Initiating systemic capacity development for leadership from the bottom-up: a realist evaluation of a leadership innovation in a South African health district

The need for leadership within district health systems is critical for the effective delivery of services and for inter-sectoral collaboration for health. Leadership capacity development (LCD) has not, however, been prioritized within health systems, and the systemic capacity (i.e. roles, structures and processes) that is needed to develop managers who can lead is not always in place. This paper aims to contribute to understanding how to build such capacity, considering a relevant bottom-up innovation. We observed, in the period 2013-15, the emergent implementation of this innovation (a 'Leadership Commission') in a South African health district. What started out as an effort to train individual leaders evolved into the development of systemic capacity for LCD. We adopted realist evaluation as the main methodological approach, as well as case study design, and we first developed a programme theory of the internally driven LCD initiative, through a round of interviews with senior managers. We then tested the programme theory drawing on 14 in-depth interviews and field notes of meetings and processes. Our analysis suggests that building systemic capacity for LCD requires leadership to be expressed as a strategic priority by those with positional authority and that bottom-up LCD requires institutional commitment through strengthening routine structures or creating new ones. The ability to leverage existing resources is another key element of systemic capacity. The mechanisms that enable bottom-up capacity development include tacit and experiential knowledge, sensemaking, systems thinking and trust between, and motivation of, those tasked with leading LCD. Leadership development is constrained by increased workloads for those involved as the prioritization of leadership becomes simply an additional task, and sustainability challenges are likely in the absence of additional resources for bottom-up innovation.