Maturity of Systemic Leadership Among District Health Management Teams in a Post-Conflict Context: A Cross-Sectional Study in the Kasai-Central Province, Democratic Republic of Congo

Abstract

Background

The systemic leadership of district health management teams (DHMs) is a pivotal factor in optimising health system performance, particularly within fragile and post-conflict contexts. However, the paucity of empirical data on its maturity level remains a limitation. The objective of this study is to evaluate and contrast the maturity of DHMs systemic leadership across six health districts in the Kasai-Central province of the Democratic Republic of Congo.

Methods

A quantitative, cross-sectional study was conducted between March 2025 and April 2026, with 84 members of DHMs selected from five urban districts (Kananga, Katoka, Tshikaji, Bobozo and Ndesha) and one rural district (Mikalayi). The data were collected using a structured tool based on a health system leadership framework by Bigirinama and al. (2023), adapted from the NHS. The following indicators were calculated: the percentage of points achieved, the overall scores for systemic leadership maturity, and the overall composite index of systemic leadership achievement in the province of Kasaï Central.

Results

The overall synthetic index of systemic leadership achievement in Kasai-Central province is moderate (62.10%), with low variability in overall systemic leadership maturity scores between districts. The dimensions related to vision and governance have the highest scores (between 70–75%), while the lowest scores concern collaboration with external partners, financial management, and internal organization (between 43–55%). Internal collaboration is generally satisfactory but marked by persistent conflicts. No significant differences are observed between rural and urban districts.

Conclusion

The maturity of systemic leadership in the DHMs in Kasai-Central is constrained by structural factors. The enhancement of leadership capacity necessitates the implementation of integrated methodologies that encompass the cultivation of skills, the refinement of leadership abilities, and the implementation of systemic reforms, with the objective of optimising the performance of health districts.

Introduction

Health systems are defined by the World Health Organization (WHO) as the set of actors, resources and actions whose main objective is to improve the health of populations.¹ Their performance is based on four essential functions: service delivery, financing, resource generation and management (leadership and governance).^1–5

The health system is a complex, adaptive system, characterised by the diversity of its functions and the multiplicity of actors involved at different levels of decision-making and action. Achieving the objectives of the framework is contingent upon effective leadership.⁶ The WHO does not subscribe to a hierarchical model of leadership; rather, it promotes a “systemic” approach, predicated on a logic of shared decision-making, adapted to the non-linearity of complex systems, and based on the coordination of actors according to a “distributed but not disconnected” model.⁶

Thus, system leadership may be defined as

A set of behaviours and practices that enable people working in very different places, spaces, and at very different levels, and across professional and disciplinary boundaries, to act collectively to address complex health needs. This approach is employed by individual leaders and leadership teams within and between organisations, who specialise in the provision of targeted leadership within the specific parts of the system over which they have influence. The concept under discussion here involves both collective action to address complex health needs and an intentional change in work habits to foster and maintain collective leadership. It is further enabled by senior managers in the organisation who take steps to diffuse organisational authority and adapt structures and processes to support system leadership.^7–10

This conceptual evolution suggests a shift in the role and responsibilities of management teams at the district health level. The time for a narrow, bureaucratic exercise of authority is over; the creation of environments conducive to the emergence of collective leadership is now imperative.¹⁰

This leadership approach is of particular importance and relevance for low- and middle-income countries (LMICs), where health systems face persistent structural constraints.^11,12 However, despite this recognition, current discussions on health system governance tend to favour institutional aspects (rules, structures, decentralisation reforms) instead of examining leadership processes as a systemic practice.^13,14 This imbalance is further compounded by the dearth of robust empirical data from LMICs, which hinders understanding of the processes through which leadership directly impacts health system performance.^15,16

In sub-Saharan Africa, these constraints are exacerbated by security, political, and health crises that further weaken the management and performance of health systems.^12,17–19 In such contexts, a number of studies have demonstrated the crucial role of leadership in improving health performance. In Kenya, the presence of systemic leadership at the health district level has been associated with enhanced coordination of activities and improved coverage indicators.^20,21 A similar approach has been adopted in Sierra Leone and Liberia, where the enhancement of local leadership capabilities has been instrumental in bolstering the resilience of health systems in post-crisis scenarios.²²

