The Covid-19 pandemic has significantly influenced Brazil’s private and governmental healthcare systems. The implemented management approaches were inadequate, leading professionals to experience extreme fatigue. Technology and innovation played a crucial role in addressing this situation. The World Health Organization (WHO) published a study outlining thirteen major global health concerns exposed when COVID-19 put the world’s healthcare systems to the test. Within a short period, we saw the rapid deterioration of public health, the global economy, and the psychological well-being of healthcare workers at the forefront of the battle against the epidemic.

At the time of writing this piece, an estimated 34.6 million individuals had contracted the infection, and the number of fatalities stood at 685 thousand. The inadequate effectiveness of government actions worsened the situation, leaving limited room for evidence-based technical choices and recurrent crises in pandemic management, leading to a sense of uneasiness among the Brazilian populace.

According to the OECD (2021) , households and enterprises in the private sector spent around R$216.97 billion (US$37.6 billion) on healthcare plans and hospitals in 2020, while private expenditures amounted to BRL 171.50 billion (US$29.7 billion).

Brazil’s public health care system’s inadequate performance has increasingly prompted middle-income and high-income families to choose private treatment. Furthermore, the private healthcare system is optional. It might be considered redundant since it provides coverage for essential curative therapies that are also covered by the SUS compared to other OECD nations (OECD, 2021) .

In 2020, Brazil had around 507,000 hospital beds, which translates to a ratio of 2.3 beds per 1000 people. This fact is almost half the average number of hospital beds per 1000 population in OECD countries. However, the density of beds is comparable to that of some European nations like Denmark (2.6), the United Kingdom (2.5), and Sweden (2.1), and higher than that of other countries in Latin America, such as Chile (2.0), Colombia (1.7), or Costa Rica (1.1). Like other OECD nations, Brazil also experiences fluctuation in the availability of beds across different regions. At the state level, the number of hospital beds per 1,000 people varies by a factor of 2, with the lowest density of 1.5 beds in the Northern state of Amapá and the highest density of 2.9 beds in the Southern state of Rio Grande do Sul (OECD, 2021) .

In 2020, Brazil had around 507,000 hospital beds, which translates to a ratio of 2.3 beds per 1000 people. This fact is almost half the average number of hospital beds per 1000 population in OECD countries. However, the density of beds is comparable to that of some European nations like Denmark (2.6), the United Kingdom (2.5), and Sweden (2.1), and higher than that of other countries in Latin America, such as Chile (2.0), Colombia (1.7), or Costa Rica (1.1). Like other OECD nations, Brazil also experiences fluctuation in the availability of beds across different regions. At the state level, the number of hospital beds per 1,000 people varies by a factor of 2, with the lowest density of 1.5 beds in the Northern state of Amapá and the highest density of 2.9 beds in the Southern state of Rio Grande do Sul (OECD, 2021) .

In 2020, around 22 percent of the Brazilian population, equivalent to 47 million individuals, opted for voluntary medical insurance to supplement their existing healthcare coverage provided by the SUS. This figure represents a decrease from the 25 percent recorded in 2014 (ANS, 2020) . Over 700 companies and insurers provide this coverage (ANS, 2020) .

In 2020, the number of individuals benefiting from private healthcare plans, including dental coverage, rebounded after a decline in 2019. The total number of beneficiaries reached 47.62 million, indicating a 1.24 percent rise compared to the previous year. Furthermore, the number of beneficiaries saw a positive growth rate that exceeded 2 percent (ANS, 2020) .

Although Brazil’s total healthcare expenditures surpass those of many comparable nations, the country significantly depends on funding from the private sector, either via voluntary private health insurance or direct payments made by families (OECD, 2021; WHO, 2020) .

Most private health plans are employer-based group policies included in employment contracts, with employers making payments. However, other options exist for individuals or collective insurance (Thomson, Sagan, & Mossialos, 2020) .

The demographic phenomenon of population aging is a contributing factor to the rise in healthcare expenditures. According to demographic forecasts from the Brazilian Institute of Geography and Statistics (IBGE), the percentage of older individuals aged 65 and over in the Brazilian population will continue to climb by more than 8 percent in the coming years. In 2020, the proportion of older people in the Brazilian population aged 60 and above was 10.13 percent. Projections suggest that this proportion would increase to 13.44 percent in 2030, 17.58 percent in 2040, and 26.77 percent in 2060 (IBGE, 2020) .

