Leadership practices and maternal and child health outcomes in Sub-Saharan Africa: a systematic review

Maternal, newborn, and child health (MNCH) remain a major public health challenge in Sub-Saharan Africa (SSA), where preventable mortality persists despite global commitments to reduce deaths. Weak leadership and management within primary health care (PHC) systems contribute to inefficiencies, inequities in access, and suboptimal quality and continuity of care. This systematic review examined how leadership and management practices influence MNCH outcomes in SSA. The systematic review followed PRISMA 2020 guidelines and was conceptually informed by the WHO Health System Building Blocks framework and governance-oriented leadership concepts. Searches were conducted in PubMed/MEDLINE, Web of Science, Scopus, CINAHL, Embase, Google Scholar, and the WHO African Index Medicus (AIM) for peer-reviewed studies published between 1978 and July 2025. The protocol was registered in PROSPERO (CRD42024514304). Clinical trial number: Not applicable. Studies were eligible if they examined leadership or management practices in PHC settings and reported MNCH outcomes. Thirteen studies from seven countries and one multi-country analysis met the inclusion criteria. Leadership approaches clustered around three domains: leadership capacity building and supportive supervision, participatory and accountable governance, and community engagement mechanisms. These approaches were consistently associated with measurable improvements in service coverage and quality. Reported gains included increases in antenatal care utilization (+ 12% to + 48%), skilled birth attendance (+ 10% to + 34%), and immunization completion rate (+ 8% to + 27%). Management practices including mentorship, routine monitoring, and data-driven decision-making strengthened provider performance, coordination, and service delivery efficiency. Leadership and management are critical system-level drivers of PHC performance and MNCH outcomes in SSA. Strengthening leadership and management capacity within PHC systems represents a high-impact strategy for improving service delivery and accelerating progress toward MNCH targets in SSA. Leadership and management are increasingly recognized as important determinants of maternal, newborn, and child health (MNCH) outcomes in Sub-Saharan Africa (SSA), yet they remain comparatively underexplored and underprioritized. Despite decades of investment in clinical training, vertical programs, and disease-specific interventions, persistent system challenges including weak governance, limited accountability, fragmented coordination, and workforce shortages, continue to undermine progress and widen inequities in access, quality, and outcomes. Evidence from global health research suggests that effective leadership within primary health care (PHC) systems strengthens accountability, coordination, provider competence, data-driven decision-making, and frontline health worker motivation for improving service coverage and care quality. However, the specific ways leadership and management practices influence MNCH outcomes in SSA remain insufficiently synthesized, limiting their visibility in policy design, implementation guidance, and resource allocation decisions. This systematic review addresses this gap by synthesizing evidence from studies conducted across seven SSA countries and one multi-country analysis to understand how district- and facility-level leadership and management approaches shape MNCH outcomes within PHC settings. By positioning leadership not merely as an administrative function but as a system-strengthening capacity, this systematic review provides contextually grounded evidence to inform policy design, guide strategic investments, and accelerate progress toward Sustainable Development Goal 3 (SDG 3): “Ensure healthy lives and promote well-being for all at all ages.” These findings highlight leadership and management as critical system-level levers within PHC that can translate policy intent into measurable MNCH gains when supported by adequate governance structures, resources, and community engagement mechanisms.