In the Democratic Republic of Congo (DRC), the health system is organised into three levels: central, intermediate, and systemic. The latter is represented by the health district (or health zone), which is managed by a senior team.²³ This level plays a pivotal role in the implementation of the country’s health policies.^23,24 However, its operation is hindered by persistent structural constraints, including governance weaknesses, inadequate coordination among stakeholders, and a strong reliance on technical and financial partners.^25,26 These are further compounded by limitations related to human resources, financing, infrastructure, essential supplies, and health information systems. The aforementioned challenges have been exacerbated by the recent Kamwina-Nsapu hotspot of armed conflict in the greater Kasai region, particularly in the Central Kasai province.

The Kamwina-Nsapu conflict severely disrupted health services in Kasaï-Central through the destruction of health infrastructure, the displacement of health workers and the interruption of essential services. The problems stemming from this conflict may still affect the management capacities and systemic leadership of district management teams in the post-conflict period.^27,28

Despite its strategic importance, there remains a paucity of empirical data on the leadership of district health management teams (DHMs) in the DRC. The work of Bigirinama and al. (2023) highlighted deficiencies in organisational management, internal collaboration, and coordination with external partners, reflecting difficulties in exercising effective leadership in constrained contexts.²⁴ Furthermore, leadership skills development remains insufficiently institutionalised, with initial training rarely integrating these dimensions and capacity-building initiatives not subject to systematic evaluation.^29–31 From this perspective, a team’s maturity in systemic leadership refers to the gradual development of its autonomy in carrying out its mission an autonomy that relies, in particular, on its members’ skills, their motivation, and their ability to collectively assume their responsibilities.^32–34

In this context, it appears essential to assess the maturity of systemic leadership within DHMs for a better understanding of governance dynamics at the health district level, particularly in post-conflict environments. The objective of this study is to evaluate and contrast the maturity of systemic leadership among management teams in six health districts in the Kasai-Central province of the Democratic Republic of Congo. This assessment addresses the need to better document leadership capacities at the health district level, which are considered a key determinant of health system strengthening, overall performance, and contribution to the Sustainable Development Goals (SDGs) and universal health coverage.^22,35,36

Methods

Research Framework and Design

A quantitative, cross-sectional study^37,38 was conducted to assess and compare the maturity of systemic leadership in the urban health district (HD) of Kananga, Bobozo, Tshikaji, Katoka, and Ndesha, and in a rural HD of Mikalayi, in the Kasai-Central province of the Democratic Republic of Congo. The cross-sectional design was selected as it illuminates a phenomenon, facilitating its exploration, description, or explanation at a particular juncture.³⁷ The selection of these HD is justified by their pivotal role as the geographical entities responsible for implementing primary health care²³ (Figure 1).

Figure 1.

Health map of the Kasai-Central Public Health Directorate in the DRC, divided into health districts, with six health districts highlighted in color.

Notes: H = General Referral Hospital; + = Health Centre; red line = main road; beige line = secondary road; blue line = river; dashed boundary = administrative boundary of Kananga City. Source: Kasaï-Central Provincial Health Division, 2024, adapted by the authors.

The conceptual framework utilised was that of systemic leadership of a health system by Bigirinama et al,²⁴ which had been adapted from the Leadership Academy framework of the UK National Health Service (NHS).^39,40 The framework is divided into six domains, each comprising 14 pillars. The domains are as follows: the perspective on DHMs leadership (Governance and Vision/Positive Influence); internal collaboration within DHMs (Positive Collaboration, Conflict and Division, and Communication); collaboration between DHMs and technical and financial partners (Communication and Planning, and Financial Management); the management and organisation of the health system (Health System Management, Health System Organization, and Collaboration between DHMs and middle-level health system managers); the perception of the state of leadership in health systems; and the leadership strengthening needs of DHMs (Communication and Planning, Autonomy and Decision-Making Power, Capacity Building). The conceptual framework utilised integrates both perception dimensions (associated with stakeholders’ representations and evaluations) and organisational dimensions (related to practices, procedures, and structures). This formulation reflects the inherently multidimensional and contextualised nature of systemic leadership within health systems.^24,37

