Background:Uganda's established HIV service platform could support integrated hypertension care, but organizational conditions required for implementation in resource-limited settings are poorly described. We characterized organizational readiness, implementation leadership, and implementation citizenship behaviour during implementation of integrated HIV-hypertension care in Kampala and Wakiso districts, Uganda. Methods:We conducted a prospective cohort study nested within a stepped-wedge cluster-randomized trial at 16 public and private-not-for-profit HIV clinics implementing "hypertension BASIC- (basic training, supply of blood pressure devices and medications)" or "hypertension PLUS (BASIC components plus enhanced training, performance feedback and differentiated service delivery for hypertension)". Healthcare providers completed the 12-item Organizational Readiness for Implementing Change scale at intervention rollout and trial completion, and the 12-item Implementation Leadership Scale and Implementation Citizenship Behavior Scale (six items) at six months and post intervention. Scores were standardized to 0-100. Changes were assessed using independent-samples tests, with facility-clustered linear regression as sensitivity analyses. Intraclass correlation coefficients (ICCs) assessed agreement between clinic-lead self-ratings and staff ratings. Results:Forty-three healthcare providers participated at baseline, 42 at six months, and 41 at completion. The median age was 34 years (IQR: 30-42), and 24 (56%) were female Organizational readiness remained high (mean scores, 88.8-94.6% across arms and assessment periods), without significant changes over time. Leadership scores generally exceeded 75%, while citizenship behaviour scores exceeded 80%. In facility-clustered analyses, HTN PLUS clinic leads reported increases in overall leadership (10.7 percentage points; 95% CI 1.1-20.3, p=0.009) and proactive leadership (12.8; 95% CI 0.8-24.9, p=0.026); HTN BASIC clinic leads reported increased supportive leadership (19.2; 95% CI 6.0-32.4, p=0.012). Staff leadership ratings and citizenship behaviour did not change significantly. Conclusion:Trial-supported HIV clinics demonstrated sustained readiness, strong leadership, and supportive citizenship behaviours for integrated care. However, declining leader-staff agreement highlights the value of multisource feedback. Future analyses should determine whether these organizational conditions translate into improved adoption, fidelity, and clinical outcomes. Trial Registration #:NCT05609513. Registration date, November 8, 2022.
Diagnostic imaging supports emergency care, trauma assessment, tuberculosis detection, maternal and neonatal care, cancer diagnosis, and surgical decision-making, yet timely specialist interpretation remains limited in many low-resource health systems. Somalia is rebuilding a health system affected by workforce shortages, fragmented information systems, uneven service distribution, infrastructure constraints, and limited regulatory capacity. This narrative review integrates peer-reviewed evidence, global guidance, and Somalia-specific policy sources to examine where artificial intelligence could support radiology and to translate that evidence into a pragmatic implementation framework. The Somalia-specific contribution is a context-sensitive mapping of priority use cases, implementation barriers, governance safeguards, and clinical workflow requirements. Priority applications include computer-aided chest X-ray screening for tuberculosis, emergency imaging triage, image quality assessment, structured reporting support, and teleradiology prioritization. The proposed framework links readiness assessment, priority use-case selection, local validation, supervised deployment, workflow integration, continuous monitoring, and cautious scale-up. It also assigns human accountability at each stage and distinguishes pre-deployment readiness from clinical and operational risks during use. Artificial intelligence may act as a human-supervised capacity multiplier, but poor local validation, weak data protection, automation bias, workflow failure, and vendor dependency can undermine safety and equity. Somalia should therefore pursue leadership-led, locally validated, and auditable implementation that strengthens existing clinical services rather than introducing isolated technology.
