in sub-Saharan Africa?
  • What must be done to get the healthcare leadership development initiatives to achieve outcomes comparable to what other geographies are experiencing?

A search for relevant articles was performed in PubMed, Semantic Scholar, Academia and other databases. Articles, journals and books that addressed the research questions were identified using the following search terms: ‘Healthcare leadership development in sub-Saharan Africa’, ‘Healthcare care leadership development in sub-Saharan Africa’, ‘Healthcare leadership development in Africa’, ‘Health care leadership development in sub-Saharan Africa’, ‘Healthcare leadership development initiative in sub-Saharan Africa’, ‘health care leadership development initiative in Africa’, ‘healthcare leadership development initiative in Africa’, ‘health care leadership development initiative in Africa’, ‘health care leadership development programme in Africa’, ‘healthcare leadership development programme in Africa’, ‘healthcare leadership development programme in sub-Saharan Africa’ or ‘health care leadership development programme in sub-Saharan Africa’. This literature search was restricted to articles written in English and published between 2003 and 2023. Articles with a general leadership focus and from a public administration perspective were excluded. The scoping review incorporated qualitative research systematics and meta-analyses.

Search strategy

Joanna Briggs Institute members and five Joanna Briggs Collaborating Centres recommended using the population, concept and context (PCC) approach to narrow the review’s focus and scope17 (Table 1).

TABLE 1: Population, concept and context framework.
Selection process, data extraction and synthesis

The principal investigator retrieved all relevant literature from the databases and duplicate titles were removed. Two researchers independently reviewed each title and abstract to identify relevance to the aim and question of the current study. The researchers reviewed the titles, abstracts and full content of the articles that were omitted or included in terms of relevance to the study question. The researchers agreed on which articles should be included in a full review. A predefined Microsoft (MS) Excel sheet charting form was used to extract the data from the complete articles of the selected articles. The predefined columns included author, year of publication, aim of the study, study design, primary findings, and study setting. A documents folder was created on the researcher’s hard drive to store all articles found to be relevant to the research. The articles identified as entirely relevant were also loaded to Mendeley for automatic citation and reference list generation. Data were extracted into an MS Excel table.

Emerging synthesis was used in this qualitative research, which included both theoretical works and relevant grey literature. Tables, graphical displays and charts were used to enable the synthesis to be possible.

The charted data were split into key thematic sections including programme structure, learning content and learning methods. Data were grouped into common categories and summarised in the tables. The findings were then analysed and synthesised in the context of the overall review questions and specified study objectives.

Consultation with stakeholders

No external stakeholders were involved in identifying the topic or deciding regarding the articles reviewed. However, the results will be presented to an external forum or policymakers.

Results

The data collation from the three mentioned databases yielded 205 articles. After the duplicate records were removed, 112 records were screened in line with the main research question. Of these, 65 studies fulfilled the inclusion criteria and were included in the review stage. Twenty-eight articles were identified as relevant. A summary of the study selection process is shown in Figure 1.

FIGURE 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram showing literature search and selection process.

Of the 2813,14,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44 articles included in the review, the distribution by year of publication is as follows: 2012 (4%, n = 1),13 2014 (7%, n = 2),18,29 2015 (4%, n = 1),39 2016 (4%, n = 1),4 2017 (7%, n = 2),31,40 2018 (7%, n = 2),30,38 2019 (7%, n = 2),31,37 2020 (4%, n = 1),14 2021 (18%, n = 5),6,23,25,36,44 2022 (11%, n = 3),26,33,35 2023 (21%, n = 6)11,22,32,41,43,45 and 2024 (4%, n = 1).42 Twenty-one per cent (n = 6) of the studies on LDPs were conducted in South Africa followed by Uganda (11%, n = 3), Kenya (11%, n = 3) and Zambia (11%, n = 3). Eight other countries contributed to the remaining 25% (n = 7) of articles (Table 2).

TABLE 2: Descriptive characteristics of the final included studies.
TABLE 2 (Continues…): Descriptive characteristics of the final included studies.
TABLE 2 (Continues…): Descriptive characteristics of the final included studies.

Twenty-one per cent (n = 6) used the ‘case study’ design. Eighteen per cent (n = 5) utilised the mixed method, and 14% (n = 4) used qualitative study. A different author published each of the 28 articles. The articles were published between 2012 and 2024 (Table 2).