Data Sources, Population and Participation Selection

The study was conducted between March 2025 and April 2026. The study population consisted of members of six DHMs (n = 158), exhaustively. Among them, DHMs members meeting the following inclusion criteria: Being a staff member of the HD, having at least two years of seniority in the HD, being present at the time of the survey and freely consenting to participate in the study, were included in the study (n=84, including n=19 for the Kananga HD, n=13 for the Bobozo HD, n=14 for the Tshikaji HD, n=10 for the Katoka HD and n=14 for the Ndesha HD, and n=14 for the Mikalayi HD).

Data, Collection Methods

Each component of the conceptual framework was then subdivided into ten items or questions. A structured questionnaire, administered face-to-face, was developed. This questionnaire contained 140 items/questions and was assessed using a 3-point scale (YES = 1 point, INTERMEDIATE = 0.5 points, and NO = 0). For each objectively verifiable element mentioned by the participant during the questionnaire, a structured observation was conducted using the structured observation guide to verify and confirm the existence of the elements reported by the participants, without undergoing separate quantitative analysis. The efficacy of these data collection tools was tested in the urban health district of Lukonga prior to their deployment. The feedback and observations gathered during this exercise from the DHMs members allowed for refinement of the DHMs. The internal consistency of the questionnaire was checked using Cronbach’s coefficient (α per domain 1=0.846; 2=0.934; 3=0.773; 4=0.866; 5=0.776; 6=0.882).

Data Analysis

The analysis of the data was conducted utilising a range of statistical procedures, including exploratory, and descriptive methods, within the Microsoft Excel 2016 software (Microsoft Corporation, USA) and the IBM SPSS version 29 software (IBM Inc., USA). In the exploratory analysis, the initial step was the processing of the data. This process entailed the validation of the questionnaire data against the structured observation data, the coding of the data by domain, and the grouping of the data by pillars of the conceptual framework and by domain structure in Excel 2016. Following harmonisation and validation in the descriptive analysis, the absolute frequency (number of occurrences) and percentage (%), measures of central tendency (means, minimum and maximum values), and measures of dispersion (standard deviation) were calculated for the sociodemographic variables.

For each pillar, the percentage of points earned by the DHMs relative to the maximum number of points expected for the DHMs is shown to facilitate comparison among the DHMs. Since the distribution of the total points obtained was not normal (p < 0.001, Shapiro–Wilk normality test), the median percentage (and interquartile ranges) of the pillars was used as the primary parameter for analysis. These were categorised as “low” (if the percentage of the points’ score out of the maximum expected points was less than 60%), “moderate” (if the percentage of the points’ score out of the maximum expected points was between 60 and 79%), and “high” (if the percentage of the points’ score out of the maximum expected points was equal to or more than 80%).⁴¹

The aggregate totals of points obtained by all DHMs members across all six domains of the DHMs systemic leadership conceptual framework (out of a maximum number of points per district) represented the DHMs “Overall Systemic Leadership Maturity Scores”, thus enabling the DHMs leadership maturity to be categorised as “low” (< 40%), “moderate” (40–60%), “good” (60–80%), and “very high” (≥ 80%).^38,42 The median of the Overall Systemic Leadership Maturity Score has been shown to indicate the overall synthetic index of systemic leadership achievement in Kasai-Central province.⁴¹

Ethical Considerations

The requisite administrative authorisations were obtained from the School of Public Health at the University of Kananga (reference: 0096/2025, serving as approval from an official institutional ethics committee for cross-sectional studies involving minimal risk) and from the medical authorities in the relevant health zones. It is imperative to emphasise that all procedures were conducted in accordance with the principles of the Declaration of Helsinki.⁴³ Participation in the study was voluntary. The study was subject to the acquisition of written informed consent, which included consent for the publication of anonymised responses. In order to guarantee confidentiality, anonymity and the protection of personal data, a rigorous set of precautionary measures was implemented. A comprehensive analysis of the results was conducted by the management team on an aggregated basis, with the objective of safeguarding the anonymity of the participants.