Vahid Barari,1 Fatemeh Ebrahimi Belil,2 Mehdi Ajri-khameslou31School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran; 2Department of Medical and Surgical Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran; 3Department of Intensive Care Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, IranCorrespondence: Mehdi Ajri-khameslou, Department of Intensive Care Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran, Email ajri.mehdi@gmail.com; m.ajri@arums.ac.irPurpose: This study aimed to investigate the relationship between moral resilience and turnover intention among nurses.Patients and Methods: This cross-sectional descriptive-analytical study was conducted from December 2024 to September 2025 among nurses working in educational and treatment hospitals affiliated with Ardabil University of Medical Sciences. A total of 330 nurses were selected using simple random sampling. Data were collected using a demographic characteristics questionnaire, the 16-item Rushton Moral Resilience Scale, and the 15-item Kim et al. Turnover Intention Questionnaire. Pearson’s correlation coefficient and multiple linear regression analysis were used to examine the relationships between variables and identify predictors of turnover intention. Data were analyzed using SPSS version 14.Results: The mean age of the nurses was 32.01 ± 4.81 years, and their mean work experience was 6.45 ± 4.46 years. Most participants were married (60.6%) and held a bachelor’s degree (90.0%). The mean moral resilience score was 40.78 ± 1.29, indicating a moderate level, while the mean turnover intention score was 16.65 ± 2.77, indicating a high level. A significant negative correlation was found between moral resilience and turnover intention (r = − 0.72, P < 0.001). Regression analysis showed that age (B = − 0.238, P = 0.047), workplace department (B = 0.145, P = 0.042), job satisfaction (B = − 1.139, P < 0.001), average number of patients per shift (B = − 0.422, P = 0.042), errors leading to patient death in the past year (B = 1.672, P = 0.010), and moral resilience (B = − 1.015, P < 0.001) were significant predictors of reduced turnover intention.Conclusion: Enhancing moral resilience can effectively reduce turnover intention. These findings suggest that strengthening moral resilience may be relevant to reducing nurses’ turnover intention. Further longitudinal and intervention studies are needed to determine whether interventions aimed at enhancing moral resilience can reduce turnover intention.Keywords: moral resilience, turnover intention, nurses, ethical challenges
Objective:This narrative review explores the processes influencing female leadership in emergency medicine, focusing on clinical, academic, and strategic management, while identifying barriers and potential solutions. Methods:Following SANRA guidelines, a systematic search of PubMed and ScienceDirect (1999-2024) was conducted. Out of 1897 articles, 47 were selected for thematic synthesis. Results:Although women make up 37-80% of EM physicians, they hold only 10-13% of leadership positions. Key barriers include persistent gender stereotypes, limited access to mentorship and sponsorship, and structural inequalities in promotion pathways. A further issue is the "glass cliff" phenomenon, whereby women are more likely to be appointed to leadership roles during periods of crisis. Current research predominantly focuses on academic and administrative leadership, thus leaving what appears to be a significant gap around "field clinical leadership" and real-time clinical team management. Nevertheless, evidence suggests that female-led teams perform as well as, or better than, male-led teams in crisis scenarios, even though women face more frequent challenges to their authority from peers. Institutional culture also influences leadership trajectories, with more supportive environments associated with greater confidence and representation of women leaders. Several interventions, including dedicated leadership development programs and structured mentorship initiatives, have demonstrated positive effects on leadership skills, career advancement, and institutional visibility for women in academic medicine. Conclusion:Female underrepresentation in emergency medicine leadership is rooted in systemic issues. Future research must shift focus toward field leadership to better understand gender dynamics in high-stakes clinical environments. Inclusive institutional reforms and standardized training should help encourage equitable promotion practices and can be used alongside strategies to address unconscious bias and workplace discrimination, as well as formal mentorship programs.
John Baptist Kiggundu,1 Fred C Semitala,1– 3 Savio Mwaka,1 Martin Muddu,1 James Kayima,2,4 Gerald Mutungi,5 Donna Spiegelman,6 Jeremy I Schwartz,7,8 Mona Abdo,6 Isaac Ssinabulya,4,8 Mosepele Mosepele,9 Anne R Katahoire,10 Chris T Longenecker111Research Department, Infectious Diseases Research Collaboration, Kampala, Uganda; 2Department of Internal Medicine, Makerere University, Kampala, Uganda; 3Makerere University Joint AIDS Program, Kampala, Uganda; 4Uganda Heart Institute, Kampala, Uganda; 5Department of Non-Communicable Diseases, Ministry of Health, Kampala, Uganda; 6Department of Biostatistics and Center for Methods on Implementation and Prevention Science (CMIPS), Yale School of Public Health, New Haven, CT, USA; 7Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA; 8Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda; 9Department of Internal Medicine, University of Botswana, Gaborone, Botswana; 10Child Health and Development Centre, Department of Medicine, Makerere University, Kampala, Uganda; 11Division of Cardiology, Department of Global Health, University of Washington, Seattle, WA, USACorrespondence: John Baptist Kiggundu, Research Department, Infectious Diseases Research Collaboration, Kampala, Uganda, Tel +256 700809041, Email jbkiggundu@idrc-uganda.org; jbkiggundu5@gmail.comBackground: Uganda’s established HIV service platform could support integrated hypertension care, but organizational conditions required for implementation in resource-limited settings are poorly described. We characterized organizational readiness, implementation leadership, and implementation citizenship behaviour during implementation of integrated HIV–hypertension care in Kampala and Wakiso districts, Uganda.Methods: We conducted a prospective cohort study nested within a stepped-wedge cluster-randomized trial at 16 public and private-not-for-profit HIV clinics implementing "hypertension BASIC- (basic training, supply of blood