An integrated leadership approach in improving service delivery in health care:A case study of a district hospital in the Limpopo Province in South Africa

This study explored the relationship between leadership styles adopted by managers in the district hospital in the Limpopo province in South Africa (SA) and service delivery to rural communities in the area. This study was essential as over 70% of district hospitals in SA are non-compliant with meeting its service delivery commitments. There was a need to investigate whether the challenges associated with the poor service delivery were related to the leadership styles adopted by managers in the district hospital. Both transformational and transactional leadership styles formed the basis of the study. A quantitative research methodology and case study were used. A Multifactor Leadership Questionnaire (MLQ) was used to determine which leadership styles were adopted and the outcomes at the hospital. The survey was completed by seventy managers in the hospital. Descriptive and inferential statistics were used for the data analysis. The findings of the study revealed that certain leadership styles, as well as attributes impacted on service delivery to communities. The data suggested that, although some transformational leadership traits were exhibited by managers at the hospital, this had not necessarily led to improved service delivery to communities. The study was therefore critical, as it has become evident to policymakers that an expansion in the scope and quality of health care to rural communities in SA is vital. Recommendations were made for the improvement of service delivery by the hospital. An integrated leadership approach is therefore essential with a view to addressing challenges in the hospital and improving service delivery to the community.


Introduction
To promote a sustainable delivery of public health services, the SA government has increasingly shifted to the most critical issue confronting public hospitals today, that of public health delivery.The goal of the SA government is to provide health care to all communities in SA (Naidoo, 2012).However, the provision of public health care to rural communities in SA are either non-existent or minimal (Mafora, 2020).Although the district hospitals have committed to addressing the disparities in the provision of health care to communities, many provinces are confronted with extensive challenges resulting in backlogs.There are several challenges impacting on district hospitals in SA, which impeded the ability of hospitals to effectively deliver health care to communities.Ineffective leadership are recurring challenges impacting on healthcare delivery by district hospitals (Mafora, 2021).According to Maphumulo and Bhengu (2019), the lack of accountability, corruption and misconduct among health officials has also contributed to failures in service delivery.However, factors such as the lack of leadership impetus, inspiration, or effective intervention by the provincial government in SA undermine the ability to deliver quality services by district hospitals.
According to Mafora (2020), these challenges were still evident during the study in 2020 and the lack of effective leadership has exacerbated the service delivery problems currently being experienced in the district hospitals.If hospital leadership is not efficient, then important duties are neglected, resulting in inferior services to communities and a hospital that is poorly administered.The authors therefore considered it relevant to explore the different leadership styles adopted in the district hospital and determine whether the leadership styles adopted have an impact on service delivery to communities.More specifically, Bass (1997) and Naidoo (2004) noted that "by identifying leadership as per the styles, the effectiveness of managers can be better understood in terms of the delivery of health services."In this regard, Farrell (2001) indicated that "the particular leadership style adopted by a manager can enhance, neutralize, or inhibit job-related outcomes and the responses of subordinates as job satisfaction, motivation, effectiveness, and performance." The aim of the study is therefore to consider the appropriateness and efficacy of the leadership styles practiced, and their impact on the sustainable delivery of health services to rural communities and, the practical functioning of the district hospital under study.The study had the following objectives (1) To determine the challenges at the district hospital impacting on the provision of health care to communities in SA (2) To determine which leadership styles are adopted and to what extent at the district hospital and (3) To consider which leadership style will most likely improve the provision of health care services by the district hospital.This study therefore sought to determine 'which leadership style is best suited to enhance service delivery by the district hospital?'The two most common leadership approaches adopted in the district hospital, being transformational and transactional leadership.The hypothesis was: transformational leadership leads to improved public health care delivery by the district hospital.
Following the introduction, the article firstly provided a literature review on public healthcare facilities in SA and the challenges impacting on service delivery to communities by district hospitals.Secondly, leadership, including traditional leadership styles were conceptualized.Thirdly, the research design and methodology were introduced.After the analysis and findings of the study, the article concluded with key points and recommendations.

Literature Review
The World Health Organization (2010) lists six components for an efficient performance of a healthcare facility, "(i) Health workforce, (ii) Information systems, (iv) Access to essential medicines, (v) Financing, (vi) Leadership and (vii) "Service delivery," (Maphumulo, 2012).An integrated healthcare facility therefore employing medical personnel, with specialist skills as well as 'frontline' staff, creates a complex organization requiring a diverse skill set of attributes, to enable its efficient functioning and optimal performance (Bagraim, 2013).Hospital managers therefore require overseeing employees with differing remits, and experiences.Consequently, healthcare managers must strive not only to meet patient needs but adapt continually to both internal and external changes, while attempting to transform work practices and organisational cultures to maximise efficiencies and achieve the desired outcomes.