Results

Sociodemographic Profile

A total of 84 members of the DHMs participated in the study. The majority of participants were male (66, or 78.57%), while women represented 21.43% (18 participants). The mean age of the subjects was 42.50 years (± 11.40 years). With regard to educational attainment, the majority of participants (58, or 69.05%) held an undergraduate degree. A smaller proportion of the participants (24, or 28.57%) had obtained a postgraduate degree or Doctorate in Medicine, while a marginal minority (2, or 2.38%) held a state diploma. In terms of professional experience, the mean seniority in the position was 5.82 years ± 4.85 years, whereas the mean seniority within the DHMs in the health zone was 7.50 years ± 4.18 years (Table 1).

Table 1.

Sociodemographic Characteristics of DHMs Members

Variables	n = 84 (%)
Sex
Female	18 (21,43%)
Male	66 (78.57)
Average age (±SD)	42.50±11.40
Level of education
State Diploma	2 (2.38)
Undergraduate degree	58 (69.05)
Postgraduate degree	24 (28.57)
Average length of service in the position (±DS)	5.82 ± 4.85
Seniority as an DHMs member in the Average Zone (±DS)	7.50±4.18

Systemic Leadership Maturity Profile of DHMs

As illustrated in Table 2, the study found that DHMs demonstrated a leadership maturity profile that was, in general, heterogeneous but predominantly moderate, with substantial variations observed across the dimensions and HDs investigated. With regard to the primary dimensions, the highest performance levels are observed in the perspective on DHMs leadership (median = 72.02%) and in the perception of the state of leadership in the HDs (median = 75.16%). Conversely, the weakest dimensions concern collaboration between HDs and technical and financial partners, particularly communication and planning (median = 55.22%) and financial management (median = 54.21%). The internal collaboration within HDs exhibits an intermediate profile, characterised by a median positive collaboration of 80.77%, accompanied by notably low levels of conflict and division, with a median of 46.64%. The level of internal communication is, at 67.05%, still moderate. With regard to the management and organisation of the HDs, the results are equivocal: HD management is relatively high (73.13%), while internal organisation remains low (43.38%).

Table 2.

Leadership Maturity Profile of DHMs in Kasai-Central Province by Systemic Leadership Domain

Domains	Pillars	DHMs1 (%)	DHMs2 (%)	DHMs3 (%)	DHMs4 (%)	DHMs5 (%)	DHMs6 (%)	Median	Q1	Q3
Perspective on DHMs Leadership	Governance and Vision	78.57	72.5	70.53	74.64	71.54	70.36	72.02	70.78	74.11
	Positive influence	74.29	70.5	71.05	86.07	64.62	60.71	70.78	66.09	73.48
Internal collaboration within the DHMs	Positive collaboration	80.00	85	65.53	72.86	81.54	82.86	80.77	74.64	82.53
	Conflict and division	57.86	39.5	46.84	46.43	39.62	59.29	46.64	41.32	55.10
	Communication	73.57	46	65.26	61.07	68.85	80.71	67.05	62.12	72.39
Collaboration between DHMs and technical and financial partners	Communication and planning	66.43	41	57.37	61.07	53.08	36.43	55.22	44.02	60.15
	Financial management	63.93	52	46.58	31.07	58.85	56.43	54.21	47.93	58.24
Management and organization of the HD	HD Management	60.00	80	59.74	66.25	82.31	81.43	73.13	61.56	81.07
	HD Organization	52.50	43	38.95	43.75	41.54	55.00	43.38	41.90	50.31
	Collaboration between the DHMs and middle-level health system managers	55.71	51	52.63	51.25	49.23	68.57	51.94	51.06	54.94
Perception of the state of leadership in the HD	Perception of the state of leadership in the HD	75.71	74	76.58	78.13	74.62	72.86	75.16	74.15	76.36
DHMs Leadership Strengthening Needs	Communication and planning	62.86	78	74.21	87.50	75.38	79.29	76.69	74.50	78.96
	Autonomy and decision-making power	68.21	57	56.32	38.75	40.00	51.07	53.69	42.77	56.83
	Representations and evaluations of stakeholders	52.86	64	57.37	58.75	77.69	65.71	61.38	57.71	65.29