The demographic transition will result in a rise in both the prevalence of chronic conditions like diabetes and the number of individuals requiring long-term care. These individuals will need assistance carrying out daily activities and acquiring essential life skills (IBGE, 2020) .

Like in OECD nations, the healthcare system in Brazil encounters several issues that may impact the long-term sustainability of healthcare expenditure. On the other hand, the administration of healthcare initiatives is very intricate (Aubry et al., 2014) . It extends beyond planning and overseeing the building or renovation of existing locations. Additionally, it entails reassessing the administration of medical treatment. The issues include service process rearrangement, information technology, human competency development, and change management (Richer et al., 2013) . Organizational project management is a modern kind that involves using flexible organizational structures to carry out strategic goals via projects to optimize value (Aubry et al., 2007) . Therefore, we address the following research question: What is the relationship between project management success and leadership variables in the Brazilian Private Healthcare System? Justification: Leadership is essential for motivating followers and mobilizing resources to fulfill its mission; it is also necessary for innovation, adaptation, and performance (Crossan & Apaydin, 2010; House, Spangler, & Woycke, 1991; Jones & Olken, 2005; Waldman & Yammarino, 1999; Yukl, 2008) .

The investigation of leadership and project management achievement aligns with the research goals. The questionnaire, as presented in Appendix A, included the LPI and PMS scales. The desire to comprehend the factors that contribute to the success of a leader is not a recent phenomenon. Throughout history, there has been an ongoing discussion over the distinguishing factors between those who assume leadership roles and those who do not, as well as the disparities between leaders and followers. Upon closer examination of this progression, albeit not exhaustive, it is feasible to assess theories up to Transformational Leadership. This research examined the crucial role of leadership and its impact on project management’s effectiveness in Brazil’s private healthcare system.

Their comparison focused on leadership and project management. Urli and Urli (2000) found that from 1987 to 1996, fewer than 0.5% of all project management studies published included an examination of leadership. This fact is particularly astonishing considering the regularity with which project manager leadership traits are included in compilations of critical success factors (CSF) for project success. Furthermore, Pinney (2002) proposed that the limited research attention given to project leadership in this field may be attributed to the perception that project management is predominantly seen as a conventional management field that emphasizes methods and techniques rather than being approached from a social sciences perspective. Although there has been a lack of attention in the literature, recent years have seen an increase in the examination of project leadership (Dias et al., 2022; Kloppenborg & Opfer, 2002) .

Organizations are undergoing significant transformations due to the perpetual need for innovation, fierce global rivalry, economic constraints, and shifting demographics. Consequently, several conventional leadership responsibilities and positions are undergoing significant changes. Extensive studies spanning decades have uncovered a multitude of behaviors in leaders and managers (Bass, 1990; Yukl, 2008) . A well-known difference in early leadership literature is the differentiation between task-oriented and relationship-oriented behaviors (Blake & Mouton, 1964; Fleishman, 1953; Ekvall & Arvonen, 1991; Yukl, 2008) . Task-oriented behaviors are more effective in increasing efficiency, change-oriented behaviors are more pragmatic in promoting adaptability, and relationship-oriented behaviors are more beneficial in bolstering human resources and interpersonal connections. A transformational leader is an individual who motivates and empowers their people to attain exceptional outcomes (Robbins & Coulter, 2007) . According to Warrilow (2012) , the transformational leadership style consists of four components: 1) Charisma or idealized influence, 2) Inspirational motivation, 3) Intellectual stimulation, and 4) Personal and individual attention. Transformational leadership is distinct from Transactional leadership since the latter is based on a system of exchanges between the leader and followers, where followers are rewarded for achieving specific objectives or performance standards (Trottier, Van Wart, & Wang, 2008) . Transactional leadership in businesses allows managers and subordinates to engage in a reciprocal exchange (Jung, 2001) . Furthermore, it is recognized that there is an interchange of incentives and objectives between personnel and management (Howell & Avolio, 1993) . Transactional leadership is a leadership style where followers are driven by incentives, as discussed by Bass and Avolio (1990) , Bass (1990) , and Burns (1978) .

