Leadership Roles of Public Health Nurses in Strengthening Local Health Systems in Low- and Middle-Income Countries: A Systematic Review and Thematic Synthesis

Public health nurses represent a critical component of health systems in low- and middle-income countries, yet their leadership contributions to local health system strengthening remain insufficiently synthesized. While existing research acknowledges the importance of leadership in improving service delivery and system resilience, evidence on the specific roles, competencies, and impacts of public health nurse leadership is fragmented. This systematic review aimed to synthesize empirical evidence on the leadership roles of public health nurses in strengthening local health systems across low- and middle-income countries. Following PRISMA 2020 guidelines and a prospectively registered protocol (PROSPERO CRD420251135472), comprehensive searches were conducted across eleven electronic databases and relevant grey literature sources for studies published between 2015 and 2025. Twenty-four studies from eighteen countries involving 3,456 public health nurses met the inclusion criteria. Data were thematically synthesized and mapped to the World Health Organization health system building blocks, with methodological quality assessed using standardized appraisal tools. Five core leadership domains emerged: clinical, administrative, policy, community, and educational leadership. Community leadership demonstrated the strongest and most consistent evidence, while clinical, administrative, and educational leadership showed moderate certainty. Public health nurse leadership was associated with improved service delivery, strengthened workforce capacity, enhanced community engagement, and increased system resilience, particularly during public health emergencies. Key barriers included inadequate leadership training, resource constraints, and restrictive organizational hierarchies, whereas mentorship, supportive supervision, and policy recognition facilitated leadership effectiveness. In conclusion, public health nurses enact multifaceted leadership that substantially contributes to local health system performance and resilience in low-resource settings. Strengthening leadership development, institutional recognition, and supportive policy environments is essential to fully harness the potential of public health nurse leadership for sustainable health system strengthening.