Notes: Cell in green color: high profile (≥ 80%). Cell in yellow: average profile (60–79%). Cell in red color: low profile (<60%). DHMs 1= Mikalayi; DHMs 2 – Katoka; DHMs 3 = Kananga; DHMs 4 = Tshikaji; DHMs 5 = Bobozo; DHMs 6 = Ndesha.

The descriptive variations observed between urban and rural DHMs, with marked contrasts. The Mikalayi DHMs (DHMs1 – rural area) generally exhibit relatively balanced performance, particularly in collaboration with partners and internal management. In urban areas, performance is more varied: The Tshikaji DHMs (DHMs4) are distinguished by their notable positive impact (86.07%) and effective management of the health district. The Kananga DHMs (DHMs3) demonstrate average overall scores, yet exhibit specific deficiencies in relational and organisational dimensions. The Ndesha DHMs (DHMs6) demonstrate relatively high performance in internal collaboration and health district management. The Katoka (DHMs2) and Bobozo (DHMs5) DHMs generally exhibit the weakest profiles, particularly in the context of internal and external collaboration (Table 2).

Overall Score and Overall Synthetic Index of DHMs Systemic Leadership Maturity Achievement

As demonstrated in Table 3, the overall Systemic Leadership Maturity scores of the DHMs are, in general, moderate and relatively homogeneous, with an overall median of 62.10% and minimal variation between 59.92% and 65.89%. The lowest overall score was observed in DHMs 3 (Kananga) at 59.92%, followed by DHMs 2 (Katoka) at 60.96% and DHMs 4 (Tshikaji) at 61.43%. Conversely, the highest scores were recorded in DHMs 1 (Mikalayi) at 65.89%, followed by DHMs 6 (Ndesha) at 65.77%, and DHMs 5 (Bobozo) at 62.77%. The distribution of scores indicates that the most accomplished performance does not necessarily align with a rural-urban divide. Indeed, the rural DHMs of Mikalayi and the urban DHMs of Ndesha are among the best ranked, while urban DHMs such as Kananga have lower scores.

Table 3.

Overall Scores and Overall Synthetic Index of Systemic Leadership Maturity Achievement of DHMs in the Kasai-Central Province

Domains	Pillars	HD Rural	HDs Urban					Overall Synthetic Index of Systemic Leadership Achievement
		DHMs1	DHMs2	DHMs3	DHMs4	DHMs5	DHMs6
Perspective on DHMs Leadership	Governance and Vision	110	72.5	134	104.5	93	98.5
	Positive influence	104	70.5	135	120.5	84	85
Internal collaboration within the DHMs	Positive collaboration	112	85	124.5	102	106	116
	Conflict and division	81	39.5	89	65	51.5	83
	Communication	103	46	124	85.5	89.5	113
Collaboration between DHMs and technical and financial partners	Communication and planning	93	41	109	85.5	69	51
	Financial management	89.5	52	88.5	43.5	76.5	79
Management and organization of the HD	HD Management	84	80	113.5	53	107	114
	HD Organization	73.5	43	74	35	54	77
	Collaboration between the DHMs and middle-level health system managers	78	51	100	41	64	96
Perception of the state of leadership in the HD	Perception of the state of leadership in the HD	106	74	145.5	62.5	97	102
DHMs Leadership Strengthening Needs	Communication and planning	88	78	141	70	98	111
	Autonomy and decision-making power	95.5	57	107	31	52	71.5
	Representations and evaluations of stakeholders	74	64	109	47	101	92
Overall Systemic Leadership Maturity Scores		1291.5	853.5	1594	946	1142.5	1289
Total expected points		1960	1400	2660	1540	1820	1960
Overall Systemic Leadership Maturity Scores (in %)		65.89	60.96	59.92	61.43	62.77	65.77	62.10 (61.08–65.02)

Notes: Yellow cell: moderate Overall Systemic Leadership Maturity Scores (40 to 60%). Cell in red color: low Overall Systemic Leadership Maturity Scores (<60%).

