Introduction

Africa continues to face a complex and persistent health workforce crisis. Although the continent accounts for approximately 18% of the global population, it bears nearly 25% of the global disease burden and is served by only 4% of the global health workforce.1 In response to this imbalance, numerous countries have expanded health professional training programs. However, a striking paradox persists, substantial health worker unemployment exists alongside critical workforce shortages.2 In some countries, up to 55% of newly graduated health professionals are unable to secure employment within the public sector.3 This paradox reflects a structural mismatch between health professional training, labor market absorption, and system-level workforce planning.

The surgical workforce remains acutely constrained, with significant gaps in access to timely, safe, and affordable surgical care. While efforts to increase the number of trained surgeons are necessary, they are insufficient without corresponding improvements in leadership and health systems integration. This is particularly urgent given the increasing complexity of health care delivery, resource limitations, and competing health priorities. Effective surgical leadership is needed to align human resources with institutional priorities and service delivery. This perspective emphasizes that strengthening leadership and management competencies among surgeons are essential for resolving Africa’s health workforce paradox and advancing health systems’ performance.

Surgeons as Leaders in Complex Health Systems

Surgeons inherently will lead teams in the operating theater, coordinate multidisciplinary care, and make time-sensitive decisions under conditions of uncertainty. These high-stakes environments cultivate critical leadership competencies such as decisiveness, communication, and team coordination. However, such attributes do not automatically translate into effective leadership at institutional or national levels without structured preparation. The leadership demands at these levels include governance, strategic planning, resource allocation, and system-level thinking.

A growing body of evidence supports the benefits of clinical involvement in health care leadership. Hospitals with greater physician representation in executive roles tend to perform better on quality and safety indicators.4–6 Furthermore, leadership styles among surgeons have been directly associated with patient outcomes. It has been shown that constructive and reflective leadership approaches are linked to lower complication rates.7

These findings demonstrate that surgical leadership matters not only in the operating room but also at the institutional level. Recent evidence from East, Central, and Southern Africa further supports this link. A large multicenter cohort study analyzing over 100,000 operative cases found that faith-based hospitals had significantly lower perioperative mortality compared with public and private institutions, even after adjusting for case mix and patient- and system-level confounders.8 These outcomes may reflect differences in institutional context, staffing patterns, and leadership practices, underscoring the importance of organizational culture and governance in influencing surgical outcomes. Rather than positioning one sector against another, these findings suggest that further study of successful practices in faith-based settings may yield valuable lessons to inform system-wide improvements across all hospital types.

Yet despite clear evidence that leadership and governance shape outcomes, leadership roles in many African health systems are often assigned based on clinical seniority or skill rather than demonstrated leadership capacity. While clinicians may rise to these roles by virtue of professional recognition, they are frequently underprepared for the administrative, financial, and political dimensions of leadership. This gap limits the potential contribution of surgical professionals to broader health system performance.

Leadership and Management: Distinct but Complementary Competencies

Leadership and management are interrelated yet distinct domains. Management entails the planning, coordination, and oversight of operations and resources. Leadership involves setting a vision, aligning stakeholders, and motivating teams toward shared goals. While effective managers ensure operational efficiency, transformative leaders drive change and innovation within systems.9

Many leadership training initiatives in Africa emphasize managerial competencies, such as budgeting, logistics, and regulatory compliance. Although these are necessary, they are not sufficient for preparing leaders to address the strategic challenges facing health systems.10 Transformative leadership also requires ethical reasoning, adaptability, policy engagement, and the ability to navigate complex stakeholder landscapes.11

Current Gaps in Leadership Preparation and Opportunities for Innovation

There is no shortage of talent among surgeons in Africa. However, there has been chronic underinvestment in formal leadership development tailored to clinicians. A recent mapping of leadership programs in sub-Saharan Africa revealed wide variability in content, structure, and access, with many initiatives operating as standalone workshops or postgraduate offerings.10 As a result, leadership training remains inaccessible to many, particularly those who cannot afford time away from clinical duties or the financial costs of further education.

Evidence from high-income settings suggests that structured leadership development programs can enhance clinicians’ confidence, strategic thinking, and leadership readiness. For example, a four-year evaluation of the Healthcare Leadership Academy in the United Kingdom and the Netherlands found that early career clinicians who completed the program reported increased preparedness to assume leadership roles and a greater appreciation of systems-level responsibilities in health care delivery.12 These findings highlight the value of structured approaches but also underscore a key limitation: most internationally recognized leadership frameworks, such as the Canadian LEADS framework or the NHS Healthcare Leadership Model, were developed in high-income countries. Therefore, they are typically grounded in institutional structures, governance mechanisms, and professional hierarchies that differ from those found in many African health systems.

While such models offer useful conceptual tools, their assumptions may not translate directly to contexts marked by resource constraints, fragile infrastructure, decentralization, and differing cultural or political dynamics. This creates an urgent need for African-led leadership development frameworks that are empirically grounded, culturally relevant, and designed with local system realities in mind.

Integrating such training into undergraduate and postgraduate surgical education could foster a sustainable culture of leadership from the earliest stages of professional development. Leadership competencies relevant to African health systems, including systems thinking, equity orientation, adaptive problem-solving, and interprofessional collaboration, should be embedded longitudinally rather than confined to elective or ad hoc modules. Institutions such as the Consortium of Medical Schools in Africa (CoMSA) and the College of Surgeons of East, Central and Southern Africa (COSECSA) are well positioned to champion the development and implementation of standardized and competency-based curricula that reflect both regional needs and global leadership principles.

Recent efforts to address these challenges are emerging from within the region. One notable initiative is the Healthcare Education and Leadership in Surgery (HEALS) Africa course, launched by COSECSA in collaboration with the Association of Surgical Education. This structured one year program is specifically designed for COSECSA Fellows, senior trainees, and surgical faculty who are actively engaged in surgical education. It combines in-person and virtual learning modalities and incorporates direct mentorship by experienced surgical educators. Participants receive focused instruction in teaching methods, curriculum development, performance evaluation, and leadership competencies tailored to the realities of African health systems. Through mentor-mentee relationships and transcontinental collaboration, the HEALS Africa program exemplifies how capacity building in surgical leadership and education can be both context sensitive and internationally informed. Programs like HEALS represent an important step forward in building sustainable African-led platforms for surgical leadership development.

Conclusion

Africa’s surgical workforce must be equipped not only to operate within operating theaters but also to lead within hospitals, training institutions, and health systems. Strengthening the leadership capacity of surgeons, is essential to ensure that human resources are effectively aligned with health system goals. Addressing the paradox of simultaneous workforce surplus and unmet need requires more than scaling up training. It also requires preparing surgeons to lead effectively, ethically, and sustainably.

Investing in surgical leadership development is both a strategic priority and a moral imperative. Surgeons must be equipped with the skills to guide teams, manage complexity, shape policy, and mentor the next generation. These efforts will ultimately improve patient outcomes, build institutional resilience, and create professional environments where a growing surgical workforce can thrive. Equipping surgical leaders is not merely a managerial task, it is an ethical responsibility to ensure that clinical expertise is matched by the ability to lead systems, inspire change, and strengthen the communities we serve.