Globally, a skilled public health workforce is essential for quality universal health coverage (UHC), which in turn contributes to improved population health (1). In disasters and crises, the public health workforce generates surveillance data with which to develop mitigation strategies and lead programs. The COVID-19 pandemic underscored the importance of public health leaders (2). Countries responded differently to the COVID-19 pandemic which, in part, was due to differing advice given by public health authorities and leaders (3). Public health professionals needed to advise despite limited evidence. Advisories given by public health experts about COVID-19, its transmission, prevention, and mitigation became controversial and were subject to political, media, and public scrutiny (4). Uncertainty resulted in the adoption of different prevention strategies such as lockdowns, in different countries. Uncertainties about therapeutics resulted in confusion (5) and misinformation. When preventive strategies became the focus, vaccine hesitancy (6) became prevalent, signifying mistrust of public health authorities and lack of confidence in their leadership. The aftermath of the pandemic has resulted in reflection about the need for leadership in pandemic preparedness (7) and the critical importance of leadership development (8).

The public health workforce and leaders must be grounded in a broad set of skills to effect Winslow’s seminal definition of public health (9)—“the science and art of preventing disease … promoting health through the organized efforts of society …” Having been trained in the broad range of disciplines—epidemiology, biostatistics, health promotion, environmental health, health economics, and health management—they need to apply these to societal health challenges to protect and promote the health of people. No single individual can have all competencies, and public health professionals and effective leaders need to operate within teams and know their limitations (10).

Leadership skills have long been identified as a core competency for Master of Public Health (MPH) courses in the United States (11). These include skills such as balancing the interests and needs of a multiplicity of stakeholders (11), working in and leading teams and being steeped in the ethos of social justice for decision-making, becoming ‘servant leaders’ (12). However, core leadership skills have not been a feature of postgraduate public health programs in other parts of the world (13), especially in sub-Saharan Africa.

In South Africa, the MPH qualification, introduced by 10 universities over the last three decades (14), is not a professional degree but is recognized as being the avenue for achieving competency in the field of public health practice. For most professionals who complete MPH programs, coursework is determined by university departments offering the degree which are accredited and quality assured by the mandated Council on Higher Education (15). There is no nationally agreed-upon set of public health competencies, course content, or graduate exit-level outcomes in the country. In addition, there is no country-wide association of schools of public health to guide or standardize these elements. In contrast, the European Association of Schools of Public Health (ASPHER) advocates for and updates its competencies for public health professionals (16). In the United States, the Association of Schools and Programs of Public Health (ASPPH) supports its member institutions through the accreditation process by the Council on Education for Public Health (CEPH), which ensures the quality of public health programs (17).

Prior research among University of KwaZulu-Natal (UKZN) MPH graduates found that they obtained report writing, critical analysis, research, leadership, and management skills (18). However, there has been limited educational research on MPH graduates from all South African MPH universities.

Consequently, a consortium of public health academics from eight South African universities conceptualized a large mixed methods study to begin to address these knowledge gaps. The broader study focused on the socio-demographic, educational, and occupational characteristics of the cohort of graduates, their motivations, career paths, perceptions of the curriculum, the utility of the degree, and its contribution to their professional and personal development. This study, which was nested in the broader research program, aimed to examine the motivations of the 2012–2016 cohort of MPH graduates for undertaking the MPH, the utility of the degree at work and in society and its contribution to their leadership skills. The study contributes to the discourse on curriculum reforms for leadership and the World Health Organization (WHO) articulated set of essential public health functions (EPHFs) (19).

We identified all eight South African universities who graduated MPH students between 2012 and 2016 with academics from public health departments formed a consortium for this study. The institutions were Sefako Makgatho Health Sciences University (SMU), the University of Cape Town (UCT), UKZN, University of Limpopo (UL), University of Pretoria (UP), University of Venda (Univen), University of the Western Cape (UWC), and the University of the Witwatersrand (Wits). Alumni from SMU and UL were merged in the dataset as over this time these institutions became a single university—UL—with the same curriculum although teaching was at two campuses in different towns. Each university identified alumni’s names and, where possible, their contact details.

A cross-sectional online survey among alumni graduating between 2012 and 2016 from all eight South African universities was conducted. We had planned to conduct the research in 2020 but delays due to the COVID-19 pandemic meant that the study was executed between 2022 and 2023. The selection of the 2012–2016 cohort allowed for a minimum of 6 years of work experience post-qualification by which time alumni would have had time to settle into and reflect on their work. The survey consisted of closed-ended questions in the form of Likert scales and open-ended questions where respondents could comment freely.