A thorough analysis of the total scores (Overall Systemic Leadership Maturity Scores) and expected points also reveals variability in relative achievement levels, with overall achievement rates ranging from approximately 60% to 66%. This confirms an intermediate overall maturity level for the DHMs studied. The median Overall Systemic Leadership Maturity Score of 62.10% has been determined to be a comprehensive index of systemic leadership achievement, indicating a moderate and relatively homogeneous level of maturity (Table 3).

Discussion

The findings of this research indicate a moderate level of systemic leadership maturity among DHMs in Kasai-Central province (Overall synthetic index of systemic leadership achievement = 62.10%), with minimal inter-DHMs variability in overall Systemic Leadership Maturity Scores. However, a considerable degree of variability is observed across leadership dimensions. The highest ratings pertain to vision, governance, and overall leadership perception (approximately 70–75%), while the lowest ratings relate to collaboration with external partners, financial management, and internal organisation (ranging from 43–55%). The present study finds that internal collaboration appears to be generally satisfactory. However, it is important to note that this is accompanied by significant levels of conflict. It is notable that no clear distinction is made between rural and urban areas.

The overall level of maturity observed is based on a logic of common structural constraints specific to health systems in a post-conflict context. Research indicates that leadership assessments at the district level typically range between 60 and 70%, reflecting contexts characterised by centralisation, lack of funding, and limited autonomy.^24,44–46 In this context, the moderate level of maturity observed does not simply indicate a lack of skills among community health workers, but rather reflects a functional equilibrium under constraints, where organisational flexibility remains limited.⁴⁷ The results of the study indicate a discrepancy between the strategic and operational dimensions. It is evident that high ratings in the domains of governance and vision are at odds with low ratings in the areas of financial management, organisational structure, and external collaboration. This profile is consistent with the findings in the DRC, where the primary concerns relate to the operational application of leadership.^25,26 This discrepancy, which has also been documented in other African contexts, suggests that leadership practices are not being institutionalised in a strong enough manner. As a result, strategic directions are not being translated into effective organisational processes.^45,46,48

The strong internal collaboration observed (80.77%) is a significant asset; nevertheless, it is undermined by conflicts (46.64%). This finding is indicative of an intermediate level of relational maturity. Research indicates that district performance is closely linked to the effectiveness of teamwork, communication, and organisational commitment.^45,46,49 In this particular context, the results indicate that DHMs have significant potential for collaboration, although this potential is insufficiently reinforced by formal mechanisms for internal governance and participatory management.⁵⁰ The substandard results observed in conjunction with technical and financial collaborators underscore a pivotal structural problem. The findings in the DRC demonstrate that partner actions are frequently siloed, poorly synchronised, and sometimes out of step with local priorities, thereby hindering the effectiveness of local leadership.^25,26 This weakness is also linked to the fragmentation of interventions and top-down approaches that reduce local decision-making autonomy and limit district team ownership of processes. Consequently, this deficiency reflects a systemic governance problem involving multiple actors, rather than an isolated skills gap.⁵¹

The absence of a substantial discrepancy between urban and rural districts suggests that the capacity for “systemic leadership” is more influenced by organisational elements than by geographic location. These findings are consistent with the observations from other studies in the DRC, suggesting that team dynamics, coordination mechanisms, and internal governance play a more decisive role than resource availability.^24,44,49 The results of the study indicate that the maturity of systemic leadership emanates from intricate interactions occurring at multiple levels within the system. A multi-level model can be utilised to interpret this phenomenon, wherein contextual factors (e.g centralisation, limited resources), organisational factors (e.g coordination, process structuring), and individual factors (e.g managerial skills) interact. Within this theoretical framework, systemic constraints have been shown to limit decision-making autonomy and hinder the institutionalisation of leadership practices. This, in turn, generates negative feedback loops that impede organisational transformation. A fundamental aspect pertains to the degree of institutionalisation of leadership. In the absence of formalised organisational mechanisms and sustained political support, leadership practices remain dependent on individuals and difficult to replicate, which limits their impact over time.

