Open Access Journal of Nursing

ISSN 2639-1783
Volume 1, Issue 2, 2018, PP: 21-33

Leadership and Management in Public Health Setting in

Somalia
Abdirisak Mohamed Artan1, Elmi Omar Haji Elmi2, Mohamed Shair Sharif Mohamed3, Halimo
Ali Hassan4, Mohamud Jama Osman5, Abdulkadir abdullahi Yusuf6, Rodo Mohamud Hassan7
Abdikarim Ali Ibrahim8, Regidor-111 Dioso*9
1
Public Health Officer, Ministry of Health, Somalia
Faculty of Medicine and Health, East Africa University, Somalia
2

3
Manager, Darul-bir Institution, Bosaso, Somalia
4
Public Health Nurse, Maternal and Child Healthcare Center, Somalia
5
Faculty of Human and Health, University of Health Sciences in Bosaso, Somalia
6
Faculty of Health Science, Bosaso University, Somalia
7
Public Health Nurse, Bosaso General Hospital , Somalia
8
Public Health Officer, Young Africans Development Action, Somalia
9
Faculty of Nursing, Lincoln University, Malaysia
duke@lincoln.edu.my
*Corresponding Author: Regidor-111 Dioso, Faculty of Nursing, Lincoln University, Malaysia.

Abstract
This study deemed to explore the lived experiences of public health care leaders in leading and managing public
health care services in Somalia. A qualitative descriptive-exploratory design determined and reported findings
the way they were said and mentioned by the respondents in a narrative approach. Purposive sampling technique
was used among 8 participants who were selected or sought for an interview, based on pre-selected inclusion
and exclusion criteria. Video-audio recorder was used to ensure that answers from the 8 interviewees were
collected and was transcribed into written responses, thus used for data analysis. The explored leadership and
management in Somalia were (1) work specialization addressing change management, (2) departmentalization
addressing organizational structure, (3) chain of command addressing leadership traits and styles, (4) span
of control addressing performance management and conflict resolution, (5) centralization addressing team
working, and (6) formalization addressing quality assurance and total quality management.
Keywords: Leadership; management; Nursing; Public health; Qualitative research; Somalia.

Introduction with International Organization of Supreme Audit

institutions. The Somalia National Development Plan
Background of the Study
2017-2019 also addresses the Strategic Development
The ministry of health (MOH) mandated several Goal Plan of the World Health Organization (2015b)
leadership and management systems to be reported and therefore must be led by strong public health
to its national surveillance office (Somalia World Fact leaders from hospitals, healthcare centers, ministries,
Book, 2005). Somalia National Development Plan 2017- universities, and other private institutions.
2019 stated that measures will be taken to increase
Problem Statement
the independence and capacity of public health care
(World Health Organization, 2015a/b). One strategy Most of the health services lack leadership and
mentioned by the Office of Auditor General (2005) to management, basically for the benefit of service-
achieve a good leadership and management in public users, and utilization of healthcare products. Both
health care setting was the international involvement leadership and management are important to achieve
with other countries and twinning arrangements a satisfying service from the public. The MOH in
Open Access Journal of Nursing V1 . I2 . 2018 21
Leadership and Management in Public Health Setting in Somalia
Somalia never developed a core health care service Research Questions
packages nor gauged the extent of resources and
1. Why are leadership traits and styles significant in
infrastructure needed to deliver them (Somalia World
managing healthcare service?
Fact Book, 2005). Wasted resources could have been
saved and eased if there was a sound management 2. How do healthcare leaders resolve conflicts?
and leadership practiced. Such information was 3. How do healthcare leaders manage changes in
occasionally tabulated and sent to the central office in health care service?
Mogadishu by the regional MOH authorities (United
Nations Development Programme, 2001). However, 4. How do healthcare leaders manage performance
of health care professionals?
the data was haphazardly collected and had little
use for effective planning and operational decisions. 5. Why is structuring organizations significant in
In addition, the capacity to gather, analyze and managing health care service?
disseminate surveillance data and other leadership
6. How do healthcare leaders make their team
management systems was not developed well (United
work?
Nations Development Programme, 2001; Somalia
World Fact Book, 2005; Office of Auditor General, 7. Why is quality assurance significant in managing
2005). healthcare service?

