Responsible leadership and sustainability performance in health systems: evidence from health and sanitation projects

Purpose This study examines the influence of responsible leadership on the sustainability performance of health and sanitation projects in Uganda. Specifically, the study investigates how ethical decision-making, accountability and transparency, and long-term orientation predict triple bottom line sustainability outcomes (economic, social, and environmental performance). Methodology A cross-sectional quantitative design was employed using data collected from 520 stakeholders across 86 health and sanitation projects in Kampala, Wakiso, and Mukono districts. Data were analyzed using Partial Least Squares Structural Equation Modeling (PLS-SEM) with SmartPLS 4. Findings The findings reveal that responsible leadership significantly and positively influences sustainability performance. Furthermore, ethical decision-making, accountability and transparency, and long-term orientation each independently and positively predict economic, social, and environmental sustainability outcomes. The results underscore the central role of relational leadership behaviors in enhancing project sustainability beyond structural governance mechanisms. Practical implications Practically, the study suggests that policymakers, donors, and implementing agencies should institutionalize responsible leadership competencies within project management systems through training, accountability frameworks, and long-term sustainability planning. Originality This study is original in that it extends responsible and relational leadership theory into the health and sanitation project context in Sub-Saharan Africa, a sector largely overlooked in prior sustainability research. By empirically linking leadership behaviors to triple bottom line outcomes in public health projects, the study provides context-specific evidence for advancing sustainable development in line with global sustainability goals.