pressure devices and medications)” or "hypertension PLUS (BASIC components plus enhanced training, performance feedback and differentiated service delivery for hypertension)”. Healthcare providers completed the 12-item Organizational Readiness for Implementing Change scale at intervention rollout and trial completion, and the 12-item Implementation Leadership Scale and Implementation Citizenship Behavior Scale (six items) at six months and post intervention. Scores were standardized to 0– 100. Changes were assessed using independent-samples tests, with facility-clustered linear regression as sensitivity analyses. Intraclass correlation coefficients (ICCs) assessed agreement between clinic-lead self-ratings and staff ratings.Results: Forty-three healthcare providers participated at baseline, 42 at six months, and 41 at completion. The median age was 34 years (IQR: 30– 42), and 24 (56%) were female Organizational readiness remained high (mean scores, 88.8– 94.6% across arms and assessment periods), without significant changes over time. Leadership scores generally exceeded 75%, while citizenship behaviour scores exceeded 80%. In facility-clustered analyses, HTN PLUS clinic leads reported increases in overall leadership (10.7 percentage points; 95% CI 1.1– 20.3, p=0.009) and proactive leadership (12.8; 95% CI 0.8– 24.9, p=0.026); HTN BASIC clinic leads reported increased supportive leadership (19.2; 95% CI 6.0– 32.4, p=0.012). Staff leadership ratings and citizenship behaviour did not change significantly.Conclusion: Trial-supported HIV clinics demonstrated sustained readiness, strong leadership, and supportive citizenship behaviours for integrated care. However, declining leader–staff agreement highlights the value of multisource feedback. Future analyses should determine whether these organizational conditions translate into improved adoption, fidelity, and clinical outcomes.Trial Registration #: NCT05609513. Registration date, November 8, 2022.Key words: HIV, hypertension, integrated care, implementation climate, organization readiness, leadership capacity
Rahmo Mohamed AliDepartment of Radiology, Dr. Sumait Hospital, SIMAD University, Mogadishu, SomaliaCorrespondence: Rahmo Mohamed Ali, Email rahmomohamedali31@gmail.comAbstract: Diagnostic imaging supports emergency care, trauma assessment, tuberculosis detection, maternal and neonatal care, cancer diagnosis, and surgical decision-making, yet timely specialist interpretation remains limited in many low-resource health systems. Somalia is rebuilding a health system affected by workforce shortages, fragmented information systems, uneven service distribution, infrastructure constraints, and limited regulatory capacity. This narrative review integrates peer-reviewed evidence, global guidance, and Somalia-specific policy sources to examine where artificial intelligence could support radiology and to translate that evidence into a pragmatic implementation framework. The Somalia-specific contribution is a context-sensitive mapping of priority use cases, implementation barriers, governance safeguards, and clinical workflow requirements. Priority applications include computer-aided chest X-ray screening for tuberculosis, emergency imaging triage, image quality assessment, structured reporting support, and teleradiology prioritization. The proposed framework links readiness assessment, priority use-case selection, local validation, supervised deployment, workflow integration, continuous monitoring, and cautious scale-up. It also assigns human accountability at each stage and distinguishes pre-deployment readiness from clinical and operational risks during use. Artificial intelligence may act as a human-supervised capacity multiplier, but poor local validation, weak data protection, automation bias, workflow failure, and vendor dependency can undermine safety and equity. Somalia should therefore pursue leadership-led, locally validated, and auditable implementation that strengthens existing clinical services rather than introducing isolated technology.Keywords: artificial intelligence, radiology, medical imaging, Somalia, low-resource settings, teleradiology, diagnostic access, health workforce, patient safety, digital health
Background:Authentic leadership has been associated with work-related well-being, job satisfaction, and quality of nursing care. However, psychometric evidence supporting instruments used to assess this construct remains limited across Latin American nursing contexts, highlighting the need for further validation studies. Aim:To evaluate evidence of validity for the Authentic Leadership Questionnaire (ALQ) among nursing staff in a Latin American context. Methods:This cross-sectional methodological study included 418 nursing staff members-registered nurses and nursing assistants-selected through proportional stratified sampling from a public high-complexity hospital in Cali, Colombia, between May and October 2025. SELF and RATER versions of the ALQ were evaluated using confirmatory factor analysis. Four measurement models were compared for each version: unidimensional, correlated four-factor, second-order, and bifactor models. The final model was assessed through standardized loadings, internal consistency (McDonald's omega, ordinal alpha, composite reliability), measurement invariance (configural, metric, scalar) between nursing staff members, and correlations with job satisfaction. Results:The revised correlated four-factor model (excluding item 9) showed the best fit (ALQ-RATER: CFI= 0.998, TLI= 0.997, SRMR= 0.045, RMSEA= 0.079; ALQ-SELF: CFI= 0.996, TLI= 0.995, SRMR= 0.047, RMSEA= 0.050). Factor loadings were significant (RATER λ = 0.661-0.945; SELF λ = 0.671-0.897). Reliability was adequate (ALQ-RATER: ω = 0.883-0.938, ordinal α = 0.887-0.952, CR = 0.899-0.957; ALQ-SELF: ω = 0.801-0.847, ordinal α = 0.846-0.880, CR = 0.850-0.880). Configural, metric, and scalar invariance were supported. Registered nurses demonstrated significantly higher latent means across all authentic leadership dimensions than nursing assistants. All ALQ dimensions were positively associated with intrinsic job satisfaction (r = 0.287-0.550) and satisfaction with supervision (r = 0.336-0.633). Conclusion:The ALQ demonstrated evidence of structural validity, reliability, measurement invariance, and external validity among Colombian nursing staff. Implications for Health Management Services:The instrument can be used to assess authentic leadership in healthcare settings, support leadership development initiatives, and facilitate research examining its relationship with job satisfaction.