Leadership development programmes were undertaken in 23 of the 46 countries in sub-Saharan Africa. Most of these LDPs are unique to each country. Table 2 provides a summary of the various LDPs in sub-Saharan Africa. It was observed that most LDPs use ‘leadership’ and ‘management’ interchangeably.

Healthcare leadership programmes and curriculum – Verification

Information on details of the type of LDPs was available for seven programmes. Four programmes are postgraduate university degrees with entry requirements, such as a Bachelor’s or Master’s degree in public health or, for the top-end qualification, a doctorate in public health. Two programmes do not have any formal entry requirements (Table 3).

TABLE 3: Summary of the entry requirements, location and aim of the leadership development programmes.

The Albertina Sisulu Executive Leadership Programme in Health (ASELPH) from South Africa offers a 10-module curriculum46; the Enhancing Leadership, Management, and Governance Competencies programme from Ethiopia offers a 4-module curriculum47; the Zambia Management and Leadership Course for District Health Managers in Zambia is a programme offering 6-module curriculum40; and five programme offerings from South Africa, Botswana, Kenya, Uganda and Ghana have 9-module curriculum offerings.14

The Zambia Management and Leadership Course for District Health Managers40 is a programme that does not offer ‘leadership’ as a module. However, it is still a healthcare leadership development initiative. The modules in these programmes cover the following subject areas: Leadership, Strategic Management, Project Management, Financial Management, Communications, Planning, Health Systems, Transformation and others.

The modules on offer are usually offered in general management training. The healthcare LDPs discussed here were designed to attract those already in management. This identified target student population casts the ‘net narrowly’ while the intent is to develop healthcare leadership. This approach differs from what is done in other geographies.

The impact of the implemented healthcare leadership development programmes

A total of 1414 students attended the seven healthcare LDPs reviewed. Overall, the participants were optimistic about the LDPs’ impact on their professional roles within the healthcare system.

The participants have seen increased knowledge, skills and confidence in key leadership competencies. In addition, the LDPs provided a systems view, which assisted in understanding the role and impact of the external context and the healthcare infrastructure. Some of the LDPs resulted in improvements in self-awareness for the attendees.45

The participants indicated that the programme structure needed improvement in terms of incorporating health system values, belief systems, and relationships, improved self-awareness and relationship management. Structured mentorship is integral to some LDPs, and the collaborative activities that must be implemented equip participants with leadership skills. Furthermore, the non-institutionalisation of LDP content hindered system thinking.29 From a health system perspective, participants indicated a need for more curriculum content on healthcare leadership, which must be inclusive or integrate traditional medical care. The LDPs must be designed to support or be part of a system that advances the aspirations of women working in the healthcare sector.42

Discussion

This scoping review demonstrated that sub-Saharan African countries implement ‘Healthcare leadership development training initiatives and programmes’.

Fifty per cent (50%) of the reviewed articles (n = 14 out of 28) affirm a positive correlation between specific leadership training and improved leader performance outcomes in targeted healthcare systems. Additionally, two key observations were made: (1) healthcare leadership development initiatives lack standardisation, and (2) interventions in healthcare leadership encompass diverse formats, including non-degree certificates, degree programmes, postgraduate diplomas, Master’s degrees and doctoral courses, indicating a lack of uniformity. Some studies also explore suitable leadership styles for healthcare settings.

Further analysis showed that seven of the studies point to a need for healthcare LDPs that can emphasise areas such as: (1) leadership development for women in the healthcare system, (2) leadership development for those working in healthcare support services (e.g., infrastructure, supply chain management, healthcare technology, and others), and (3) making the healthcare leadership development initiative contextually relevant, with a focus on healthcare leadership development as the core training intervention.

The findings are that six different types and levels of healthcare LDPs are presented from West Africa, East Africa and Southern Africa. These offerings differ from country to country. The wide spread of the offerings points to complete coverage of healthcare leadership development in sub-Saharan Africa.

However, the variety of the programmes will, in the future, create sustainability challenges. The sustainability of health and social care systems and the support of professional staff to enable them to practise is an imminent future healthcare challenge.45

There are ‘healthcare leadership development’ programmes in sub-Saharan Africa, which are a platform for growth. However, these programmes are of different types and levels of healthcare leadership development, and no two or more countries are implementing the same programmes.