Hospitals in SA are categorized as regional hospitals, where cases that cannot be managed at the district hospital are referred to the regional hospitals.The other category is the tertiary hospitals having specialists in complex cases.District hospitals are a key constituent of the healthcare system (from community clinics to general hospitals) receiving referrals from community health centres and clinics, and are responsible for services from maternity, surgery to rehabilitation."(Mafora, 2020).According to Le Roux and Couper (2015) well-managed district hospitals are important in attracting and retaining a core community of skilled healthcare workers and can form a hub to support primary care services while providing a link in the chain of referral.In the view of Le Roux & Couper (2012) high-quality primary care will only be achieved if district hospitals are integrated into the planning and delivery of primary services.As part of the SA Government's stated goal to implement Universal National Health Insurance coverage, the reengineering of primary healthcare is critical, and district hospitals are viewed as an integral part of the primary health care delivery system.
It has become evident through the literature review that several challenges impacting on the district hospitals has impeded the ability of hospitals to effectively deliver services to communities.The present researchers became aware of the challenges after the quarterly audits revealed that there was a lack governance, leadership, and management.District hospitals are expected to deliver services with extremely limited resources (Department of Health, 2019/2020).However, the extreme resource shortages, impacts on service delivery to communities.Malakoane et al., (2020) noted that human resources constraints, include widespread inefficiencies, staff shortages, inconsistency in skillsets between impoverished and wealthier urban areas, emerged as among the main contributory factors to poor health delivery in SA.It has become evident that doctors and health professionals often prefer to work in the urban areas or towns leading a sparsity of expertise in district hospitals.Furthermore, compared to developed countries with an average of 1.6 doctors per 1000 head of population, SA has 40% less medical professionals (0.9% doctors per 1,000 people).
In addition, Naidoo & Fields (2015) study of a district hospital in KwaZulu-Natal suggested that ineffective operations management tended to exaggerate long patient queues, leading to a disorganized outpatient department, and disgruntled employees.Mafora (2020), also indicated that district hospitals also did not have training resources and facilities to develop and equip the leadership in hospitals with the necessary knowledge and skills to manage the hospitals effectively.Also, there is a lack of competencies in scarce skills in district hospitals.Consequently, health professionals became demoralized and did not show the required commitment to render a high-quality service, leading to strikes and protests.Such inadequate health care is but one contributory factor to frequent community protests.According to 'Municipal IQ,' there were over four hundred major protests in SA during the first half of 2023, one of the root causes being the exclusion of communities from access to, and delivery of, effective public services provision such as health care.
Indeed, as Obici and Mwesigwa (2021) noted in their 2021 study of the performance of mid-level healthcare workers, lack of policy implementation, the absence of effective leadership and decision-making skills has an effect of crippling a hospital.Of even more concern is the finding by de Villiers, (2021) that the SA health system faces a range of systemic and structural challenges, such as, deficiencies in patient care satisfaction and management.In their study of challenges faced by the district hospitals in the Free State in SA, Malakoane et al., (2020) surveyed and interviewed health care managers in medical facilities.Amongst the concerns of respondents were that weak leadership and poor governance posed 'considerable risks to patient care' which led to poor priority setting,' lack of policy implementation' and in one case the 'non-appointment of hospital board members.'According to Van Rensburg (2012) ongoing litigation has been instituted against district hospitals by numerous patients for both negligence and the mediocre performance of health professionals.According to Ruigrok, (2010) the litigation costs in district hospitals being researched in the Limpopo health department were high.According to a report in Polity, (2022) medical negligence litigation claims threaten to bring the Limpopo health department to its knees.The Vhembe district health facilities have 500 medico legal cases amounting to R5,251 billion, Capricorn district has 330 claims amounting to R2,356 billion, Mopani district has 322 cases amounting R2,683 billion, Sekhukhune district has 305 cases amounting to R3,006, billion and Waterberg district has 118 cases amounting to R766,053 million.Additionally, the credibility of the hospitals suffered due to adverse publicity (George, Gow, & Bachoo, 2011) and (Mafora, 2020).