Introduction:While the impact of physician leadership training has been demonstrated through descriptive studies, work comparing such programs to control groups of self-directed or on-the-job leadership training has proven challenging to implement. Methods:We designed a comparative study, using pre-and post-test methodology, to assess change in leadership skill level and skill use. We compared 2 groups of OBGYN physicians including individuals who had completed an annually offered Intentional Leadership Training (ILT) program as compared to those completing self-directed or on-the-job leadership training (SD-OJT). ILT program participants completed self-assessment evaluations 6 months after ILT course completion, reflecting on their leadership development on 11 leadership competencies. The SD-OJT group, recruited from a convenience sample of OBGYN educators participating in an annual OBGYN educators' conference (2020), reflected on whether they had experienced on-the-job or self-directed leadership development over the previous 5 years. If they responded affirmatively, they reflected on leadership skill level and skill use on the same 11 leadership competencies before and after their training. Results:For the ILT group completing the annual course from 2013 to 2019, statistically significant improvement in both leadership skill level and skill use was noted for all 121 participants across all 11 competencies. For the SD-OTJ group (2020), no statistically significant change in skill level or use was noted for any of the 11 competencies. Conclusion:While self-directed or on-the-job leadership training experiences can offer leadership development opportunities, significantly improved leadership skill level and skill use were seen only in the ILT group studied for the 11 leadership competencies assessed.
Cheryl A Maurana, Heather Carroll, Sarah Williams, Alicia WittenKern National Network for Flourishing in Health, Medical College of Wisconsin, Milwaukee, WI, USACorrespondence: Cheryl A Maurana, Kern National Network for Flourishing in Health, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI, 53226, USA, Email cmaurana@mcw.eduAbstract: This paper aims to address the limited availability of reflective approaches designed for healthcare leaders to consider ethically consequential decision-making by introducing a flourishing-centered reflective inquiry into a single temporally structured process. To inform the development of this approach, we conducted a scoping literature review of peer-reviewed articles and scholarly book chapters published in English between 2015 and 2025. Because healthcare is often situated in academic medical centers influenced by higher education concerns, the search was conducted across both healthcare and higher education. Relevant literature set in a military context was retained when it illuminated leadership in settings where hierarchy or moral injury are relevant. Publications were screened for relevance to ethical leadership and were categorized and synthesized by setting, participant group, timing of reflection, and type of ethical tension addressed. The final corpus included 40 publications: 27 in healthcare, 11 in higher education, and 2 in military contexts. The review found that reflection is widely used in professional learning, clinical practice, and team-based settings, but is less often structured as a discipline for leaders’ own ethical reasoning in operational and executive decision-making. Across the corpus, reflection appeared in retrospective, ongoing, and multi-phase forms, and ethical tensions repeatedly spanned individual, institutional, and societal goods. These findings informed the development of a reflective cycle in three phases: reflection-for-action, reflection-in-action, and reflection-on-action. Each phase is guided by an inquiry guide developed using the KNN Framework for Flourishing’s elements of character, caring, and practical wisdom toward flourishing across socio-ecological systems. This paper contributes a conceptually integrated and practically oriented reflective inquiry for healthcare leadership that offers structured guidance for ethical discernment before, during, and after consequential leadership decisions.Keywords: healthcare leadership, ethical leadership, character, caring, practical wisdom, flourishing
Survival from critical illness is not equivalent to recovery, particularly in low-resource health systems where ICU survivors may return home with weakness, respiratory vulnerability, medication problems, poor wound care, malnutrition, psychological distress, caregiver burden, and limited follow-up. This commentary responds to the post-ICU care gap in Somalia by proposing a Somalia-adapted nurse-led home recovery framework. The framework is not presented as a fully validated intervention, but as a pragmatic implementation model for settings where ICU beds, rehabilitation services, transport, digital access, and specialist follow-up are constrained. It defines nurse-led home care as a tiered pathway coordinated by an ICU discharge nurse, supported by ward nurses, community health workers, physicians, rehabilitation providers, and referral facilities. The model includes risk stratification, discharge preparation, caregiver education, early phone follow-up, selective home visits, multidisciplinary referral, digital communication safeguards, and outcome tracking. Key implementation issues include workforce capacity, financing, supervision, quality indicators, privacy, medico-legal responsibility, transport barriers, gendered caregiver burden, and the digital divide. Strengthening post-ICU home recovery in Somalia requires local empirical evaluation, but immediate low-cost improvements can begin through structured discharge and follow-up systems.
