Who leads the district health system? RHAP puts leadership practice at the centre
In a health setting, leadership is not simply about holding a senior position. Instead, leadership in a health system context is a presence — something demonstrated through relationships, teamwork, decision-making and how people respond to pressure.
And a trait that all employees have and should feel comfortable to enable.
This was the central theme in a lunchtime session RHAP hosted at the Rural Health and Family Physicians Joint Congress 2026 in Midrand this year.
The session explored the question central to the future of South Africa’s district health system: Who leads the district health system?
Led by RHAP exco chair Prof Richard Cooke, the session moved beyond the idea that leadership sits with specific individuals.
South Africa’s district health system operates under significant pressure. Clinics and district hospitals often serve large geographical areas with limited resources, while different parts of the system do not always work together as effectively as they should.
Prof Cooke identified three priorities: making the health system more integrative, putting people at the centre of care, and strengthening leadership and governance.
A key theme was leadership without authority. Healthcare workers frequently take responsibility, solve problems and bring colleagues together without having formal authority. Prof Cooke shared the example of a junior registrar who established a multidisciplinary meeting to improve chronic care, eventually creating a practice that continued beyond her involvement.
However, leadership without support can also lead to burnout. Formal leaders therefore have an important role in recognising, legitimising and supporting leadership that already exists within teams.
The discussion also highlighted the realities of working in a complex health system: staff shortages, broken equipment, changing guidelines, transport barriers, financial pressures and patients facing challenges that extend beyond the clinic. These situations require more than technical solutions; they require people to navigate uncertainty together.
Trust and psychological safety were also central. Teams need to feel safe enough to acknowledge weaknesses, have difficult conversations and learn from mistakes. Prof Cooke emphasised that conflict can be constructive when approached with curiosity rather than judgement.
Importantly, the session recognised what often remains beneath the visible pressures of healthcare: burnout, anxiety, grief, moral distress and emotional load.
The practical takeaway was simple: leadership starts with self-awareness. On Monday morning, Prof Cooke encouraged healthcare workers to notice their emotions, understand how these emotions influence their behaviour and practise self-regulation.