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Addressing Low-Value Care Among Healthcare Workers in Africa

Posted May 1, 2026  |   By Alfred Tumwesigye   |   Uganda

The rising burden of low-value care (LVC) in Africa is a dual threat, characterised by medically unnecessary tests, prescriptions, and surgeries. This results in both patient harm and resource depletion. This article argues that systemic leadership and management challenges in the public and private sectors drive LVC. Through a synthesis of current literature, the study identifies how clinician behaviour, patient expectations, and institutional frameworks interact to perpetuate LVC. To address these issues, the paper applies John Kotter’s 8-Step Change Model, contending that professional competence alone cannot drive reform. The core argument is that only a structured change methodology fosters accountability, alignment, and long-term sustainability. Findings show that merging ethical clinical practice with change management principles can reduce LVC, conserve scarce resources, and improve health equity. The article specifically explains how healthcare leaders can apply Kotter’s principles to reduce LVC and improve public health outcomes.

Africa’s healthcare landscape is a fragmented mix of public, private, and traditional providers. This fragmentation is worsened by instability, corruption, and unequal out-of-pocket costs. As Konde-Lule et al. note, care quality is inconsistent; informal private providers often deliver sub-standard services. The health system faces key systemic crises: severe staffing shortages, chronic medicine scarcity, and growing commercialisation. These issues drive “double exclusion”: the wealthy leave the public sector, while the poor cannot afford private care.

Watt and Graham state that commercialisation drains resources, neglects staff training, and puts profit over patient needs. Market pressures reward those who can pay, not those needing care, which leads to ruinous costs for the vulnerable and unnecessary treatments for the ‘worried well.’ This split deepens social divides, leaving the poor out and the wealthy disengaged. Experts urge leaders to mentor, build teams, and connect care with community values. Ciulla defines leadership as a moral partnership with a shared vision; transformative leaders help people lift themselves and their communities.

Africa’s healthcare crisis is made worse by commercialisation and double exclusion. A sustainable solution does not lie only in resource allocation. Instead, it requires a leadership model that values mentorship. This model should align clinical delivery with community values. Using Kotter’s change principles can help build equitable care. True healthcare reform in Africa demands a shift from profit-driven management. It calls for value-based mentorship, long-term equity, and strong system resilience. 

Addressing Low-Value Care within African Healthcare Systems: A Leadership Imperative

To improve health outcomes across the continent, healthcare administrators in Africa must focus on reducing low-value care (LVC). LVC includes medical interventions that offer little patient benefit, risk harm, or waste resources. LVC is a major barrier to a strong health system.

Evidence shows that LVC increases patient risk and financial instability. Zadro and Maher group the drivers of LVC into three categories:

  • Systemic Factors: Fee-for-service reimbursement models. High out-of-pocket expenditure. Pharmaceutical industry influence. Defensive medicine is aimed at avoiding litigation risks.
  • Epistemological Factors: Methodological flaws in medical reporting. Biased research outputs. Industry-aligned medical curricula.
  • Sociocultural Factors: The “more is better” thinking in clinical care. Over-reliance on new technologies. Patient demands are often based on health misinformation.

LVC leads to longer wait times, increased provider absenteeism, and reduced trust between patients and providers. In Uganda, out-of-pocket spending is 41% of health costs. That is much higher than government spending at 15% and voluntary insurance at 2.3%. These regressive systems put health care out of reach for the poor.

LVC in Africa is rooted in history, politics, and economic instability. These problems have caused system failures, including chronic underfunding, supply chain disruptions, and the deterioration of rural infrastructure. Weak governance and slow progress with digital health also make things worse. Human resource gaps are a main problem. Staff often do not want to work in remote areas, which hurts the use of primary care and overall public health.

To eliminate LVC, management must move to leadership that follows an “ethic of responsibility.” Keohane says this requires a “devotion to a cause,” or putting systemic integrity first. Such leadership is needed to fix health setbacks from past social and economic problems. Responsible, moral leadership and the setting of clinical goals are crucial for the transition to high-value, fair health care across Africa.