The population has been growing annually at a rate 8. How does total quality management play a role in
of 2.8%, although it experienced high mortality rates managing healthcare service?
during the civil war in the early 1990s (Population Justification
Reference Bureau, 2005). The health care needs
The research questions are justified to be explored
were increasing while resources and enabling
as an effective leadership and management are
infrastructures were diminishing or ceasing to
prerequisites to an equitable health care delivery
function (World Health Organization, 2017). As a
system (Weber, 2010). Exploring the governance of
result however, the people’s health suffered (World
an organization is also justified to address leadership
Health Organization, 2017). Many factors were and management. In Somalia, it is hoped to pave new
attributed to this desperate situation. Among the main challenges for growth and development of public health
factor is the leadership and management system in services (United Nations Development Programme,
Somalia however, it lacked necessary infrastructure, 2001). In addition, the research questions are justified
since funding, insurances, and equipment are not to be befitting in order to explore solution(s) to the
managed well enough. Skilled manpower is also not problems of governance in public health settings.
available that could be useful for strategic planning
and policy development (World Health Organization,
Significance
2010). Somalia’s health care system has suffered from This study is significant to help the potential researchers
inadequate manpower, funding, mismanagement, and to have an in-depth knowledge about the leadership
poor planning and policy development ever since and management system in Somalia. Secondly, it is
independence (Population Reference Bureau, 2005). also significant among the policy makers, government
This has caused a serious setback to the development and concerned agencies, to identify the challenges of
of public health sector in Somalia, hence, the need leadership and management system in Somalia. Lastly,
to study leadership and management system (World it will enable Somali healthcare leaders to prescribe
Health Organization, 2017). recommendations which can pave new avenues in
overcoming their public health crisis.
Aims of the Study
Methodology
On account of these issues this study deems to explore
the lived experiences of public health care leaders Research Design
in leading and managing public health care services The study used a qualitative research design. This
in Somalia. Stemming out from this aim, research study described the patterns of conditions by persons,
questions are formulated. places, and times (DeFranzo, 2015) in relation to the
22 Open Access Journal of Nursing V1 . I2 . 2018
Leadership and Management in Public Health Setting in Somalia
independent variables – leadership and management. -Can you give an example on how you demonstrate
This design deemed to explore the lived experiences conflict resolution?
of public healthcare leaders in Somalia.
-Do you have any final suggestions on how to resolve
Research Type conflicts?
A descriptive-exploratory research type determined How do healthcare leaders manage changes in health
and reported findings the way they were said care service?
and mentioned by the respondents in a narrative
-What kind of specialized skills do you need to
approach (Burns and Grove, 2015). It attempted to
implement change?
describe factors such as performances, attitudes,
characteristics, and leadership and management -Can you give an example on how healthcare leaders
techniques. It obtained information concerning the succeed in managing change?
current statuses of public healthcare leaders, to
-Do you want to give more advice for other healthcare
explore what exists with respect to the conditions in a
leaders to manage change?
situation in the public health sectors in Somalia.
How do you as a healthcare leader manage
Research Population and Sample Size
performance from members of staff?
The target population for the study is mainly the
-How to make sure employees maintain their good
Somali public health care leaders. These leaders are
performance?
more into management and governance and not the
science of public health. This study selects 8 public -Can you give an example on how you demonstrate
health care leaders to be interviewed. performance management?

