There is a close connection between hospital capacity and the quality of services given to patients. As hospital capacity strains during important events, such as epidemics and pandemics, the service quality of a hospital profoundly strains and thus results in a mismatch between supply and demand on any resources concerning beds, nurses, physicians, and equipment. Hospital capacity strain impacts not only the quality of care and service in hospitals but also the well-being of clinical staff and teams and their ability to do their job ( Arogyaswamy et al., 2021 ). For example, as the number of arriving patients’ peaks, the ability to expand services and beds is critical ( Mahendradhata et al., 2021 ). Similarly, medical supplies for hospitalized patients are essential ( Mahendradhata et al., 2021 ).

As for the quality and services, unfortunately, African countries have weaknesses in their health systems, which do not allow them to reduce the burden of diseases. The common challenges included a lack of good leadership, governance, medical products, and a healthy workforce ( Othieno et al., 2013 ). The health institutions deteriorated because of inadequate leadership and management, variations in poor-quality care, and inefficiencies. Somalia is one of these countries that have a poor health care system. In Somalia, most managers of the health sector were doctors and nurses who had no specific management training system during their university studies.

The purpose of this research is to investigate the capacity of hospitals and the impacts of leadership on service delivery in the health sector in Mogadishu, Somalia. The first objective was to assess the capacity of three hospitals in Mogadishu, Somalia, and the second objective was to determine the impacts of leadership on health service delivery in three hospitals in Mogadishu, Somalia. The study will be significance to health policymakers, healthcare managers, and academic institutions to improve healthcare delivery in Somalia. Also, the study enabled accountable people to create functioning institutions in a well-organised manner to supply services successfully and dependably.

Somalia has a long history of internal conflicts, characterized by almost three decades of civil war. Currently, Somalia is among the countries in the world that are least able to cope with the health system due to low levels of access to healthcare and limited government capacity. Healthcare services are either unaffordable, unavailable, or not trusted ( Ahmed et al., 2020 ).

On the side of investment, there is limited investment in the health sector, with Somalia’s health spending at just 1.3 percent of total government spending, which is below the 15 percent Abuja Declaration target set by African Union countries ( World Bank, 2021 ).

Healthcare in Somalia is mostly provided by the private sector with little government intervention, resulting in Somalia having some of the lowest health and well-being statistics in the world. Long decades of conflict and insecurity, worsened by recurrent intense droughts and accompanying food insecurity, have wrecked the population’s health and severely harmed the country’s weak health system ( WHO, 2023 ). Private health services and the pharmaceutical sector are largely unregulated in Somalia but could contribute to improving access and achieving universal health coverage ( World Health Organization, 2019 ).

Maternal, neonatal, infant, and under-five child mortality rates are gradually declining, although all remain high compared to the other countries in the region. Childhood malnutrition remains a key problem. Contraceptive use is among the lowest in the world. The immunisation coverage of children in Somalia is very low. The number of children who have not received a single dose of vaccine is around 60%, which indicates a critical weakness in the coverage of primary care services ( MOH, 2021 ).

The country is at the bottom in terms of 13 core health regulation capacities and emergency preparedness indexes, including preventing, detecting, and responding, among others ( Warsame, 2020 ).

“There are only three government hospitals in the capital (Benadir Hospital, Madine Hospital, and de Martini Hospital), Mogadishu, and one mental hospital called Forlanini Hospital, and people often have to seek health care services at a private health facility and pay out of their own pocket very high amounts for their own treatment. Only a few people can afford these services, thereby leading to high child and maternal mortality.” ( United Nation, 2022 )

Medical care provided by doctors and hospitals in Somalia is below average compared to the world population. The country provides 0.9 hospital beds per 1000 inhabitants. The global mean here is 2.9 beds. Within the EU, 4.6 beds are available for every 1000 residents. With about 391 physicians in Somalia, there are about 0.02 doctors per 1000 inhabitants ( Worlddata, 2023 ).