The SA Medical Journal (SAMJ) reported that more than half of surveyed respondents in district hospitals had either suffered or observed bullying or identified unhealthy workplace environments, underscoring the 'low value' placed on front-line medical staff in an already stretched system (Conco et.al., 2021).These challenges have undoubtedly had a significant effect on the provision of health care to communities.This is clearly reflected in the Department of Performance Monitoring and Evaluation report, (2019) which stated that "over 70% of public hospitals are non-compliant with the service delivery requirements, and over 70% of hospitals are non-compliant in ensuring that sound policies and systems promote ethics and values."These challenges also highlight the gap in terms of leadership skills that are critical in the management of hospitals and the efficient delivery of health care to communities.
There is little doubt that SA public health care system remains under severe strain (Naidoo & Sguazzin, 2023).As Rooke, (2018) concludes, "Leaders in public hospitals are particularly challenged by complex and ambiguous contexts.They need to extend their leadership capacities to be able to lead effectively in such contexts."

Conceptual framework of leadership and leadership styles
According to the Department of Health (2021/2022), over the last five decades, the practice of 'good leadership' has been seen as a critical skill for qualified medical professionals and has become a specialist field of study for health care managers, being taught in several SA academic institutions.The concept of 'leadership' in public health management has evolved and is continuing to do so, in which regard it is important to point out that "leadership is the process by means of which power and influence are deployed to motivate followers achieve specific goals and objectives by persuasive means."(Naidoo, 2004).According to Simmonds (2015) leaders need to be creative and analytical and use 'transformational leadership' techniques in a proactive, enabling manner, to inspire their subordinates.Leadership entails developing and implementing a mission statement setting out the vision, mission, and the policies of the hospital.The senior leadership of the hospital has a responsibility to ensure that it is staffed with sufficient skilled, experienced, knowledgeable, and qualified staff to ensure its efficient and smooth running to achieve its objectives, and where failures are identified, methods to develop a turnaround strategy (National Centre for Healthcare Leadership, 2012).Leadership can therefore be described as setting a vision or roadmap towards an intended goal or set of objectives and the exercise of influence to achieve these.Leadership should provide an enabling environment to enable management and staff to strategize a 'pathway' towards achieving an organisation's objectives, as well as the setting of ethical boundaries and the clarifying and solving of problems.By contrast, management can be distinguished from leadership in being less concerned with the vision, and more focused with the 'here and now' of how to achieve these goals and improve performance through processes such as organizing and controlling as well as human resources management.
It was deemed essential to provide an overview of the two most common leadership approaches adopted in district hospitals in SA, these being transformational and transactional leadership (Mafora, 2020).The term "transformational leadership" was coined in 1973, in a sociological study conducted by the author Downton, (1973).Subsequently James McGregor expanded on the transformational leadership concept in his book " Leadership" (1978).Bass (1985) presented a formal transformational leadership theory depicting transformational leaders as motivating "their followers to do more than they really expect they can do, increasing the sense of importance and value of the tasks, stimulating them to surpass their own interests and direct themselves to the interests of the team, organization or larger community and raising the level of change to a higher level." According to a study by Komakech, Obici, and Mwesigwa, (2021) transformational leadership emphasizes extracting high performance and engagement from subordinates by utilising a 'motivational toolkit' combining "idealized influence, inspirational motivation, intellectual stimulation, individualized consideration."'Idealized influence' involves a combination of passion, charismatic communication, and commitment to enthuse others to practice the quality of excellence in all that they do in the organisation.A leader who practices positivity by rewarding good performance, enthusiastic praise and encouraging effort can be perceived as providing 'inspirational motivation' (Van Rensburg, 2012).Such leadership characteristics can help stimulate more active participation in 'day-to-day' management by those in lower levels of the organisation.'Intellectual stimulation' encourages creativity and participation from less senior colleagues in the organisational hierarchy as well as the 'freedom' to think creatively and independently encouraging employees to feel engaged and valued.'Individualized consideration' cultivates the development of those in less senior levels of management to 'grow' their skills and abilities through coaching, mentoring, and teaching.A leader who practices 'idealized consideration' displays a high concern for those reporting to them, treating them as individuals, listening to their concerns and ideas.According to previous research by Jaffe (2012), regarding staff nurse perception of leadership styles among nurse managers, transformational leadership leads to improved nursing performance, safer nursing, and higher rates of nurse satisfaction and retention.