Sampling Technique -Do you have any final suggestions on how to manage
performance?
Purposive sampling  was used among participants
who were selected or sought after, based on pre- Why is structuring organizations significant in
selected inclusion and exclusion criteria (Burns and managing health care service?
Grove, 2015).  This study may be attempting to collect -How organizational structure affects group
data from public health leaders in Somalia. Primarily,
divisions by distributing employees to designated
Somali public health care officers were included.
departments?
Data Collection -Can you give an example on how you demonstrate
A comprehensive self-administered written open structuring of your department?
ended questionnaire guided the respondents. The
-Do you have any final suggestions on how to structure
questions are translated in the Somali language as
organizations?
it deems necessary. The questions include follow
up questions to enable further explorations of the How do healthcare leaders make their team work?
respondents’ lived experiences that are as follows: -Tell me about a time you faced an ethical dilemma
Why are leadership traits and styles significant in destroying team working?
healthcare service? -Can you give an example on how you demonstrate
-Why is it important to have a leadership traits and building team working?
styles in your field of work?
-Do you have any else to say regarding team working?
-Can you give reasons why you chose that specific
Why is quality assurance significant in managing
leadership traits and styles?
healthcare service?
- Do you have any final words regarding the significance
- Why do you practice the routine of quality
of leadership traits and styles?
assurance?
How do healthcare leaders resolve conflicts?
-Can you give a reason why you demonstrate quality
-May you describe conflicts that you faced? assurance?
Open Access Journal of Nursing V1 . I2 . 2018 23
Leadership and Management in Public Health Setting in Somalia
-Do you have any final suggestions on how to Answers were also organized in a systematic way
maintain quality services? in order to make the analyses useful. If the answers
were said in the Somali language, we translated it to
How does total quality management play a role in
English and explained it to the respondents, word per
managing healthcare service?
word. Should there be any changes as explained by
-How does your organization achieve recognition of the respondents, it is again shown to them before final
total quality service? transcription of the findings.
-Can you give an example on how you demonstrate Ethical Considerations
total quality management?
Ethical approval will be sought from the public health
-Do you have any final suggestions on how to achieve organizations of the respondents. If the organization
total quality service? is a government-owned institution, permission was
sought from the MOH. Approval was also sought from
Video-audio recorder was used to ensure that answers
the Lincoln University, Research Management Centre
from the respondents were collected. The video
in Malaysia for academic reviews.
recorded interview was transcribed into written
responses and thus used for data analysis. It was ensured that the respondent gave their consent
to be video recorded. The known benefits and risks
2.5 Data Analysis
or disadvantages of becoming a part of the study
We used an exploratory-descriptive approach in were clearly explained to all the respondents. Exact
analyzing the narration of each respondent during description of the information to be transcribed was
the interview sessions. By playing and replaying communicated orally or in writing. We considered
the videos we were able to write down the answers the freedom of the respondents to withdraw from the
word per word. Open ended written questions study anytime. We reassured them that the findings
were distributed to public health leaders before the will be kept confidential and private.
interview commences. Thus videos recording became
easier since the respondents already understood
Results and Findings
and prepared their answers and recommendations. Overview
Therefore, the answers transcribed were without
This chapter presents the findings from the data
misunderstandings.
collected, analysis, and interpretation. More emphasis
One main question was the focus for each respondent. has been placed on the interpretation of leadership
Since there are eight questions addressing the 8 themes and management in relation to public health care
for this study, only one theme (one set composed of 4 settings.
questions) will be used per respondent. Therefore, the
respondents will only have to explore one main theme Profile of the Respondents
with 1 main question and 3 follow-up questions. The 8 The interviewees from different public health offices
themes were the change management, organizational in Somalia were mostly above 30 years old. The profile
structure, teamwork, styles of leadership, performance of public health leaders as respondents are found on
management, conflict resolution, total quality table 1.
management, and quality assurance.
Table 1. Respondents profile

Respondent job description Age Theme

Finance manager in University of Health Science 33 conflict resolution
Health academic officer Bosaso University 27 quality assurance
Hospital manager in Daryel hospital of Bosaso 30 leadership traits and styles
Director Biyo Kulule health center 30 management of change
District health officer 34 structuring organization
Health care officer of Puntland in Bari region 36 performance management
Manager of Puntland Public Health Organization 35 total quality management
Human resource 38 team work

