Achieving universal health coverage in sub-Saharan Africa: the role of leadership development

Abstract

Countries world-wide are striving towards Universal Health Coverage (UHC). Financial resources are extremely limited in developing countries and many developing countries are in the midst of multiple interconnected social, economic, epidemiologic, demographic, technological, institutional, environmental and political transitions. According to the World Health Organization (WHO), accelerating progress towards UHC in Africa will require strong leadership. At the recent Global Conference on Primary Health Care (PHC), the Astana Declaration, the world recommitted to comprehensive Primary Health Care as a keystone of Universal Health Coverage. There is evidence that PHC works. Countries that followed the Alma Ata PHC principles have demonstrated population health outcomes and reduced inequalities at low costs as seen in Chile, Cuba, Ethiopia and Rwanda. What seems to be missing is leadership to apply and uphold these PHC principles. There is consensus that if Astana is to be realized, strong political, economic, education, health, science, institutional, and community leaders are needed to make PHC work this time around. Governments and leaders in Africa have been conveying a constant message, that those leading and managing health systems are not sufficiently prepared to succeed in leadership roles they now occupy. Africa has had different leaders with the same results for decades. Leadership development efforts made to date seem not to be producing desired results. Students taken out of Africa to be trained in leadership at western universities, seem to go back home and carry on as usual. Many students have been taken to the West for education, developed great visions and ideas of how they can transfer knowledge learnt, got home and got swallowed by the system. Pumping more money into a health system with no leadership development will not help us achieve ‘Health for All’ in sub-Saharan Africa. How can accountable leadership with a sense of consciousness for social justice be developed successfully in these contexts? If leadership is key for Universal Health Coverage to be achieved in sub-Saharan Africa, is it not high time attention is paid to leadership development approaches.

Testing the Contextual Interaction Theory in a UHC pilot district in South Africa

“…According to Meyers and Dillon 1999, something happens within the organization that can either halt the process of implementation or speed it on its way. This something seems to be associated with organizational leadership [10,19,31] One of the limitations is that our study was carried out in only one pilot district though our ndings concurred with studies from other pilot sites. Another drawback is that UHC policies were the focus of our study and so we did not touch on other national policies that were also in implementation at the same time.…”

“…The third generation of implementation research is illustrated by using CIT factors to understand how the policy-practice gap comes about. We also expand the theory by adding one more core variable: leadership to information, motivation, resources and power [31]. Leadership Interaction is de ned as an occasion when two or more people communicate with or react to each other [32] particularly between senior and junior actors including supervisor-supervisee relationships There were discrepancies with regards to all CIT tenets when policy makers are compared with policy implementers [10].…”

“…This section introduces a new variable leadership into the four CIT core construct framework. In all the analysed cases for this study and published papers [10,30,31,33], it became apparent that ignoring leadership in policy implementation could leave out important contributions that illustrate how leadership in uences the implementation process. The critical roles of leadership, the human factors and our proposal to adapt the CIT tenets to (information, motivation, power, resources, leadership and interaction of these) are discussed.…”

“…In the context of our study, meaningful leadership interactions are formal relationships in the health system, implementing actors can fall back on for support, role clari cation, motivation and problem solving. Effective leaders have decision making power and nancial delegations to unlock resources and solve existing problems and challenges impeding implementation [31,35]. There is a two-way open communication where leadership is present.…”

“…PHC supervision seen as policing and not supportive [10,31] National core standards failing facility staff for issues beyond their control [10,30] According to Elmore, authority relationships affect implementation [13] -…”