Respondents were alumni from seven universities who graduated MPHs between 2012 and 2016. From Table 2, this graduate cohort was a mid-career group of alumni, with a mean age of 35, who had a mean 8.2 (CI: 7.9–8.3) years’ work experience in public health post-MPH graduation. There were more women (57.5%) than men (41.6%). Most (53.2%) were South African, and less than 4% (3.5%; CI: 1.8–7.1%) came from outside Africa. Nearly two-thirds (65.4%; CI: 58.6–71.6%) had an undergraduate training in health. Post-graduation, respondents worked mostly as health service managers (40.7%; CI: 33.5–48.3%), in research or as academics (19,8%; CI: 14.4–26.5%), in health promotion (12.2%), or health policymaking (8.7%). Nearly one-third (31.0%) were employed by international or country-based non-governmental organizations (NGOs); over a quarter (27.0%) in government run health services; one-fifth (21,3%) by academic or research organizations; and 12.1% in hospital settlings. Respondents did not differ significantly from all MPH graduates from these universities over the same period by age, gender, or origin—South African compared to international students.

This research, the first known from South African and African universities with MPH programs, explored graduates’ motivations for undertaking the MPH, their leadership skills and their perceived impact of public health skills in their workplace in four domains—management, academic, advocacy, and social responsiveness as well as their impact in society, and the contribution of the MPH to these (20).

This set of graduates, mostly in their mid-30s from sub-Saharan Africa, with undergraduate training largely as health professionals, was motivated to complete the MPH to improve their career prospects and skills sets, promoting their personal development for senior management and leadership roles. They took on roles as health managers—both in program and line management, in research and as academics, and in health promotion and policy work. These findings are similar to two South African studies that explored the motivations of applicants for MPH studies (21) and a graduate survey of doctors who completed an MPH (22). The former highlighted that applicants wanted to do an MPH to acquire knowledge about public health promotion and prevention, acquiring skills to become public health practitioners, and the latter found that they wanted to transition from clinical to management or academic work, believing that the MPH opened career opportunities.

The focus on developing skills that enabled career advancement highlighted in this study may be due to this cohort of graduates having on average nine pre-MPH work years and a mean of eight post-MPH work experience, a total of 17 years, giving them time for reflection, interpreting the meaning and role of the MPH in their careers.

Overwhelmingly, respondents were confident using most leadership skills (81%) which were required at work (78%). Yet, just half were obtained through the MPH, implying that leadership skills needed to be obtained elsewhere. Indeed, following the COVID-19 pandemic, a review of accredited MPH programs in the United States found that leadership training was found to be sorely lacking (23) and the importance of leadership competency has been highlighted for European programs (24). In this study, the only group who scored differently worked as researchers who scored leadership skills significantly lower by their confidence to exercise these, being needed at work, and being obtained from the MPH.

Motivations for undertaking the MPH were congruent with their self-assessed impacts and over three-quarters of alumni were involved in activities in public health domains such as management—particularly in policy development, in academic functions, advocacy, and social responsiveness at work and in society. Nonetheless, some academic activities such as publishing in a book (relevant for 45%), raising a grant (relevant for 66%) and teaching (relevant for 70%) scored low. These activities are primarily undertaken by senior academics, so it is not surprising that many had not engaged in them or rated that the MPH contributed substantially to these. Nonetheless, research skills, such as proposal writing, were used by close to 90% of respondents who rated the MPH as having a large contribution (78%) to these skills.

Overall, the MPH contributed to respondents’ impact in all domains. Some skills learnt in the MPH were rated highly, such as working in high level committees which suggests alumni’s leadership roles. There were some differences among respondents by educational background and roles at work, particularly those who had a pure science background or worked as researchers. Significantly larger proportions of these respondents rated that they did not perform many activities associated with social responsiveness at work or impact in society, suggesting that larger proportions of these respondents performed defined technical roles. However, those scientists involved in these activities scored the MPH’s contribution significantly higher to their ability to make contributions beyond the workplace. Conversely, researchers scored the MPH lower in enabling them to work intersectionally.

Leadership skills probed and those impacting on workplaces include those that are core to respondents’ job descriptions as well as activities initiated independently. For example, program managers were more confident using leadership skills suggesting that their work required them to lead teams and make decisions.

Contributions in the four impact domains also depended on the jobs they assumed. For example, only 20% were employed as academics and researchers, and consequently, it is not surprising that high level academic roles such as grant writing and book publishing were important for a minority. While research skills are core to the MPH and producing a research report is required for the degree., the majority presented at conferences which suggests personal agency and confidence.