24 Open Access Journal of Nursing V1 . I2 . 2018

Leadership and Management in Public Health Setting in Somalia

Key Elements of Leadership and Management Departmentalization

The interview defined the 8 themes as the manner in On the key element departmentalization,
which subunits in organizations are inter-related and organizational structure was explored as it activates
grouped. A major advantage of the 8 themes is that inter-departmental coordination, task allocation,
it gives a focus on leadership and management (Yukl, and delegation of jobs that are directed towards
the achievement of organizational aims. The most
1989). However, the researchers have explored that
important question asked was “how organizational
the 8 themes can be still be further synthesized in to
structure affects group divisions by distributing
6 key elements.
employees to designated departments?”
1. Work specialization addressing change
“… in two ways, #1 it provides the foundation on which
management. standard operating procedures and routines rests
2. Departmentalization addressing organizational and #2 it determines which individuals get to participate
structure. in which decision making processes, and thus to what
extent their views shape the organizational action”.
3. Chain of command addressing leadership styles.
Each department is a part of the foundation of an
4. Span of control addressing performance organization and the chain of command is controlled by
management and conflict resolution. each departments. This is why the chain of command
is an element addressing leadership traits and styles
5. Centralization addressing team working.
that are also essential to be explored.
6. Formalization addressing quality assurance and
Chain of Command
total quality management.
On the key element chain of command, leadership
Integrating the 6 key elements with the 8 themes is traits and styles were explored particularly from
found to be appropriate in this study. Some of the a flexible leader. The most important question
themes were fused together in one key element while asked was “can you give reasons why you chose that
most themes are addressing the key elements as it is. specific leadership traits and styles?”
Work specialization “…to improve work oriented tasks, flexible time and
space among employees, and people relationship,
On the key element work specialization change
control and command must be done. However, I chose
management was explored as the process tools to
to be a flexible leader”.
technically manage the change among members of
staff. The most important question asked was “what Employees are given their flexible time and space
kind of specialized skills do you need for change?” in order to avoid stress and anxiety, thus create an
environment without conflicts. This exploration shows
“It depends on the interest of the employee. But we that conflicts will not happen in public health services
provide key skills for effective change managers such if your control over members of staff is flexible. This
as personal resilience, trust-building, coaching, forcing is why span of control is also an element that needs
clarity, skills pecialization, organization, and follow- to be explored addressing performance management
through. Therefore, we make them pursue continuous and conflict resolution.
education to specialize in their expertise”. Span of Control
This will achieve the required outcome by helping an On the key element span of control, performance
employee specialize, commit to, and decide on changes management is explored in controlling appraisals
in their current departments. This is why it is also among staff. The most important question asked was
essential to explore the element departmentalization “how to make sure employees maintain their good
in order to synthesize further knowledge on performance?”
how specialists make changes in their respective “when we select employees we look at their CVs and
departments. qualifying certificates and ensure that the certificates
Open Access Journal of Nursing V1 . I2 . 2018 25
Leadership and Management in Public Health Setting in Somalia
are valid. We give them salaries that are based on their year, we must make sure that the quality of our service
qualifications and ensure that they get promoted based is maintained”.
on their annual appraisals”.
International paradigms and global resolutions
However conflict may occur because of unfair of audits have influences on work specialization,
appraisals and lacking of good judgment on staff departmentalization, chain of command, span of
performance. That is why conflict resolution is also control, and centralization as elements achieving total
explored. quality management of services.
On the key element span of control, conflict resolution On the key element formalization, total quality
is explored from a public health leader on how to management is explored to achieve successful
avoid unfairness and discrimination among members implementation of all the elements together. The
of staff after or before performance appraisals. The most important question asked was “how does your
most important question asked was “may you describe organization achieve recognition of total quality
conflicts that you faced?” service?”
“…sometimes conflict may occur because of jealousy “We aim to achieve accreditation in order for our
between employees and/ or iscrimination and personal services to be internationally and globally recognized.
grudges among other staff… but it is eventually solved”. In addition, we keep the quality of the organization by
communication with employee the best possible service
Delivering solutions are a system of control. This is
and apply for continuous accreditation”.
