Distributed leadership as an enabler of community participation in primary health care in Malawi

Abstract

Community participation is a foundational principle of primary health care (PHC), yet its meaningful implementation remains limited in many low- and middle-income countries (LMICs), including Malawi. Although formal community governance structures such as Health Advisory Committees (HACs), Village Development Committees (VDCs) and Area Development Committees (ADCs) are recognised in policy, their influence on facility-level decision-making is often constrained by hierarchical leadership arrangements, weak coordination and persistent power asymmetries between health professionals and community representatives. This article examines community participation in Malawi’s PHC system through a distributed leadership (DL) lens and explores how leadership practices can be strengthened to enhance facility-community governance. A narrative review and policy analysis were conducted using National Health Policy documents and relevant literature on PHC governance, community participation and DL in Malawi. Community structures play an important role in representing community interests and monitoring service delivery but largely function in advisory capacities. Leadership authority remains concentrated at facility and district levels, limiting shared ownership. Coordination among health workers, community committees and local government structures is weak, resulting in fragmented leadership and limited accountability for service improvement. The article argues that challenges in community participation are fundamentally leadership challenges. Distributed leadership provides a practical framework for strengthening PHC by promoting shared responsibility, collaboration and accountability across community and facility levels.