The success of a radical transformation in any complex system requires strong leaders and policy entrepreneurs (champions) as well as solid governance, e.g. planning and policy/decision-making rules and processes, regulation and accountability mechanisms, at all levels of implementation of the proposed changes. To change the education of health professionals is not a mere technical exercise. It is a very political process that takes place in a complex environment; it affects the values, objectives, power and interests of numerous stakeholders. A new model for the education of health professionals supposes major cultural and organizational changes, and it requires important new investments. All this requires a strategic approach to transforming and scaling up, and some form of planning, in terms of clearly defining the expected results, what needs to done to achieve them, how it will be done and with what resources. A plan is certainly useful but far from sufficient: stakeholders must commit and stay committed to implementing it, resources need to be mobilized, and political support maintained. This is where leadership and good governance become critical to progress on education reform, which is “a road strewn with obstacles” (Jolly, Louis and Thomas, 2009).
The leaders who are most needed are those who can grasp the multiple dimensions and interconnections of the components of the transformation and scaling up of education and training, as well as the complex relationships between the various stakeholders. Governance also needs to be adjusted. By this we refer to the formal and informal rules and norms that define roles, responsibilities, and policy and decision mechanisms in a certain sector (Brinkerhoff and Bossert, 2008).
Good governance results from the combination of institutional and organizational mechanisms that support change, and the technical and political capacity and will to conduct change. Often governance in matters relating to the health workforce is concentrated in ministries of health at levels where capacity is weak, as is the case in sub-Saharan Africa, which has the greatest number of countries experiencing a human resources crisis (Nyoni and Gedik, 2012).
Lack of good governance is an open door to ineffectiveness, haphazard and politically motivated decisions, lack of transparency, accountability and corruption. “Smart governance” in health has been defined as governing by collaborating, by engaging citizens/stakeholders, by mixing regulation and persuasion, through independent agencies and expert bodies, and by adaptive policies, resilient structures and foresight (Kickbush, 2012). This is a major departure from top-down, centralized governance based on coercion, and it requires leaders who understand change, who believe in it and who can engage others.