why teams in an organization are centralized with
a higher appraisal system as a whole department in In addition, organizations are to be globalized and
addition to their individual performance evaluation. internationalized via accreditations. Total quality
This is why it is important to explore how each staff management will make members of staff move
work together as a team and avoid conflicts. forward to achieve higher levels in leadership and
management.
Centralization
On the key element centralization, team working is
Discussion
explored in order to see how the whole organization Introduction
centralizes their chain of command and span of
In this section it will clearly explore and describe the
control despite different structures and cultures are
8 eight research questions synthesized with the 6
found on an institution. The most important question
elements of leadership and management. Strength,
asked was “Tell me about a time you faced an ethical
weaknesses, and limitations of the study will also be
dilemma destroying team working?”
discussed.
“… similar to that scenario (ethical dilemma), problems
Strengths of the Study
with team working occur during audits. We require
everyone to work together because each department can A qualitative exploratory design allowed more in-
also be in trouble if we screw up the audit in general”. depth understanding of a process or a phenomenon
(DeFranzo, 2015) by interviewing respondents in
Centralized command and control will reduce conflicts
this study. We have explored new ideas from Somali
thus everyone will work together as a team. This is
healthcare leaders and managers and how their
why it is also necessary to explore the formalization of
healthcare system in the actual context of the issues
delivering quality service provided by each members
provides insights and solutions. Finally, we have
of the team.
uncovered trends in thoughts and opinions, and dived
Formalization deeper into the problem (Burns and Grove, 2015).
On the key element formalization, quality assurance is However, weaknesses and limitations were still
explored through routine audits of services provided. encountered.
The most important questions asked was “why do you Weaknesses and Limitations of the Study
practice the routine of quality assurance?”
Primarily, we had problems with data collection that
“…because audits of healthcare services happen every was time consuming as it was collected based on
26 Open Access Journal of Nursing V1 . I2 . 2018
Leadership and Management in Public Health Setting in Somalia
appointment dates fixed with individual respondents. 2005). These training institutions boosted the
Also issues of anonymity and confidentiality were also human resources for public health specialists. Thus
present problems. For example, most of the health organization gave them key skills for effective work.
care leaders and managers as our respondents were Other research agreed with our findings that personal
not comfortable with video recording, therefore we resilience, trust-building, coaching, forcing clarity,
need to eliminate those who refuse, making it more managing others’ uncertainties were important in the
time consuming. Lastly, some of the answers were in management of change and work specialization (West
Somali language; therefore, we have to translate it to et al, 2014).
English and shown back to the respondents before
final interpretation of the transcribed messages Some donor nations provided scholarships to MOH
are done. personnel for public health training. In addition, the
faculty of Medicine of the Somali National University
It was also difficult to synthesize new knowledge has started postgraduate training for public health
on integrating the elements of leadership and experts in the early 1980s (Somalia World Fact Book,
management with the 8 themes even though we were 2005). However, most of those who completed their
successful on doing it so. training either joined international organizations or
Exploring Work Specialization Addressing sought better opportunities in the oil-rich Arabian
Change Management countries in the gulf (Population Reference Bureau,
2005). Thus, a massive brain drain in the 1980s
In Biyo Kulule health center, a 30 year old male hampered any planned progress in Somalia (Office of
physician is the public health leader who became our Auditor General, 2005).
respondent. He stated clearly and truthfully that “the
organization provides work specialization to their staff”. Exploring Departmentalization Addressing
He also added that the management of change “results Organizational Structure
to an employee who has the capacity and capability to A Bosaso district health officer 34 year old male
specialize in their own fields of expertise”. The answers stated clearly and truthfully on the structured
were credible and reliable regardless of his age, gender, departmentalization of healthcare workers in the
and title. However, being a male medical doctor, his district health offices such as the District Health
answers may have affected his personal points of Management Information System (DHMIS), Public
view because he himself as a Somali believe that male Health Center (PHC), and the Nutrition department.
leaders (like him) are more effective specialists than Furthermore, he added that “departmentalization
females as a nomadic culture in the Somali settings. In determines which individuals get to participate in
addition, physicians have high qualifications that are which decision making processes, and thus to what
specialized. Nevertheless, his example as a specialist extent their views shape the organizational action”.
gave an impact to the employees even though it was a
Again being a male leader may be a factor on