Unlike transformational leadership, transactional leadership refers to an exchange relationship between leaders and their followers (Naidoo, 2004).This leadership style typically involves power over, reward to, or sanction imposed on employees.Transactional leaders require confidence and communication skills to achieve clearly stated organisational goals and plans.By exercising the tools of authority, reward and sanction in an organizational environment, transactional leaders can successfully motivate employees to achieve organizational goals and operate efficiently.
In the district hospital under pressure, effective decision-making is required.Leaders need to be analytical, accurate and decisive.Inertia or conservative decision-making may disadvantage the hospital.In environments characterized by flux however, transactional leaders may prove less effective, because their leadership style focuses on power and reward to the detriment of employee engagement and development (Dong, 2023).Transactional leaders who lack the ability to adapt their leadership style to suit different situations, changing organisational requirements or understand their employees' needs may therefore detract from the effective functioning of that organisation.Unless transactional leaders are proactive and flexible in their strategies, such an organisation may face the prospect of failure or collapse.

Research and Methodology
The study adopted a quantitative approach which was aimed at ensuring that an interpretation and analysis of the respondents' views revealed the actual meaning of what was investigated.Furthermore, quantitative research allowed the testing of the research hypotheses (Anon., 2015).According to Creswell (2012), "quantitative research provides sufficient detail about a study to replicate it for verification."Quantitative research is objective and uses numerical data elicited from a sample of a population to generalize the findings to the population under investigation (Fox, 2015).The study includes an outline of how the sample was selected, the methods used to collect data, how the data was interpreted and analysed and how trustworthiness was ensured for this study.
The Department of Health ( 2011) and Statistics SA (2012) indicated that SA has about 4,776 public health care facilities.The Matlala district hospital case study was "comprehensive" and "generated detailed information.A non-random sampling method was used as participants were categorised according to their status and time employed by the hospital.A standardized questionnaire was used to measure the perceptions and experiences of junior and middle managers involved in managing and administering the district hospital.An exploratory and descriptive research design was also deemed necessary for the purpose of this study.
A Multifactor Leadership Questionnaire (MLQ) adapted from Avolio, & Bass (2004) was used to determine which leadership styles were adopted and the outcomes at the district hospital.The MLQ survey was administered and completed by seventy managers in the district public hospital.Both the survey and the interviews were conducted, so that the findings are verifiable by the variation in the data collected.Descriptive and inferential statistics were used for the data analysis.A significant principle of quantitative research is that it is objective and uses numerical data elicited from a sample of a population to generalize the findings to the population under investigation (Fox, 2015).

Analysis and Findings
The transformational leadership style was measured using five characteristic descriptors, which were "Idealized Influence Attributed, Idealized Influence Behavior, Inspirational Motivation, Individual Consideration, and Intellectual Stimulation.The characteristics were measured on a five-point Likert scale for rating the frequency of observed leader behaviours, which ranged from 0 (not at all) to 5 (frequently, if not always).An average of at least 2.5, meant that the behaviour occurred quite often, whilst a mean of less than 2.5 meant that the behaviour was less observed."(Mafora, 2020).
With 'idealized influence attributed' the data reflected that about 70% of those surveyed indicated that their senior managers displayed a sense of power and confidence, and 71.4% indicated that the senior managers acted in a way that built on respect for individuals and 61.4% indicated that the senior managers sacrificed self-interest for the good of the group.However, less than 50% indicated that senior managers instilled pride in others about being associated with them.The analysis indicated that while instilling pride in others or being associated with their subordinates occurred sometimes, the leaders did not display a dominant propensity to exercise power and confidence that went beyond self-interest for the good of the group or acted in ways that built others' respect for them, and thus did not conform to the characteristic qualities of a transformational leader, in which leaders provide a vision and develop emotional relationships that go beyond self-interest (Murphy, 2008).
Upon measuring idealized influence behavior, the data reflected that over 75% indicated that the senior managers specified the importance of having a strong sense of purpose and such behaviour was observed 'fairly often'.The item "your senior manager emphasizes the importance of having a collective sense of mission" saw 75.3% indicating that it occurred at least 'fairly often', while 64.3% responded that senior managers considered the moral and ethical consequences of decisions.However, only 47.1% of those surveyed indicated that their senior manager talked about their most important values and beliefs (occasionally).Although senior managers stressed the importance of having a strong sense of purpose and emphasized the importance of having a collective sense of mission, they mostly overlooked consideration of important values and beliefs, such as the lack of communication by the leader to his/her subordinates is therefore inconsistent with transformational leadership (Mafora, 2022).