Background:The systemic leadership of district health management teams (DHMs) is a pivotal factor in optimising health system performance, particularly within fragile and post-conflict contexts. However, the paucity of empirical data on its maturity level remains a limitation. The objective of this study is to evaluate and contrast the maturity of DHMs systemic leadership across six health districts in the Kasai-Central province of the Democratic Republic of Congo. Methods:A quantitative, cross-sectional study was conducted between March 2025 and April 2026, with 84 members of DHMs selected from five urban districts (Kananga, Katoka, Tshikaji, Bobozo and Ndesha) and one rural district (Mikalayi). The data were collected using a structured tool based on a health system leadership framework by Bigirinama and al. (2023), adapted from the NHS. The following indicators were calculated: the percentage of points achieved, the overall scores for systemic leadership maturity, and the overall composite index of systemic leadership achievement in the province of Kasaï Central. Results:The overall synthetic index of systemic leadership achievement in Kasai-Central province is moderate (62.10%), with low variability in overall systemic leadership maturity scores between districts. The dimensions related to vision and governance have the highest scores (between 70-75%), while the lowest scores concern collaboration with external partners, financial management, and internal organization (between 43-55%). Internal collaboration is generally satisfactory but marked by persistent conflicts. No significant differences are observed between rural and urban districts. Conclusion:The maturity of systemic leadership in the DHMs in Kasai-Central is constrained by structural factors. The enhancement of leadership capacity necessitates the implementation of integrated methodologies that encompass the cultivation of skills, the refinement of leadership abilities, and the implementation of systemic reforms, with the objective of optimising the performance of health districts.
Abdishakur Mohamud Hassan HidigowDepartment of Intensive Care Unit, Dr. Sumait Hospital, SIMAD University, Mogadishu, SomaliaCorrespondence: Abdishakur Mohamud Hassan Hidigow, Email abdishakur.hidigow@simad.edu.soAbstract: Survival from critical illness is not equivalent to recovery, particularly in low-resource health systems where ICU survivors may return home with weakness, respiratory vulnerability, medication problems, poor wound care, malnutrition, psychological distress, caregiver burden, and limited follow-up. This commentary responds to the post-ICU care gap in Somalia by proposing a Somalia-adapted nurse-led home recovery framework. The framework is not presented as a fully validated intervention, but as a pragmatic implementation model for settings where ICU beds, rehabilitation services, transport, digital access, and specialist follow-up are constrained. It defines nurse-led home care as a tiered pathway coordinated by an ICU discharge nurse, supported by ward nurses, community health workers, physicians, rehabilitation providers, and referral facilities. The model includes risk stratification, discharge preparation, caregiver education, early phone follow-up, selective home visits, multidisciplinary referral, digital communication safeguards, and outcome tracking. Key implementation issues include workforce capacity, financing, supervision, quality indicators, privacy, medico-legal responsibility, transport barriers, gendered caregiver burden, and the digital divide. Strengthening post-ICU home recovery in Somalia requires local empirical evaluation, but immediate low-cost improvements can begin through structured discharge and follow-up systems.Keywords: critical care nursing, post-intensive care syndrome, home-based care, Somalia, transitional care, patient safety
Background:Small- to medium-sized healthcare organizations (SMHCOs) are often led by clinicians who simultaneously deliver care and manage organizational systems. Although organizational learning is recognized as an important driver of organizational adaptability, practical tools to support its application within SMHCOs remain limited. Objective:To develop and evaluate the Healthcare Organizational Learning (HCOL) Compass, a prototype systems-oriented leadership tool oriented around the foundational concepts of leadership that reinforces learning (LRL), organizational context (OC), and knowledge management and mobilization (KM/KMb). Methods:Guided by principles of complex intervention development and design-based research, this iterative multiple-methods study evaluated and refined the HCOL Compass across two sequential rounds (n=8). Content validity was assessed using the Content Validity Index (CVI), while implementation utility was evaluated using the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM). Semi-structured interviews were analyzed using deductive, inductive, and axial thematic coding. Participants included organizational learning experts and clinician-leaders in Canadian community-based optometry. Results:Content validity and implementation scores improved from Round 1 to Round 2 (S-CVI: 81% to 94%; AIM from 80% to 95%; IAM from 73% to 96%; and FIM from 67% to 91%). Qualitative analysis identified four themes: sense-making through visual design, balancing guidance with reflective practice, hidden sources of organizational complexity through structured scaffolding, and systems thinking as an integrative mechanism. Conclusion:The HCOL Compass showed preliminary evidence of feasibility and utility as a systems-oriented leadership tool for SMHCOs. The emergence of a Systems Thinking layer suggests that organizational learning may be strengthened by intentionally designing for redundancy, margin, and shared understanding across organizational domains.