The research shows that a wide range of theories, frameworks, and survey instruments have been used to study project management leadership (Pan, 2022; Jiang, Klein, & Chen, 2001; Lewis, 2005) . The research on project leadership models is significant due to the documented correlation between leadership and project results. Nevertheless, there needs to be more understanding of the correlation between distinct leadership characteristics and their impact on project results. Furthermore, no all-encompassing model has been created for the healthcare system to explain these behaviors. This study utilizes a Leadership Practices Inventory (LPI) tool to investigate the connection between project manager behaviors and project performance. It improves upon earlier research by examining particular leadership behaviors.

The questionnaire was created to cover the Leadership Practices Inventory (LPI) survey instrument established by Posner and Kouzes in 1988. The formulation of LPI used a combination of qualitative and quantitative research methodologies, including triangulation. Kouzes and Posner used comprehensive interviews and case studies of “personal-best leadership experiences” to construct the model’s conceptual framework. The model categorizes its observations of leader practices into five distinct kinds of leadership behaviors: 1) Modeling the Way; 2) Inspiring a Shared Vision; 3) Challenging the Process; 4) Enabling Others to Act (EOA); 5) Encouraging the Heart (Posner & Kouzes, 1988) . Finally, Zagorsek, Stough and Jaklic (2006) suggested that LPI is suitable for assessing low—to midlevel leadership abilities, but it is less trustworthy for evaluating high-quality leaders or for training purposes.

Project Management Success (PMS) has been the focus of scholarly research in recent decades. Scholars such as De Wit (1988) , Shenhar & Dvir (2007) , Cooke-Davies (2002) , Zwikael & Smyrk (2012) , Serra & Kunc (2015) , have all contributed to this field of study. Furthermore, PMS aligns well with the research goals since this study included internal and external project success criteria. The references used are Freeman & Beale (1992) , O’Brochta (2002) , and Shenhar and Dvir (2007) . De Wit (1988) states that PMS is assessed by evaluating criteria that include conventional metrics, cost, time, and quality, sometimes called the triple constraint. Pinto & Slevin (1988) and De Wit (1988) argue that the traditional approach of evaluating project performance solely based on the triple constraint is no longer sufficient. They advocate for a more holistic method that takes into account project goals. De Wit (1988) further expands on this, introducing additional measures of success, such as client satisfaction, functionality, contractor contentment, project manager and team happiness, and adherence to budget and deadlines. Alternatively, Pocock et al. (1996) propose considering legal factors, such as the absence of legal issues in projects. This shift in perspective underscores the evolving nature of project management and the need for a more comprehensive approach to project success evaluation.

Atkinson (1999) presents a classification for assessing project success based on various criteria, including the iron triangle, information systems, benefits for the organization, and stakeholder benefits. Shenhar and Dvir (2007) attempt to categorize success metrics into groups. Projects inside companies are often integrated into their strategic management and must be assessed according to their impact on the desired outcome. The authors propose a multifaceted method to ensure the success of the initiatives, which aligns with the company’s strategic goal and commercial objectives. The authors propose evaluating the project’s short- and long-term success by considering five categories: efficiency, customer impact, influence on the team, business, direct hit, and preparedness for the future.

The concept of Project Management Success (PMS), as defined by Zwikael and Smyrk (2012) and Serra and Kunc (2015) , was a key focus of Ul Musawir’s (2017) examination. PMS, considered the primary variable in this research, plays a crucial role in creating advantages and value for companies. It encompasses the project’s outputs at the end of the project, the project’s outcomes in the months following its completion, and the project’s long-term impact in the years after its completion (Turner et al., 2009) . This study integrates the conceptual framework provided by De Wit (1988) , Turner et al. (2009) , Shenhar & Dvir, 2007 ; Cooke-Davies, 2002 into the concept of “Project Success”. The concept of “Project Success” in this study, derived from the works of Zwikael and Smyrk (2012) and Serra and Kunc (2015) , is defined and evaluated as the dependent variable. The value of the project is determined by its adherence to cost, time, and scope requirements, as well as its ability to meet customer needs and expectations. The project’s alignment with the parent organization’s strategy and return on investment also contributes to its overall value (Thomas & Mullaly, 2008) .

H1a: Impact Team (ITM) predicts Challenging the process (CHP), i.e., a significant causal relationship exists between ITM and CHP.