Surge capacity has four elements: 1) staff (medical personnel, doctors, nurses, pharmacists), stuff (equipment, supplies), structures (hospitals), and systems (successful coordination and management of various levels of the healthcare). All elements should be considered together ( Izmirlieva, 2020 ).

Capacity planning is a crucial component of healthcare governance. Hospital capacity planning involves several dimensions: capital investment in existing facilities and new developments; investment in expensive equipment and technology (such as magnetic resonance imaging service delivery); and allocation of human and financial resources. However, healthcare capacity planning takes place at national, regional, or local levels, reflecting the various tiers of government within health systems ( Dubas-Jakóbczyk et al., 2018 ). Increases in patient needs can strain hospital resources, which may worsen care quality and outcomes. Moreover, hospital capacity strain is associated with increased mortality and worsened health outcomes in highly developed countries. Evidence-based solutions to improve outcomes during times of capacity strain are needed ( Eriksson et al., 2017 ).

Smith et al. (2018) have reviewed evidence on the nature of effective leadership in inter-professional health and social care teams. They found twelve themes: facilitating shared leadership; transformation and change; personal qualities; goal alignment, creativity, and innovation; communication; team building; leadership clarity; direction-setting; external liaison; skill mix and diversity; and clinical and contextual expertise. They also summarized that effective inter-professional health leadership requires a unique blend of knowledge and skills that support innovation and improvement in health service delivery ( Smith et al., 2018 ).

Australia’s prepared health leadership framework also mentions the importance of innovation; they wrote that innovation has also been evident as Health Lead Australia has been integrated into existing academic curricula and new professional development offerings ( Shannon & Sebastian, 2018 ). Malila et al. (2017) studied a review of authentic leadership in healthcare. The four research themes include well-being, patient care quality, work environment, and authentic leadership promotion ( Malila et al., 2017 ). Other scholars also found that incorporating leadership competencies and evidence-based leadership training strengthens students’ clinical skills, enhances workforce development, and increases interdisciplinary healthcare practices ( McGrath et al., 2019 ).

The use of management practice or leadership style as an indicator of a healthcare organisation’s performance means types of health service delivery, ways of satisfying patients, and outcomes of healthcare organisations will be the measuring points of each health management. So, health managers must be competent and have the leadership skills to support innovation and improvement initiatives.

After demographic characteristics and hospital frequency, the data is divided into three sections: the first section describes each hospital’s overall capacity to provide health services (staff, essential medications, and infrastructure); the second section assesses the effects of leadership; and the third section will have subsections. The third section discusses qualitative data interpretation.

The first objective of the study was to assess the hospital’s capacities, which includes determining whether general facilities are operational and available, as well as whether essential medicines and medical staff are available. The current state of general facility availability and functionality shows that all hospitals are fully functional, with the exception of four items—the pharmacy, the examination room, and the fridge for medications and vaccines. Additionally, some hospitals do not have counselling rooms ( Table 4 ).

Additionally, this investigation showed that although all essential medicines were available, there was a shortage, indicating inconsistent hospital supply ( Table 6 ). Three of them—Atenolol 50 mg capsule/tablet, Captopril 25 mg capsule/tablet, and Simvastatin 20 mg capsule/tablet—seemed insufficient at all hospitals, whereas the remaining medications showed notable variations.

Once more, it was discovered that there was ample staff available, with the exception of midwives and physician assistants. Not all hospitals had access to physical and occupational therapists, and others did not have dieticians. This suggests that staff availability does not have a significant impact on health care. However, the question’s null hypothesis was rejected, meaning that while all staff members were available, the staff members of dieticians and physician assistants were not significant, therefore their null hypothesis was retained ( Table 8 ).

Which resources are lacking or insufficient in your hospital? When questioned, a few key informants claimed that the hospital lacked a blood bank, a cardiac unit, advanced emergency equipment, and enough training for certain staff members. Additional informants include “inadequate staffing, facilities, medical equipment, inadequate financial resources, medications and supplies, and inadequate information technology (IT).”