This review noted that the need, role, healthcare development approaches, healthcare leadership programmes, and curriculum verification should be collaborative. For example, in North America (United States and Canada), collaboration is being developed based on a matrix leadership structure.4 Globally, integrated care reports are needed, and policymakers highlight the importance of collaboration in organisations and among employees; continents and countries have different cultural values, spending priorities and funding streams within healthcare structures.

This review showed that the assessment of design, content, theory, practices and impact on healthcare service delivery positively affected the skills of the target student population. However, low-income countries have financial constraints that compromise the need for further healthcare leadership training and the inclusion of more modules to reach the standard of the developed world.5 Furthermore, the study also found that women’s leadership advancement aspirations and the importance of the totality of all healthcare system components must be supported.

Even though the programmes are marketed as ‘healthcare leadership development’, closer scrutiny of the curriculum shows that their focus is on ‘health care management development’ programmes instead. Leadership and management cannot be viewed as synonyms. In addition, initiatives to develop competencies in either leadership or management are different, and there are no overlaps. Furthermore, the study found improved leadership self-awareness and potential for further self-improvement.

There is a need to streamline the current ‘healthcare leadership development’ offerings and focus them on ‘leadership’ rather than ‘management’. Leadership is about motivating and inspiring organisations, whereas management is about using organisational resources to attain efficiency.

The studies indicate that practitioners and persons employed by the healthcare sector are eager to attend all the offered ‘leadership’ training, and there is overwhelmingly positive feedback on its impact. Redirecting the leadership training will create a network of people who will motivate and inspire the healthcare delivery system for better outcomes.

This study finds that sharing experiences and the impact of the implemented healthcare LDPs improves leaders’ knowledge, skills, confidence and competence. Effective healthcare leadership depends on training in the right skills and values and the development of agents of change.48 The rapid expansion of technology, a constantly changing disease profile, and accessibility to evidence, contrasted by the global health inequities, demonstrates the complexity of the required leadership and confirms the relevance of sharing information.

We must determine the contexts and needs for healthcare leadership development across sub-Saharan Africa. Leadership development should not be restricted to the few in or close to the Executive Management ranks.

Healthcare LDPs are generic because the curricula focus on subjects easily provided in other programmes, such as strategic planning, communication and human resources management. This confirms the argument that with many LDPs, the assumption is that ‘one size fits all’. Furthermore, when attention is not sufficiently paid to the participant’s baseline inventory of skills and developmental goals, the focus on the behaviour that truly matters in the organisation’s context would need to be recovered. Response of the curricula to diverse contexts remains critical.

Study limitations

The scoping review research is based on published articles. Some articles can be viewed as outdated, thus creating doubts about their relevance and applicability in the current period. The low number of articles that specifically address healthcare leadership development may also develop doubts about the representativeness of the research data.

Conclusion

Healthcare LDPs exist in sub-Saharan Africa. However, their focus is more on healthcare management development, Context and needs-based healthcare leadership development, underpinned by healthcare-specific competency models, provides an essential cornerstone for designing strategically aligned healthcare LDPs. Effective leadership, which continuously improves health system performance, requires leadership models to be adapted for local contexts with a focus on healthcare leadership competency development.

Implications and recommendations

By addressing the established gaps in healthcare leadership practices and implementing context and evidence-based interventions, policymakers and practitioners in sub-Saharan Africa can strengthen health systems, improve service delivery and ultimately enhance the population’s health outcomes.

Policymakers are advised to consider standardisation of curricula and institutionalisation of programmes if the impact of healthcare leadership development is to deliver the much-desired health system’s outcomes.

This scoping review provides a foundation for future research around healthcare LDPs localisation, standardisation and institutionalisation, as well as the actions needed to build a resilient and effective healthcare leadership in the region.

Acknowledgements

We would like to acknowledge the assistance of the librarian at the University of KwaZulu-Natal and the administration at the Health Professional Council of South Africa.

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Authors’ contributions

M.A.M. conducted the analysis and drafted the article. O.M. reviewed and finalised the article.

Ethical considerations

Ethical clearance to conduct this study was obtained from the University of KwaZulu-Natal Biomedical Research Ethics Committee (No. BE690/18).

Funding information

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article.

Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

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