**4. Leadership: improving maternal and child health within a new lens**

As aforementioned, SSA is one of the poorest regions on the earth in spite of plenty resources in the SSA countries. That is where leadership comes into play as it is usually posited that "to great evils, great remedies." In this chapter, it is assumed that a transformational leadership is compulsory for SSA countries to achieve SDGs and substantially improve MCH in the region in the context of weak economies and heightened pressures for action, including global economic crisis and austerity

#### *The Role of Leadership in Sub-Saharan Africa in Promoting Maternal and Child Health DOI: http://dx.doi.org/10.5772/intechopen.105773*

politics, demographic changes [46], and increasing inequity of maternal healthcare utilization between poor and rich [17], and amid the rampant consequences of urban poverty [16], and the unstoppable effects of COVID-19 in SSA.

Kuhlmann et al. offer an interesting perspective to further our understanding of healthcare policy and governance within an integrative approach to include, among others, policies and governance to ensure universal coverage, access to healthcare, financing, quality of care, and health equity [46]. Deepening all these areas is beyond the scope of this chapter. These notions have been extensively discussed elsewhere [47]. Furthermore, previous research clearly identified eight governance principles to account for to better activate the workplace in health sector [48]. These include information, accountability, strategic vision, transparency, efficiency, equity, responsiveness, and voice and participation. More importantly, they pointed out to leadership as a key action in Health Action Framework. Turning now on what should be the role of leadership in enhancing MCH in sub-Saharan Africa, this chapter borrows from the demographic dividend (DD) to sharpen its importance in the MCH context (see **Figure 5**).

The overarching question from **Figure 5** stems from the precedence in the "enabling environment" to more likely reach the goal of improved maternal and child health in sub-Saharan Africa, while assuming all factors (education, health, economics, and governance) are important. In a previous work, I argued that governance was the most important piece to manage if SSA countries wanted successfully to reach SDGs, and specifically SDG-3. Before expanding on the role of leadership on MCH in SSA, let us revisit what scholars have done so far regarding the role of governance on MCH.

#### **4.1 Governance and maternal and child health in sub-Saharan Africa**

There are several attempts to address the importance of governance in SSA concerning challenges and opportunities to substantially improve MCH at both national, subnational, and local levels [18, 49–52]. These studies identified strengths and weaknesses. Kaplan et al. provide a good summary of strengths and weaknesses within the human resource perspective [48]. Strengths include among others, increasing transparency of financial flows and responsiveness to population needs through training of new cadres of health workers to address shortages and deliver care to more vulnerable populations and remote areas; implementing pilot programs that apply financial and nonfinancial incentives which ultimately increase efficiency; and easing onboarding process for health workers. Regarding weaknesses, most countries lack to develop, implement, and evaluate health workforce policies that outline a strategic vision, to implement accountability regulations in the health workforce, and to use health information systems to provide evidence for better decision-making. However, as shown later, most interventions to strengthening governance in healthcare have mainly focused on the use of resources. Indeed, Schneider et al. showed that initiatives to strengthen the governance of district health systems in South Africa which are pivotal to reach SDG-3 have used various methodologies [52], and therefore results are not necessarily comparable on the one hand, and on the other hand, have focused on improving the efficiency of resource use. This is likely because most SSA countries spend less moment in national budgets and mostly rely on public aid on development (PAD), with high control over resource is a requirement to benefit PAD. But overall, governance in SSA countries has been ineffective given the results obtained in terms of improving MCH in these countries. There is still then an unanswered question, why is governance so ineffective in SSA countries yet it is of crucial importance to boost MCH in this deprived region of world? This chapter addresses this question in the next section.

#### **4.2 Leadership and maternal and child health in sub-Saharan Africa**

The interlinkages between governance and leadership are important to catch up at a glance if one might understand the chief importance of leadership in shaping MCH in SSA countries. There are many reasons to seriously address the role of leadership in the context of MCH in SSA. First, and as it was shown earlier, the region is lagging very behind in terms of socioeconomic indicators. Second, the region is the most politically unstable region in the world. The recent coups in Mali, Burkina Faso, and Guinea may tell us more. Third, there are almost no indications that the region will perform well in the next few decades with the observable effects of COVID-19 placing SSA in the most vulnerable position [53, 54].