H2a: Impact on the organization (IOO) predicts inspired a shared vision (ISV), i.e., a significant causal relationship exists between IOO and ISV.

H3a: Impact on the organization (IOO) predicts enabling others to act (EOA); i.e., a significant causal relationship exists between IOO and EOA.

H4a: Impact on the Future (IOF) predicts Challenging the process (CHP), i.e., a significant causal relationship exists between Impact on the Future (IOF) and challenging the process (CHP).

H5a: Customer Impact (CUI) predicts enabling others to act (EOA), i.e., a significant causal relationship exists between CUI and EOA, as illustrated in Figure 1 :

First, a combination of convenient and snowball samples was used in the pre-test with 40 respondents and 77% of responses. After adjustments, the strategy adopted is random, based on a population of 215,000 employees in 130 private hospitals in Brazil. The research questionnaire was pre-tested with nine academics and 22 practitioners for face and content validation and then applied to the selected sample. After validation and content testing, the questionnaires were reviewed and distributed for data and information collection in both Portuguese and English languages. The electronic survey invitation was sent via e-mail to 303 leaders from 130 private hospitals from the National Association of Private Hospitals, with a 72 percent tax response (218 respondents). The raw data were collected from April to June 2022 through Google Forms^®. All members of the study population pool had their identities preserved for ethical purposes.

Data collection was carried out through the researcher’s professional network in the Private Healthcare System in Brazil and with the support of ANHAP (National Association of Private Hospitals), illustrated in Figure 2 .

Based on their current activities and roles, a total of 46 project team, 22 functional project manager, 112 project manager, and 38 project clients in the healthcare system were identified and invited to participate via a link made available from the Google Forms platform. The questionnaire measured variables on five-point and ten-point Likert scales. In addition, the questionnaire has 68 questions, one open, three ethnographic questions, seven multiple-choice questions, 2 questions 7-point Likert, 25 questions 5-point Likert, and 30 questions 10-point Likert. The respondents were invited by e-mail with a 72 percent tax response (303 e-mails were sent with 218 respondents). Finally, all questions in the survey were mandatory.

In order to select the appropriate statistical method for data analysis, the following procedures were adopted: 1) identification of the type of variable to be analyzed; 2) analysis of data distribution through the histogram; 3) analysis of the data distribution through the quantile-quantile graph (QQ-Plot) and; 4) verification if the data are normally distributed using the Shapiro-Wilk normality test. Once it was identified that the data did not have a normal distribution, the Spearman Correlation and Chi-Square Test methods were used to assess the association between the variables.

The study contributes to consolidating theories and concepts and has developed a theoretical framework that can be explored in future research to explain the relationships between transformational leadership practices in project management and measures of project success.

It has been demonstrated that individuals charged with managing, directing, or championing projects or project work must be aware of the importance of providing leadership to achieve successful outcomes. Although the literature has emphasized this importance in the past, in practice, the strong correlations have mainly been on leadership issues regarding:

1) Leader’s experiment, take risks and see setbacks as learning opportunities for themselves and their team.

2) Leaders passionately believe they can make a difference in their environment, and bring their visions to life and make people see exciting possibilities beyond the horizon.

3) Leaders make people feel like winners by appreciating and valuing team contributions and creating a sense of community by celebrating wins.

4) Leaders clear the objectives that must be pursued, creating standards of excellence and being an example for others.

The strong relationship observed between leadership and success suggests that organizations select, train, and challenge their project leaders to Model the Way, Inspire a Shared Vision, Challenge the Process and Encourage the Heart of their peers, subordinates, customers, and managers. This may require integrating people and communication enablers and more project management training, professional certification criteria, and methodologies.

The findings can be used to implement new human resources policies to achieve better goals, select leaders and use best practices in project management.

Replication of this survey for a larger sample is recommended to validate or refute these results. A more extensive selection would increase statistical validity and, more importantly, allow model building and testing. Other internal factors may include scope and other project-oriented metrics. In addition, external measures of stakeholder perceptions can be designed to capture the perceived benefits of specific project stakeholders, including team members, project managers, project sponsors, senior management, and the customer. Breaking down the leadership construct into specific leader roles or stakeholder perspectives can be an essential step towards better modeling the dynamics of the project’s leadership-success relationship and is recommended as a topic for future research.