All the items assessed in the construct 'Inspirational Motivation', indicated that the means were greater than three, indicating that the attribute was observed 'fairly often.'The item "your senior manager expresses confidence that goals will be achieved" received a score of 71.4% indicating that it occurred fairly often while the item "your senior manager talks optimistically about the future" scored 75.7% indicating that the attribute occurred fairly often.
Over 64% responded that the senior manager talked enthusiastically about what needed to be accomplished, and 61.8% revealed that the senior manager articulated a compelling vision of the future (but with a mean of 2.75 which was not high ( = 2.75,  = 1.15).The results show that the senior managers often talked optimistically about the future, enthused about what needed to be accomplished, but articulated less about a compelling vision of the future or confidence in achieving set goals.These results are consistent with the expectation that transformational leaders clearly articulate their vision of the institution and are also consistent with Bennis and Nanus ' (1985) theory that transformational leadership guides and communicates a direction that transforms an institution's culture through values and norms and create an openness and trust in the institution through the strength of moral convictions (Mafora, 2022).
All the items for 'intellectual stimulation' had means close to three indicating that the characteristic occurred 'fairly often.'Over 68% indicated that the senior manager suggests new ways of looking at how to complete specific assignments with a mean of 2.86 not high ( = 2.86,  = 1 .17).Over 65% revealed that the senior manager re-examined critical assumptions to question whether they were appropriate (with a mean of 2.8 ( = 2.8,  = 1 .06),while 61.4% responded that the senior manager sought differing perspectives when solving problems (with a mean of 2.67 was not high ( = 2.67,  = 1.05).Close to 60% felt that the senior manager encouraged others to look at problems from different perspectives, with a mean of 2.56, which was not high ( = 2.56,  = 1 .16).Overall, the means for 'intellectual stimulation' were not high indicating that leadership lacked transformational impetus (Mafora, 2022).
Four items were used to measure 'individual consideration' to determine whether senior managers paid attention to everyone's need for achievement and growth.70% percent indicated that their senior manager acknowledged that every individual had different needs, abilities, and aspirations; while 65.7% responded that senior managers helped others to develop their strengths.However only 45.7% felt that senior managers treated others as individuals rather than just as a member of a group (with a mean of 2.11 which is not high ( = 2.11,  = 1.42) which attributes were observed at least fairly often.However, senior managers often neglected to treat team members as individuals (and just part of a group), which is less consistent with transformational leaders (who seek to promote and encourage the full participation and commitment amongst the followers to be able to better achieve their set goals (Rearick, 2007).Although there is a debate that subordinates need to feel 'part of a group', and that everyone is being treated equally to maximize participation, the overall impression was that respondents merely regarded themselves as 'subordinates' with little influence, rather than the inspired innovators that could potentially have been engendered by transformational leaders (Mafora, 2020).
Table 1 below presents a summary of the descriptive statistics for each dimension of transformational leadership.(Mafora, 2020) Overall, the descriptive characteristics of the transformational leadership construct had an average close to 3 (and the overall mean for transformational leadership was 2.74), indicating that the respondents perceived such leadership behaviour as occurring 'fairly often.'The variation coefficients for each of the transformational leadership attributes were all less than 35% (indicating that there was not much variability).The means for 'idealized influence' and 'idealized influence behaviors' were 2.66 and 2.67 respectively, The findings however suggest that transformational leadership is important for the effective management of the hospital because effective leadership can determine the success of the institution.Also, it assists managers to meet future challenges.Transactional leadership skills should also be developed so that the goals set by the hospital can be reached, while regular staff reviews need to be conducted to assess whether the set goals are being met and to provide feedback on how the hospital is being managed.The critical factor is that managers of the hospital should adopt an appropriate leadership style that is aligned to the values and attitudes of followers to encourage and motivate them to commit to institutional goals for optimum performance.
By becoming conversant with the transformational leadership approach and combining the four aspects of idealized influence, inspirational motivation, individualized consideration and intellectual stimulation, managers can become more effective leaders in the hospital setting.One can also use transformational leadership in one-on-one group situations.Using this approach, the manager and the followers become transformed to improve job performance and assist the hospital to be more successful and productive.Transformational leadership can also complement transactional leadership to improve the health delivery to communities by the district hospital.

Limitations of study
Although several other district hospitals in SA faced service delivery challenges, the research was carried out at the District Hospital in Matlala.

Future research
Future research can be undertaken to evaluate the impact training of specific leadership styles on public health care delivery.