personal opinion.
structuring an organization and its departments. Most
The setting on the other hand is in Biyo Kulele district. health care leaders in DHMIS follow the leading of a
This geographical factor has also affected his answers male Somali. The employees in DHMIS and Nutrition
having a setting that is mostly populated with a lot departments believe that male leaders are more
of specialized workers (at Biyo Kulele health centre) effective in structuring organizations. As a result of
influencing each other, but not in other regions. male leadership, the needs of the health care system
There were several milestones of work specialization and its effective operation were misconceptualized
in the history of health care services in Somalia. In (West et al, 2014; Weber, 2010). However, the type
1966, a nursing school was established in Hargeisa, and competencies of female manpower in DHMIS for
and another one in Mogadishu in 1970 for nurses the provision of core health care services at different
who wants to specialize in public health (Population levels of delivery points and departments were
Reference Bureau, 2005). In 1973, a faculty of medicine never yet determined. The argument of the chain
with specializations on public health and surgery was of command by empowering female leaders and
set up in Mogadishu (Population Reference Bureau, managers in Somali is thereby explored.
Open Access Journal of Nursing V1 . I2 . 2018 27
Leadership and Management in Public Health Setting in Somalia
Exploring Chain of Command Addressing to avoid the dilemma of lacking the elements of team
Leadership Styles working”. Other researchers agreed that being
centralized having one head or director may ensure
In Daryel hospital, a manager and a leader was a 30
that team members will be working together following
years old female. She stated clearly and truthfully
a leader (Adeyoyin et al, 2015; Heathfield, 2015). Her
that “there is a hierarchy and chain of command answers were credible and reliable regardless of her
according to the style of leadership, which improves age and position.
tasks orientation”. However, female leaders are always
found in the nursing profession, and may have affected Human resource managers in Somalia distribute
the answers as well, since leaders in Somalia are employees to a designated department to ensure
preferably males in order to ensure a concrete chain of team working. Nevertheless, being a female human
resource manager may have affected the answer of the
command. Contrary to male leadership, according to
respondent being emotional on the aspect of conflict
the respondent, female leadership style was “a flexible
management and team development (Duttweiler,
leadership, combined with commitment, dedication,
2008; Adeyoyin et al, 2015). She is rather emotional
sincerity, and a motherly nature”. Flexible leadership is
in a sense saying that in Somalia, there are lesser
also democratic by nature (Weber, 2010). That is why
teams that work together since it is governed by the
the Daryel hospital has achieved a smooth execution
male leaders. On this account, she further added that
of tasks orientation and chain of command because of “females are more committed to team working”. Women
their female leaders and managers. have pooled their resources and strengths, increasing
However, female leaders in Somalia are mostly passive the potential of their leadership and management
as compared with males who are not so emotional strategies (O’Neil and Domingo, 2016). That is why the
when running an organization (United Nations Entity span of control addressing performance management
for Gender Equality and the Empowerment of Women, is necessary to be explored also among male genders
2012). The United Nations Entity for Gender Equality in contrast to females.
and the Empowerment of Women (2012) also said Exploring Span of Control Addressing
that Somali women are reliant on the male factor for Performance Management
judgment, power and decisions. This is due to the fact
that women are blinded by customs and their position A 36 years old male health care officer of Puntland in
in society being under the male jurisdiction. Those Bari region says that “performance management system
who are responsible for taking decisions are literally action include developing clear  job descriptions  using
called Aqalka Odayaasha or “Male Traditional Elders” an  employee recruitment plan and providing effective
in Somali (United Nations Development Program, new employee orientation, assign a mentor, and orient
2012). This denies the women the right to become new employees into the organization and its culture”. In
leaders and managers and even further their careers addition, ongoing education and training will facilitate
since they have to respect the decisions of the men in and reduce conflicts in the organization (Heathfield,
their organizations (O’Neil and Domingo, 2016). 2015). However, he added that “a prominent weakness
of the Somali health care system was the lack of a strong
Other researchers agreed that the chain of command regulatory body”.
depends on the organization’s leaders and managers
and not merely based on genders (Adeyoyin et al, A successful performance management for example
2015; Yukl, 1989). That is why it is also important was the smallpox eradication campaign in the mid-
to explore how female leaders and managers ensure 1970s in Somalia (World Health Organization,
team works together. 2016/2017). This was the first introduction to
Primary Health Care (PHC) together with the new
Exploring Centralization Addressing Team tuberculosis treatment regimens by the Finnish
Working International Development Agency (FINIDA) in the