Roles listed under management practices demonstrate that most graduates participated in decision-making, contributed to generating evidence for policy and decision-makers. They participated in high level committees and policymaking—evidence for their senior managerial roles. Those with backgrounds in non-patient-facing health training and those working in health promotion scored the MPH higher for enabling them to create evidence for decision-making/policymaking at a higher level and making recommendations on population needs/participation in high level committees, respectively. While the majority took on advocacy roles, two-thirds of the specified items are specific to job-descriptions such as health promotion and two—working intersectionally and with social determinants of health—could span a range of managerial or technical roles. These latter two complex roles, involving a range of stakeholders, require social strategy and interpersonal skills, a hallmark of public health leaders (11).

Most impacts, given under social responsiveness, speak to agency to improve work environments—working with teams to create environments conducive to productive work. Their impacts in society point to their agency to effect changes in the broader society. Again, close on 80% rated that they were change agents beyond their workplace—participating in other organizations and interventions toward social justice and equity, values that are core to ‘servant leadership’ (12). Some activities such as promoting an understanding of public health in society and changes to regulations indicate that they took on innovative roles at a high level in organizations, as leaders.

The MPH in South Africa was initially intended to produce a workforce to improve health status and healthcare in the region (25). While universities offer a heterogenous range of MPH tracks, most require completion of core courses that include public health foundational domains such as epidemiology, health systems and policy, and social and behavioral sciences. Some programs explicitly intend to prepare professionals to take on leadership roles (26–28), and others focus on acquiring skills to make a contribution to health systems (29, 30). Some offer health management courses, but none offer dedicated courses focused on leadership. Instead, some university public or global health departments offer post-graduate diplomas in health management and leadership believing that health leaders require exposure to a range of management skills and experiential learning to enable the navigation of complex health systems (31–33).

Nonetheless, graduates participated in policy processes and contributed to social responsibility, which implies an engagement in leadership roles. Their roles in complex work and societal settings indicate that these skills were acquired despite not being explicitly taught in the MPH. Many may have been acquired elsewhere and experientially over time, which is possible given that graduates had approximately 16 years’ work experience prior to completing the survey.

This mid-career cohort of MPH graduates reported that they used leadership skills and had an impact at work and in society which was in part due to skills obtained through the MPH. Public health professionals require a keen analysis of context-specific disease burdens, their determinants, and competencies to determine how best to manage these in the short, medium, and longer term. This requires a recognition of one’s limitations (11), of other team members’ strengths and an appreciation of the importance of transparent processes. In addition, in crises, evidenced by the COVID-19 pandemic, leaders require excellent communication, collaboration, and critical decision-amidst considerations of social justice and equity (34). Health system leaders and decision-makers require astute health managers and public health trained experts to weigh in and advise. These experts, in turn, must be supported by technical staff who can generate information from a range of sources.

While public leadership skills are not the focus of many MPH programs in South Africa, they are clearly needed. In view of the growing number of MPH programs and the increasing numbers of graduates who, through the MPH, intend advancing careers, MPH programs should place a greater emphasis on preparing MPH graduates for leading teams and playing key roles in health systems leadership, which is echoed elsewhere (23, 24). These skills need to be purposefully introduced and could be integrated into MPH courses through, for example, students reflecting on their experiences and roles in projects through both formative and summative assessments.

MPH program reviews are timely and need to adapt to a post-COVID-19 world. Given that the MPH is largely the degree for public health work in LMICs, programs need to produce a workforce that is ‘fit for purpose’. This requires an alignment of education objectives with workforce systems in country contexts so that the transition between being a learner and worker is seamless (19). In some Asian country settings, there is advocacy for public health educational frameworks to include communication, leadership, and management skills as well as analytical, policy, and planning skills for country settings (35–37). In South Africa, consideration needs to be given for the formation of an association of a national schools of public health, who can engage with the range of employers about required competencies.

Such initiatives align with the ambitious World Health Organization (WHO) roadmap project, which, responding to the dearth of public health personnel globally, aims to embed the public health workforce (38) in country health systems (39). Their detailed project report (19) identified 20 competencies in six domains—community-centeredness, decision-making, communication, collaboration, evidence-informed practice, and personal conduct for public health practice, which are patently the skill sets of health leaders. The translation and application of the WHO Roadmap project into country health systems requires bold leadership; an appreciation of country-specific disease burdens and health systems; and maps of diverse public health actors. This must comprise the full range of public health professionals, their professional organizations, training organizations, employers, and certifying institutions (40). This project requires trusting intentional collaboration among this range of actors who need to clearly articulate shared goals. They must be credible public health leaders, who develop strategies and transparently operationalize plans to reform educational programs and robust health systems able to deliver essential public health functions.