Background:Hospital redevelopment projects are among the largest and most costly changes undertaken in health systems. Despite abundant methodologies and frameworks that offer theoretical guidance, the literature reports persistent gaps in managing change of this scale effectively. To examine this gap between theory and implementation of change management in practice, we explored change managers' experiences of leading change in hospital redevelopment projects across one Australian state, using a qualitative approach. We aimed to understand the change management approaches used, the perceived value and limitations of those approaches, the capabilities change managers need to lead change, and the barriers and enablers encountered through the change cycle. Methods:Semi-structured interviews were conducted with 28 change managers of varying levels of experience and project scope in hospital redevelopments. Data were analysed using the Framework method. Subthemes were developed inductively from the interviews and then mapped deductively onto the three stages (planning, implementing, and sustaining change) of a statewide health infrastructure change management framework that guided practice in this setting. Inductive subthemes not able to be classified using the framework formed a fourth theme on change managers' capabilities. Findings:Four themes were developed: 1) Planning for change, 2) Implementing change, 3) Sustaining and reinforcing change, and 4) Change managers' capabilities and support. Participants described several effective approaches to managing change in hospital redevelopment, including progress tracking, prototypes, site visits, and ongoing stakeholder consultations, with local staff central to facilitating engagement. Executive sponsorship was repeatedly identified as an enabler of change, although securing it early and sustaining it across the project proved a recurring challenge. Further challenges included aligning change plans with broader project processes, transitioning change into business as usual once the project ended, and evaluating whether the change delivered its intended benefits. Some participants reported not being aware of available resources and how to utilise them. Conclusion:Change management frameworks offered useful guidance particularly for less experienced change managers. However, participants often described challenges utilising these frameworks for effective stakeholder engagement, for sustaining change in long-term projects, or where change management and project processes were misaligned. The findings have practical implications for successful change management in redevelopment projects, including the importance of structured training and mentoring for change managers, a need for early and sustained executive and stakeholder engagement, planned transition to business as usual, and closer alignment of change management with project delivery so that the people side of change is supported throughout the project lifecycle.
Child malnutrition in Somalia represents one of the most severe and protracted public health crises of the contemporary era, rooted not solely in acute food scarcity but in a complex architecture of structural failures, governance deficits, climate vulnerability, and inadequate health system capacity. An estimated 1.7 million children under five years of age in Somalia faced acute malnutrition in 2025, including 466,000 cases of severe acute malnutrition (SAM) and 1.2 million cases of moderate acute malnutrition (MAM). This commentary argues that meaningful progress against child malnutrition in Somalia demands a decisive shift away from perpetual emergency response cycles toward integrated, development-oriented, and sustainably funded national strategies. We examine the epidemiological burden, the structural determinants of malnutrition, the limitations of exclusively humanitarian approaches, and propose a multi-sectoral framework encompassing health system strengthening, food system transformation, nutrition-sensitive social protection, gender-responsive programming, and community-based management. Addressing child malnutrition in Somalia is not merely a humanitarian imperative but a foundational prerequisite for national development.
