Gilson and Agyepong (2018) argue that leadership development in health systems requires more than training individuals in isolation. An effective leadership programme must equip individuals with the strategic vision, technical knowledge, political skills, and ethical foundation necessary to guide complex processes of policy formulation and implementation (Gilson, 2016). However, this learning should occur within the workplace, where individuals can gain practical experience and develop tacit knowledge.

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Importantly, training alone is insufficient. Effective leadership development must be accompanied by organisational changes that create an environment where new leadership skills can thrive. The goal is to nurture a critical mass of individuals whose “micro-practices of governance” collectively reshape organisational contexts. These structures must enable dispersed decision-making and establish multiple methods of accountability, ensuring that governance is collaborative and adaptable.

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This approach acknowledges the interdependence of leadership and governance, embedding leadership development within the broader framework of Complex Adaptive Systems (CAS). By situating leadership strengthening within a CAS, this model not only enhances leadership capacity but also reinforces the health system as a whole, fostering resilience and innovation (Cleary et al., 2018; Gilson & Agyepong, 2018).

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Barriers to Effective Leadership and Governance

Leaders in African health systems often operate within authoritarian and hierarchical structures that stifle participatory and distributive leadership. These barriers stem from resource shortages and entrenched organisational cultures characterised by centralised and individualised decision-making and the dominance of medical professionals. Such hierarchical practices negatively impact staff motivation, professional practice, and patient care (Gilson & Agyepong, 2018).

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Participatory leadership offers an alternative by promoting teamwork, collective problem-solving, and the spread of motivation and positive attitudes among staff. This leadership model encourages collaboration, adaptability, and shared responsibility, which are essential for addressing systemic challenges and improving health system outcomes.

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Distributed and Relational Leadership

Distributed leadership moves away from command-and-control models, advocating for leadership roles to be spread across various levels and positions within an organisation. This model fosters a flow of power that aligns a diverse range of actors around shared goals (Gilson, 2016). It emphasises sustained collaboration, networking, and collective action, enabling organisations to innovate and adapt to evolving challenges.

Relational leadership complements this approach by focusing on mentorship and relationship-building. Leaders practising relational leadership prioritise coaching others, fostering commitment, and creating a supportive environment where teams can work effectively toward common purposes (Cleary et al., 2018).

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Governance Practices: Local Expertise and Decentralisation

A key strategy for improving governance involves shifting focus from technostructural actors and centralised authority to empowering professionals operating within local contexts. Governance practices should prioritise the ideas and expertise of these local professionals, granting them greater discretionary power and implementing horizontal decentralisation. This approach allows decision-making to align more closely with the unique needs and challenges of specific contexts, ensuring that outcomes and results take precedence over rigid processes.

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The South African Context

Despite initiatives such as ‘Primary Health Care re-engineering’ and ‘the Ideal Clinic,’ South Africa’s health system continues to struggle with inadequate leadership and governance, which hinder effective service delivery (Mathole et al., 2018). The persistence of hierarchical and authoritarian practices undermines efforts to build a more inclusive and adaptive health system.

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A Path Forward

To transition from rigid, hierarchical leadership models to distributed and relational leadership, South Africa must implement strategies that encourage collaboration, shared responsibility, and innovation. By moving toward governance practices that prioritise local expertise, horizontal decentralisation, and results-oriented approaches, the health system can better address structural challenges. This transformation requires not only developing individual leadership skills but also reshaping organisational contexts to enable participatory governance. By embracing these principles, South Africa’s health system can deliver more effective, equitable, and adaptive healthcare for its population.

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References:

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Cleary, S., Toit, A. D., Scott, V., & Gilson, L. (2018). Enabling relational leadership in primary healthcare settings: lessons from the DIALHS collaboration. Health Policy Plan, 33(suppl_2), ii65-ii74. https://doi.org/10.1093/heapol/czx135

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Fourie, D. J. (2012). The use of performance management for effective governance in Public Administration. Administratio Publica, 20(4), 124-138. 

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Gilson, L. (2016). Everyday Politics and the Leadership of Health Policy Implementation. Health Systems & Reform, 2(3), 187-193. https://doi.org/10.1080/23288604.2016.1217367

 
Gilson, L., & Agyepong, I. A. (2018). Strengthening health system leadership for better governance: what does it take? Health Policy Plan, 33(suppl_2), ii1-ii4. 

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Mathole, T., Lembani, M., Jackson, D., Zarowsky, C., Bijlmakers, L., & Sanders, D. (2018). Leadership and the functioning of maternal health services in two rural district hospitals in South Africa. Health Policy Plan, 33(suppl_2), ii5-ii15. https://doi.org/10.1093/heapol/czx174