What causes a lack of prescription drugs and fewer hospital beds? We were also questioned. Key informants said “the lack of the health instrument industry and biomedical equipment firms are among the contributing factors.” While some informants mentioned “administrative and overcrowding factors,” others mentioned “resource constraints, increasing demand, supply chain issues, and inefficient bed management.”

In the second objective, it was found that the most common leadership styles in hospitals are authoritarian, bureaucratic, and managerial, all of which have an immediate effect on the quality of care provided ( Table 10 ). The opinions of the workers, the actions and communication of the leaders, the tardiness of worker wage payments, subpar working conditions, unequal opportunities for advancement, and a lack of involvement in decision-making are some of the main variables that have an impact on hospitals ( Table 11 ).

This result is in line with the results of Aberese-Ako et al. (2014) , who found that frontline health workers in Ghana believe that policies and Organisational issues are unfair, which has an impact on their motivation and ability to provide effective care for mothers and newborns ( Aberese-Ako et al., 2014 ). However, workers who are intrinsically motivated can overcome these obstacles and deliver quality care. When comparing the hospital’s working conditions to measure promotion equality, equality is present ( Table 12 ). According to Manyisa and van Aswegen (2017) , the main causes of the unfavourable working conditions in public hospitals include the heavy workload, the pandemic of diseases, shift work, lengthy workdays, inadequate resources, and staff scarcity ( Manyisa & van Aswegen, 2017 ). So that there were highly significant differences between Madina and SOS Hospital, Madina and Aden Abdulle Hospital,Benadir and Aden Abdulle Hospital, and Benadir and SOS Hospital ( Table 13 ).

Consequently, that implies the Benadir and Madina hospitals are completely distinct from each other. Researchers talk to employees about how the activities of those leaders may affect hospital services; specifically, how a leader’s style may affect patient care, employee performance, service quality and outcome, and employee commitment and motivation. The majority of healthcare professionals said that a leader’s actions primarily affect the quality, outcome, and patient-care services. Specchia et al. (2020) , found that leadership styles significantly impact nurses’ job satisfaction, which in turn positively or negatively impacts healthcare quality and patient outcomes ( Specchia et al., 2020 ). Key informants said after being interviewed, “The leadership actions that can impact the health services include a lack of communication, setting goals, collaboration, and recognition,” and others pointed out the “lack of consistently high-quality, compassionate care as a top priority.”

How do these leadership actions impact hospital services? Was another question posed by key informants; they responded that “leaders can influence by improving team, staff, and performance.” According to additional sources, “it can improve patient care, teamwork and collaboration, and employee engagement.” Other groups’ responses included “can affect awareness, staff performance management, and task and error management.”

One of the study’s weaknesses is that some respondents declined to answer our questionnaire as a result of concern for their employment, and some hospital key informants suppressed factual information. The sample size was much smaller than the hospital staff as a whole, but it was still enough. The study proposed employing two or more instruments at the same time. We employed certain capacity assessment techniques.

The study concludes that the availability and functionality capacity of hospitals had a strong positive impact on health services in general, but essential medicine was not enough in general, and all staff were sufficient except for three occupations: physician assistance, dieticians, and physical occupational and therapists. The activities of the leader have a detrimental impact on both the employees and the health services as a whole, but there are always ineffective leadership styles that need to be modified in all hospitals to lessen the effects of these existing styles on the entire health service.

This study therefore recommends that management of hospitals provides an effective system of evaluating leadership styles and periodical assessment of management activates and makes training workshops for the management system of hospitals. It is also recommended to elaborate on other assessment tools to provide more detailed data; finally, recommend to the Minister of Health that a standard assessment be set for public and private hospitals to check the availability and functionality of the services.

I’d like to thank my supervisor, Kakuba Sultan Juma, and May Prof. Ali Gunes for their motivation and support, and the President of Hope University, Prof. Najib Shiekh Abdikarim, as well as our colleagues.