Healthcare Leadership in Resource-Limited Settings: Reimagining Public Hospital Governance in Somalia.

Somalia's healthcare system remains among the world's most challenged, shaped by fragmentation, chronic resource scarcity, and a longstanding urban bias that leaves rural and peri-urban communities underserved. Service quality in public hospitals is frequently constrained by weak governance arrangements and leadership approaches that emphasize command and control over learning, adaptation, and accountability. Existing literature on Somali public hospitals has emphasized resource shortages and infrastructure deficits while examining how governance and leadership shape service quality and equity, suggesting a strategic entry point for reform. A reimagined governance model is needed that shifts from top-down bureaucracy to relational and adaptive leadership suited to a fragile context, embeds clinical governance, strengthens federal and state coordination, and institutionalizes mentored leadership development to cultivate hospitals capable of delivering equitable, safe, and high-quality healthcare. The novel contribution of this paper is the integration of relational leadership, adaptive leadership, clinical governance, and federal coordination into a single, context-sensitive governance framework, accompanied by a clear distinction between short-term feasible priorities and long-term institutional reforms. This commentary aims to reframe public hospital governance in Somalia by advocating for a shift from top-down control to relational, adaptive leadership supported by stronger clinical governance and improved federal and state coordination as a pathway to more equitable and higher-quality care.