Leadership with Moral Vision: Doing What Works

Addressing LVC needs multiple strategies, but the main one is to have leaders and managers who act responsibly. Keohane calls this steady devotion to a higher purpose, not just personal gain. Such leadership is critical to overcoming political, social, and economic setbacks, especially in Africa. Responsible leaders with strong morals are needed to deliver high-value care everywhere.

Leadership without morality is incomplete; we need leadership driven by mission. Adindu notes that people are at the core of health services—managers, health workers, and clients. Every health worker, from executives to frontline staff, has a moral duty to use solid management: set clear objectives, plan well, and use resources wisely to meet client needs in local settings.

Building good teams takes firm, tactful, and broad leadership. Pope Francis says leaders should “heal wounds and warm the hearts.” Gini and Green add that leadership is about interaction. Kotter’s eight steps help health leaders prepare new leaders to fix system problems.

Many in Africa cannot get good care because of poverty, joblessness, and unfair systems. This leads to worse health and lower life expectancy. We cannot ignore the realities of disease and insecurity.

Jim Collins says, “Breakthrough results come from a series of good decisions, well executed.” To improve health in Africa, we need a systematic, change-focused approach. This means using technical and business models to make the most of scarce resources. Health leaders have to balance technical management—like policy and planning—with the moral call to reduce health inequality.

To reduce LVC, leaders must ensure everyone understands their roles, from top managers to local staff. By promoting shared vision, teamwork, and sound decision-making, we can inspire excellence and navigate change to improve health.

The Value of Strategic Visioning: Integrating Ubuntu Ethics and Change Management

The future of healthcare requires a deep reconsideration of current social and systemic challenges. Discussion about these problems often sparks urgent action, which is vital for inspiring change. At the centre of this vision is Ubuntu ethics—a community-based mindset where people rely on and care for each other and the wider world. This means placing solidarity, kindness, and dignity at the forefront, and tying morality to the good of the community.

This relational ontology aligns significantly with specific stages of Kotter’s 8-Step Process for Leading Change. Specifically, Step 2 (Building a Guiding Coalition) and Step 4 (Enlisting a Volunteer Army) mirror the African value system’s emphasis on communalism and kinship as primary ethical guideposts. In Step 2, Kotter International Inc. argues that a “volunteer network needs a coalition of committed people—born of its own ranks—to guide, coordinate, and communicate its activities.” In a healthcare context, such coalitions should comprise multidisciplinary representatives from across the continuum of care to synthesise organisational data into innovative operational models.

The Ubuntu philosophy posits that human existence is fundamentally communal; survival and flourishing depend on reciprocal relationships. Consequently, a guiding coalition must demonstrate a steadfast commitment to institutional change, characterised by an ability to operate across various organisational functions with mutual respect and vigour. As noted by Prosci, large-scale transformation is only achievable when a significant number of individuals unite around a common opportunity.

By systematically applying Kotter’s Change Management Model, healthcare administrators can implement reforms that not only improve clinical outcomes but also empower “the voices of the voiceless.” This dual approach—marrying Western strategic execution with the Ubuntu-based ethic of care—demands a leadership style characterised by mentorship rather than autocratic control. Such leaders serve as ethical models, utilising these integrated tools to transform systemic uncertainty into sustainable, high-value care across the African continent.

Conclusion

The prevalence of low-value care in health systems worldwide results in significant resource waste and patient harm, with those in peripheral areas often bearing the brunt of non-evidence-based practices. Combating this requires a collaborative approach involving clinicians, professional organisations, funders, and policymakers. By leveraging Kotter’s framework for change, health authorities must reform service delivery to enhance access to high-value care, reduce financial burdens on patients, and mitigate risks. Although public-private partnerships have demonstrated success in enhancing coordination, a persistent challenge is reconciling these collaborations with health workers’ desire for professional autonomy. In conclusion, effective leadership is crucial to navigating these challenges and ensuring that, regardless of ownership, health systems are geared toward improvement and accountability.

References

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