The findings of this study are largely consistent with those documented in other sub-Saharan African contexts, where leadership levels at the middle level remain moderate and are characterised by analogous structural constraints.^45–47 However, the observed absence of rural-urban differentiation lends support to certain prevailing hypotheses, suggesting that organisational and relational factors exert a more significant influence than geographical factors. This observation contributes to the ongoing debate on strategies for enhancing district health systems, underscoring the predominance of internal dynamics over structural resources.

The findings underscore the significance of adopting a systemic approach to leadership development, integrating skills development with the implementation of organisational reforms. It appears crucial to enhance the practical capacities of chief executive officers in planning, financial management, and organisational management, while simultaneously establishing leadership through process formalisation, role clarification, and improved coordination systems. The enhancement of internal governance, particularly through the optimisation of conflict management, effective communication, and participatory leadership, is also a critical factor. Moreover, it is imperative to redefine the relationships with partners in order to ensure more effective strategic alignment and to enhance the autonomy of Chief Executive Officers. In order to facilitate sustainable leadership development, it is important to promote participatory approaches such as tutoring, mentoring and peer exchange.⁴⁹ These factors emphasise the necessity for measures that address both individuals and the underlying structural deficiencies of the health system.^45–47

The present study has several strengths. The present study makes an original empirical contribution to the extant literature on systemic leadership in health systems by offering a quantitative and multidimensional operationalisation of a concept that has been addressed in qualitative research to date. The present study goes beyond mere description of leadership levels to propose an empirical operationalisation of systemic leadership at the health district level in a post-conflict context. It is highlighted that leadership maturity is less a result of individual characteristics than of organisational and systemic dynamics. In this sense, it contributes to a shift in the analysis of leadership in health systems from an individual-centred approach to one of shared leadership. The coverage of several health districts, both urban and rural, provides a relevant comparative perspective, while the calculation of a comprehensive composite index facilitates the interpretation and use of the results.

However, it is imperative to acknowledge the limitations that are inherent to this approach. It is imperative to exercise caution when interpreting the results, given the cross-sectional design of the study. This approach facilitates the description of leadership maturity levels at a given time; however, it does not establish causal relationships or capture the evolving dynamics of systemic leadership. The observed associations therefore reflect co-occurrences rather than explanatory relationships. Furthermore, systemic leadership assessment tools remain imperfectly adapted to certain contexts, which may limit the ability to grasp the full complexity of the phenomenon.³⁷ The findings are contingent on the prevailing context, thereby constraining their generalisability to disparate settings. The partial reliance on self-assessment may introduce subjectivity bias. Furthermore, the quantitative approach, despite its structured nature, falls short in fully encapsulating the informal dimensions of leadership. In conclusion, the absence of analysis of explanatory factors (characteristics of actors or districts) and the lack of a link with health performance limit the interpretative scope of the results.

Conclusion

The findings of this research suggest that the level of systemic leadership development among DHMs in Kasai-Central is, on the whole, average and fairly uniform, reflecting shared structural obstacles specific to post-conflict contexts. The findings reveal a discrepancy between adequate strategic competencies and persistent deficiencies in operational domains, including management, organisation, and collaboration with partners. The descriptive differences observed between rural and urban areas confirm the central role of organisational factors. These observations emphasise the necessity of integrated approaches that combine capacity building, leadership development, and systemic reforms to ensure the sustainability of leadership at the district level.

Statement on the Use of Generative AI and AI-Assisted Technologies in the Drafting Process

In the course of preparing the present work, the authors utilised ChatGPT 5.0, Quillbot and DeePL White to verify grammar and spelling as they composed this manuscript. Following the utilisation of these tools, the authors conducted a thorough review and rectification of the content, assuming full responsibility for the publication’s content.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.