Background:Generative artificial intelligence (GenAI) is rapidly transforming eHealthcare, promising substantial gains in diagnostic accuracy, workflow efficiency, and decision support, yet raising concerns about automation bias and clinician deskilling that may erode core diagnostic expertise and professional judgment over time. Aim and Objectives:This systematic review investigates the dual impact of GenAI in eHealthcare, focusing on how it enhances clinical efficiency and decision support while potentially diminishing clinicians' diagnostic expertise and professional judgment. Methods:A systematic search was conducted across PubMed, Scopus, Web of Science, and Google Scholar. A total of 11,269 records were identified, and 29 studies met inclusion criteria following PRISMA 2020 guidelines. Studies were synthesized using a narrative approach due to heterogeneity in design, clinical domains, and AI system maturity. Results:Across the included studies, recurrent themes included automation bias (reported in 10 studies), concerns regarding clinician deskilling (9 studies), and impacts on diagnostic reasoning (9 studies). Evidence was predominantly observational, experimental simulation-based, or conceptual in nature. Findings reveal that GenAI significantly improves diagnostic accuracy, workflow efficiency, and decision quality across radiology, telehealth, and education domains. However, overreliance introduces risks of automation bias, cognitive deskilling, and loss of interpretive autonomy. The review identifies key mitigation strategies, including human-in-the-loop frameworks, explainable AI (XAI), ethical governance, and continuous clinician reskilling. Theoretically, the results redefine the clinician-AI relationship as a dynamic cognitive partnership, while practically they emphasize responsible integration through education and regulation. Conclusion:Sustainable adoption of GenAI demands balanced implementation-leveraging its analytical capabilities without compromising human judgment, clinical reasoning, or professional accountability.
Background:Evidence on digital health maturity in Africa remains limited. We characterized maturity across countries in the World Health Organization African Region between 2023 and 2025 to generate a regional baseline for policies and investments. Methods:We analyzed the Global Digital Health Monitor data, which scored seven domains of the digital health enabling environment on a 5-phase scale. All assessments from the 2023, 2024, and 2025 cycles were extracted in April 2026, yielding 50 country-year observations from 32 of the 47 member states of the World African Region, with 17 of these 32 countries reassessed in at least one subsequent cycle. Assessment coverage declined over time (29, 17, and four countries in 2023, 2024, and 2025, respectively); therefore, the 2025 comparison rests on a small subset. The data are self-reported by the country focal points and published only after government approval. We used descriptive statistics (means with medians and interquartile ranges for the ordinal phase scale), choropleth mapping, short-term descriptive change analysis, Spearman correlation (reported with sample size and p-values), hierarchical clustering with internal validation (silhouette score, gap statistic, and linkage sensitivity), and within-country gap analysis. Results:We analyzed 32 countries and 50 country-year observations. Most countries were in Phase 3 (established; 21 of 32, 66%), with none in phases 1 or 5; 5 were at Phase 4, and 6 were at Phase 2. Leadership and governance were consistently the strongest (mean phase 3.00 in 2023 and 3.75 in 2025), and the workforce was the weakest. Of the 17 reassessed countries, three improved and none declined; one country (Kenya) advanced two phases in one year. Standards and interoperability were strongly correlated with services and applications (Spearman ρ = 0.70, n = 30, p < 0.001). Clustering yielded three archetypes: infrastructure-oriented, governance-led, and early stage. A total of 26 of the 32 countries had gaps of two or more phases between the strongest and weakest domains, typically strong governance with a weak workforce. Conclusion:Among the assessed countries in the World Health Organization African Region, digital health rests on established governance but is constrained by a weak workforce and uneven interoperability. Targeted investment in the workforce, shared data architectures, and broader maturity monitoring are the most consequential levers for progress in this field. The findings should not be extrapolated to non-assessed Member States or to the wider African continent, which extends beyond the World Health Organization's African Region.
Background:Remote leadership has gained increasing recognition and become possible across sectors. Still, this approach is relatively new in the healthcare sector. The literature shows that the dynamic interaction among digitalization, remote working, leadership, and culture in the healthcare sector is under-researched. This review aimed to investigate how remote leadership is defined and conceptualized in healthcare organizations, how it is practiced across Western and non-Western cultures, and how these practices impact the healthcare sector. Methods:We conducted a scoping review and applied the JBI and PRISMA-ScR frameworks to guide it. Articles from PubMed, Scopus, and Web of Science were used as sources of literature. All studies were analyzed using descriptive and inductive thematic analysis. Results:Of 5310 studies, 17 met the inclusion and exclusion criteria. Our findings identified 4 themes: key concepts of remote leadership, competencies needed by remote leaders, opportunities and challenges of remote leadership, and how remote leadership is practiced in Western versus non-Western cultures. Remote leadership impacted on health system, organization, and service delivery. Lastly, we found that remote leadership in relation to culture was implicitly explored and is associated with leadership styles. Conclusion:This review indicates that conceptual clarity remains underdeveloped within the healthcare-specific literature. A notable finding was that cultural context remained underexplored, with culture frequently treated implicitly through leadership style rather than as a distinct analytical dimension of remote leadership in healthcare. Further research is needed to provide a comprehensive understanding that helps remote leaders manage remote work environments and enhance the sustainability of healthcare services in an evolving digital era.