What is governance? The concept is not new and has been over decades in political and academic spheres. Governance comprises collective actions and measures adopted by a group of people to achieve common goals [55]. According to The World Bank, collective actions and measures are not an end, instead they should be guided by a number of formal and unformal rules [56]. According to Rhodes, "governance refers to: a new process of governing; or a changed condition of ordered rule; or the new method by which society is governed" [57]. In practice and for the best of people's wellbeing, the international community has introduced the concept of "good governance" as opposed to "poor governance" which is a multifaceted concept comprising eight factors, including Participation, Rule of

#### *The Role of Leadership in Sub-Saharan Africa in Promoting Maternal and Child Health DOI: http://dx.doi.org/10.5772/intechopen.105773*

Law, Transparency, Responsiveness, Consensus Oriented, Equity and Inclusiveness, Effectiveness and Efficiency, and Accountability [58]. All these components are important; however, responsiveness refers to as the leadership required to boost the collective actions and measures taken by the national governments. Therefore, one might question the interlinkages between leadership and effective MCH interventions in SSA countries.

This chapter builds on a modified framework from policy interventions facilitating demographic dividend (see **Figure 5**) [59]. There have been several attempts to address the linkages between leadership and MCH; however, they have mainly focused on "lower levels" targeting professionals and cadres in health workforce [60–64]. Most studies have focused on capacity-building, development of skills to better serve more deprived segments of the population, and accountability. Although this research agenda is quite important, this chapter posits that it is not sufficient to reach SDG-3 given the results obtained during the MDG momentum. Therefore, it is of paramount importance to bring the debate at higher levels to expect a substantial shift which can really change the current situation of MCH in SSA, including the African Union (AU)'s and country's commitments to improve MCH in the region. This is not unexpectable because countries such as Thailand or Korea have shown such great successes in the past to improve population wellbeing, including maternal and child health [15, 65, 66].

#### *4.2.1 Maternal and child health in sub-Saharan Africa: AU agenda*

In 2016, the African Union (AU) discussed its heath strategy in Addis Ababa in preparation of the 2016 meeting of Ministers of Health in Geneva, Switzerland, in May 2016 [67]. In the situation analysis, one might read that the "region still faces urgent need to accelerate progress" toward (*i*) improving child health. Indeed, even though a decline of 40% in infant mortality rate (IMR) between 1990 and 2014 from 90 deaths per 1000 live births to 54 deaths per 1000 live births, there still are substantial variations across and within countries, and therefore impeding the regions to reach SDG-3. Furthermore, the region still experiences a significant percentage of unmet need for modern contraceptives estimated at 26% which has almost flattened between 1990 and 2013.

Expectedly, the AU report pointed out the path to better MCH outcomes as it indicated that top-level commitment, stewardship, accountability, and transparency in the leadership and governance within the health sector are critical to improve health in SSA countries in general, and specifically MCH. It also extended saying that SSA countries should consider instituting effective decentralization of functions, authority, and resources to improve health sector performance. However, the report is silent about the time horizon on the one hand, and on the other hand it does not provide any indication of dictatorship and centralized power in the region, and how they are detrimental to achieve good health [68]. Previous research showed that despite of some progress made in SSA countries to improve maternal healthcare utilization [17], there are increasing inequalities between poor and rich and this might impede the progress observed so far.

The report mentioned among other strategic approaches, health research, and innovation as a transformational path to health sector and the African economy as a whole by suggesting an investment of 2% of the national budget in Science and Technology between 2014 and 2024. The reality is that Research & Development still unfunded (or at least poorly funded) in most SSA countries. Most initiatives of research funding are foreign/international, and therefore, they do not sound and sustainable research on the one hand, and on the other hand, they might overlook specific needs of SSA countries. For instance, the Innovating for Maternal and Child Health in Africa (IMCHA) Initiative aimed at improving maternal and child health in SSA countries through research and was funded by International Development Research Centre (IRDC) of Canada [69]. The project is certainly worthy since it addresses critical knowledge gaps and increases awareness among policymakers; however, it is not sufficient to provoke a significant shift in the organization of health systems in most SSA countries without enlightened leadership from national and local governments in SSA countries. First, the project was geographically unbalanced since it was led in 11 countries. Second, the project less focused on ownership of the outcomes, and it is not obvious that policymakers will use the generated knowledge to implement sound policies to improve MCH in SSA countries. Likewise, African Population and Health Research Center (APHRC) in Nairobi (Kenya), the 2015 UNFPA Population Award, has been doing since 2000s such an incredible job in generating knowledge and evidence for the African continent [70]. This organization operates through international research grants since its inception and has rarely benefited money from African governments to undertake research which African-funded, African-led research, and context-specific. Observers would ask themselves if African governments do really understand the importance of research and evidence-based policymaking. It is time to make the shift if SSA countries want to achieve SDG-3.
