Abstract
This thesis explores what constitutes effective leadership in health care in Sub-Saharan Africa and how those capabilities can be fostered and developed. The research takes Sierra Leone as a case study to explore how doctors in the country understand effective leadership and, through detailed literature review and qualitative research, including a process of co-design, seeks to identify what measures can be taken to empower them to lead. The contextual challenges to practising leadership are clarified through that investigative process, specifically in terms of the constraints that the political landscape places on the career decisions of doctors and ultimately their motivation to lead. Much of the thesis research is rooted in qualitative methods, primarily through the use of semi-structured interviews, as well as scoping review and co-design methodologies.The first study reviewed evidence on leadership development programmes for health professionals in Sub-Saharan Africa and found there has been a substantial growth in the study of such initiatives in recent years, but that many of these are not based on a clear theory of leadership, nor are they consistently well evaluated. The second, qualitative study identified that doctors in Sierra Leone perceive effective leadership based on four main leadership styles (transformational, relational, servant, and managerial), but that seven contextual challenges acted as barriers to leadership, including politicisation and donor dependency. Study three, which drew specifically on Hirschman’s theory of exit, voice, and loyalty, found that challenges to practicing leadership was a driver for doctors in Sierra Leone to emigrate abroad or move into the private sector, while those that remained generally fell silent, with few continuing to advocate for change. The final study used co-design methodology, and followed the Kern model of medical curriculum development, to produce a new twelve-week undergraduate health leadership and management programme in Sierra Leone.
This thesis illuminates how leadership is perceived by health workers in Sierra Leone largely according to established international leadership models and sets out in detail the specific skills and attributes they think are needed to be effective. A range of barriers were identified to leading successfully however, ranging from generally broken administrative systems in health care to intense politicisation. A culture of retribution against those who challenge the status quo has, in particular, been a driver for health workers to exit the public health system and has served to silence those who remain. Unpacking these dynamics enables the thesis to present policy options for national governments to create a more conducive environment for health leadership. It also reminds health system strengthening agencies that their work must always be understood as a political as well as technical exercise, so that they are not blind to how their work can be used to strengthen the power of those in the system who are against grassroots efforts towards reform and positive change.
| Date of Award | 1 Jul 2023 |
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| Original language | English |
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| Supervisor | Nick Sevdalis (Supervisor) & Ann Kelly (Supervisor) |