Strong leadership crucial for primary healthcare reform

Building stronger primary healthcare is not just about policy, financing, and clinical care—it is also about effective leadership. True reform happens when leaders are equipped to translate strategy into action.

In many counties, women make up the majority of the health workforce but remain underrepresented in senior leadership roles. Photo: Speak Media Uganda

I have spent more than two decades working to strengthen health systems across Africa, contributing to workforce strategies, regulatory reform, primary healthcare service delivery, and leadership programmes. One lesson stands out above all others: primary healthcare does not fail because of weak policy; it fails because of weak leadership.

A strong health workforce is essential to delivering care. We have health workforce strategies that emphasise planning, performance, and decent work conditions. We produce policy briefs exploring the role of emerging cadres like community health workers and advanced practice nurses. We work to expand access to primary care, educate communities, identify risks, and manage disease threats.

But policy coherence does not automatically translate into frontline transformation. That translation happens—or fails—at the leadership and governance level.

Leadership reform is personal

There was a moment when I suddenly understood what was missing. I was facilitating leadership sessions in Nairobi, Kenya, for health managers as part of a leadership, management, and governance programme focused on strengthening primary healthcare.

These were competent clinicians and administrators who understood clinical guidelines and knew their service delivery targets. But when they were introduced to professional coaching, self-awareness tools, and leadership initiatives, something shifted. Managers began asking different questions, like: “How do I build trust within my primary care network?” or “Why is my team resistant to change?” or “How do I advocate for workforce reforms at country level or at my facility?”

That was the turning point for me. Health workforce reform is technical, but leadership reform is personal. And unless we address both, efforts to strengthen primary healthcare will remain uneven.

When health managers strengthen their leadership and governance skills, service delivery improves—not because more money suddenly appears, but because there is a mindset change and they apply their new thinking to make the systems around them begin to function better.

There is improved coordination within primary healthcare service delivery, stronger workforce planning at national and sub-national levels, more deliberate use of data for decision making, and increased inclusion of women in leadership conversations.

Leadership is not an abstract concept. It determines whether workforce policies are implemented, whether supervision is supportive, and whether health workers feel valued and are retained. If Africa is serious about primary healthcare reform, we must institutionalise leadership development as part of workforce strengthening—not as an optional add-on.

Women leaders crucial agents of change

In many counties, women make up the majority of the health workforce but remain underrepresented in senior leadership roles. When women are supported through mentorship and coaching to take on leadership positions, decision making becomes more participatory, workforce welfare gains visibility, and community engagement strengthens. Leadership development is not a luxury—it is a lever for equity.

My own journey has shaped my conviction. As a physician, public health leader, mother, and coach, I have navigated high-pressure policy environments while raising a family. I once believed resilience meant pushing through exhaustion. Today, I understand that sustainable leadership requires harmony—not just output.

When leaders are burnt out, workforce morale declines, reform fatigue sets in, and innovation narrows. When leaders are grounded, they use data wisely, delegate effectively, advocate strategically, and sustain reform momentum.

Primary healthcare reform is long-term work. It requires women leaders who can endure not through force, but through clarity. When women lead, systems benefit. Diverse leadership enhances responsiveness, empathy, new perspectives and innovation.

Workforce reform must therefore include deliberate pathways to support women’s advancement—not as token representation, but as strategic necessity.

Coaching leaders benefits all

We often think of governance in structural terms: laws, regulations, reporting lines. But governance is also relational. It is about how decisions are made, whose voices are heard, and how accountability is experienced.

In leadership coaching sessions, I often ask managers: when was the last time you asked your team what would make them stay in their positions? Many cannot answer. Coaching may sound like a luxury in the face of workforce shortages, but it is not—it is a performance multiplier.

When a health manager develops clarity of self, they stop reacting defensively and start leading intentionally. When they develop clarity of connection, they build trust and workforce conflicts reduce. When clarity of purpose is strengthened, policy documents become operational roadmaps. When clarity of action improves, they deliver measurable impact with accountability and strengthen systems to function. This is governance in practice.

Good leadership and governance determine whether investment translates into service delivery. Health workforce strategies emphasise planning using data ecosystems. Investments, legal, and policy reforms need to be galvanised with political commitments from country leadership. Health systems do not become resilient through policy declarations alone; they become resilient through emotionally intelligent, systems-oriented leadership. But governance capacity at national and sub-national levels is often underfunded.

A new reform agenda

Africa stands at a pivotal moment. Health financing reforms are underway, primary healthcare service delivery is expanding, and digital systems are evolving. But unless we invest equally in workforce planning, leadership, and regulation reform, we risk building structures without strengthening foundations. I believe we must:

Accelerate regulatory harmonisation to reduce fragmentation, improve health professional education, and practise with the goal of protecting the public.

Invest in interoperable data systems for better workforce planning and deployment.

Prioritise women’s leadership as a core health systems reform strategy.

Institutionalise leadership and management training within national human resources for health strategies, and insert mentorship and peer learning in primary healthcare service delivery designs.

Normalise coaching for national and sub-national health managers and policymakers and embed coaching into governance frameworks.

Fund coaching as part of workforce strengthening, not as an afterthought, so health managers have protected time for reflective leadership.

Governments and donors should finance leadership capacity development alongside digital systems, service delivery, or other health systems initiatives.

Over the years, I have helped shape workforce strategies and regulatory reforms. I have sat in meetings negotiating workforce planning and advocated for policy reforms. I have worked with global partners mobilising investments. But the most transformative moments I have witnessed were not during budget approvals. They were when a health manager said: “I now understand how to lead this change.”

Investment is essential. Regulation is critical. Data is powerful. But leadership is the connective tissue that makes them work. Primary healthcare is not strengthened only by infrastructure or financing reforms. It is strengthened by leaders who are self-aware enough to listen, courageous enough to reform, and grounded enough to sustain change.

Leadership is not adjacent to primary healthcare reform; leadership is the reform.

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The opinions expressed are those of the author and do not necessarily reflect the position of Re:solve Global Health.

Dr Janet Muriuki is the executive director and led consultant of Ideal Health Organization, a medical doctor, public health leader, governance expert, and executive coach with over 24 years of experience in health systems, government affairs, policy formulation, regulatory reform, and workforce development across Africa. She serves on boards of various organisations as well as holds technical expert and advisory positions. She integrates coaching, policy, and systems thinking to build resilient leaders, strengthen primary healthcare, and promote people-centred and sustainable health systems.