Background:Professional certification is increasingly promoted as a strategy for enhancing leadership competencies among healthcare administrators. However, evidence on its influence on leadership practices and effectiveness remains limited. Objective:To examine the relationship between professional certification, leadership practices, and leadership effectiveness among healthcare administrators. Methods:A cross-sectional mixed-methods study was conducted among healthcare administrators working in diverse healthcare settings. Using purposive sampling, 200 administrators were invited through email, institutional networks, and professional forums; 163 completed the survey. Leadership practices were assessed using a six-item Leadership Practices Scale, and leadership effectiveness was measured using a two-item Leadership Effectiveness Score. We evaluated Reliability and validity using Cronbach's alpha and exploratory factor analysis. We examined associations between certification status and leadership outcomes through Independent-samples t-tests, multiple linear regression, and logistic regression. We use thematic content analysis method for qualitative responses. Results:Participants reported high levels of leadership practices (M = 4.48, SD = 0.44) and leadership effectiveness (M = 4.12, SD = 0.69). The Leadership Practices Scale showed acceptable reliability (Cronbach's α = 0.772) and a unidimensional structure. Although certified respondents reported slightly higher leadership practices and leadership effectiveness scores than non-certified respondents, these differences were not statistically significant in either bivariate or multivariate analyses. Certification was not an independent predictor of leadership practices or leadership effectiveness after controlling for education level and years of experience. Nevertheless, respondents perceived certification as beneficial to leadership development. Frequently reported areas of improvement included decision-making (71.7%), strategic thinking (68.6%), communication (67.9%), and organisational planning (63.5%). Additionally, 89.0% of respondents reported that certification increased or significantly increased their confidence as leaders. Qualitative findings highlighted enhanced leadership competencies, increased professional credibility, positive organisational outcomes, barriers to certification, and recommendations to expand certification opportunities. Conclusion:Professional certification was not significantly associated with leadership practices or leadership effectiveness. In contrast, participants reported improvements in leadership competencies following certification and viewed it as contributing to teamwork, decision-making, and organisational effectiveness. These findings suggest that expanding access to certification programs may support leadership development in healthcare organizations.
Laura Klösges,1,2 Barbara Maria Löfflad-Bürkin,1,2 Katarzyna Czabanowska,3–51Education Department, Swiss Tropical and Public Health Institute, Allschwil, Switzerland; 2University of Basel, Basel, Switzerland; 3Department of International Health, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands; 4Department of International Health, WHO Collaborating Center for Public Health Leadership and Workforce Development, Maastricht University, Maastricht, the Netherlands; 5Department of Health Policy Management, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University, Kraków, PolandCorrespondence: Laura Klösges, Education Department, Swiss Tropical and Public Health Institute, Kreuzstrasse 2, Allschwil, 4123, Switzerland, Email laura.kloesges@stud.unibas.chPurpose: We explored the interdependence of contextual influences and transformational leadership by examining how women surgeons in leadership enact transformational leadership, navigate gender-related challenges, and influence surgical teams. The study further sought to propose key transformational leadership competencies among women surgeons.Patients and Methods: We conducted eight in-depth interviews with women surgeons in leadership positions. Data was analyzed by a sequential combination of thematic analysis and directed content analysis. An inductive approach and interpretation of themes at the semantic level guided thematic analysis. In a second step, transformational leadership served as the underlying theoretical framework for directed content analysis.Results: Participants acknowledge that “gendered perceptions of behavior”, the “surgical culture”, the “degree of congruence between inclusive policies and their implementation”, “endorsement of competence” and the need to “balance private and professional roles” influence how they reach, retain, and shape leadership roles. For women surgeons, transformational leadership competencies significantly shape their leadership style. They emphasize different competencies according to cultural, institutional, or individual context.Conclusion: The way women surgeons conceptualize and shape leadership practices corresponds to the four dimensions of transformational leadership. Organizational dynamics and cultural constructs are key influences on how women surgeons emphasize various competencies of transformational leadership behavior. We propose a transformational leadership competency profile based on these findings.Keywords: transformational leadership, surgery, gender, qualitative research, competency framework