A human resource manager from the MOH was also a 1980s that brought in massive external assistance
38 years old female. She stated clearly and truthfully (World Health Organization, 2016; Population
that “every staff works with their own centralized Reference Bureau, 2005). It established PHC training
specialties with department leaders and managers institutions and opened the door managing medical
28 Open Access Journal of Nursing V1 . I2 . 2018
Leadership and Management in Public Health Setting in Somalia
specialty training among public health specialists. to wrest formal administrative and governmental
These inputs expanded access to health care services control from the transitional federal government
and improved the quality of care given to the public. as well as impose a system of Shari’s law upon the
Nowadays, the massive resources of the 21st century country. They seek to bring order of some sense to the
Somalia, injected into the health care system lack the chaotic region, thus ending the long period of disorder
proper control and management thus other countries’ since 1991. A more radical faction of the SCIC has
contributions such as the FINIDA faded (World Health
emerged throughout 2007 and early 2008 – Al Shabab
Organization, 2016). Conflicts then started to rise.
(‘the lads’ in Somali). These had been internationally
Exploring Span of Control Addressing Conflict attributed Al Qaeda. These groups continue to commit
Resolution gross abuses / violations of human right in Somalia
The PHC officer of the Bari region in Somalia who which in turn worsen the situation and create a hub
was 36 year old female stated clearly and truthfully for other organizations to get involved in the conflict.
that performance management is the key for This is when the downfall of organizations came one
conflict resolutions. Being a PHC manager and a by one. The quality of service has been in jeopardy
leader, he added that “conflicts may come across in due to the conflicts that arose.
any institutions and should be handled with caution
Exploring Formalization Addressing Quality
avoiding favoritisms in appraising performances and
Assurance
giving salary increments”.
An academic officer at the Bosaso University who was
In any organizations, a team of committed staff and
a 27 years old male, stated clearly and truthfully that
the very useful support members of the team may also
they do practical audit every year to ensure quality
help managers and leaders resolve conflicts (West et
of service. He said that “annual audit is a system
al, 2014). The Somali people have always suffered from
that helps an organization to identify weaknesses
long-standing oppression and conflicts at the hands
and inconsistencies in the system as a part of  quality
of their fellow Somalis (United Nations Development
management  which focuses on providing confidence
Program, 2001). Somali regardless of being the most
that quality service is provided”.
homogeneous Islamic region in Africa has witnessed
a civil war for over 2 decades. This history has led to Development of a national health plan with such
clan animosity. Divisions are defined by clan and sub attributes could have traced an efficient and
clan lines even in organizations. The Somalia society progressive path (Welch and Grove, 1991) for quality
is made up of main clan families like Darod, Dir, Isaaq, health care system. He added that “audit reports
Hawiye and Rahanweyn, and minority clans. Clan on the performance of the members of staff provides
divisions have been a source of conflict used to divide opportunity to the legislators, public servants, investors,
Somalis, fuel endemic clashes over salary increments, business leaders, citizen groups, media, development
job positions, and power. A broad based reconciliation agencies, academicians and other stakeholders to know
and conflict resolution became very difficult to achieve how public funds are spent and to assess the quality of
especially inside organizations and institutions. Most public health administration”.
of the Somalis conflicts have been fought in the name
The auditing bodies in Somalia are from the Office of
of clans often as a result of political leadership and
the Auditor General, the International Organization of
management. Political empires then have arisen.
Supreme Audit Institutions Development Initiatives,
The main political resistance to the government and the International Standards of Supreme Audit
consists of the Supreme Council of Islamic Courts Institutions (Office of Auditor General, 2005). In the
(SCIC) also known as the Islamic Courts Union (ICU), 1980s, research in medical sciences was initiated
Joint Islamic Courts, Union of Islamic Courts (UIC), or by the faculty of medicine, in collaboration with
the Supreme Islamic Courts Council (SICC), a cluster several universities in Sweden, through the National
based on fundamental Islamic law that is attempting Academy of Science and Arts in Mogadishu (Office of
Open Access Journal of Nursing V1 . I2 . 2018 29
Leadership and Management in Public Health Setting in Somalia
Auditor General, 2005). This allows public scrutiny of Why are Leadership Traits and Styles
Government operations and generates pressure for Significant in Healthcare Service?
honest and productive public servants and facilitates
Effective leadership traits and styles of healthcare
a system of governance necessary for efficient service
professionals is critical for strengthening the system
delivery.
of governance. There should be a hierarchy and chain
Exploring Formalization Addressing Total of command according to the style of leadership,
Quality Management which will improve task orientation.
A manager of Puntland Public Health Organization How do Healthcare Leaders Resolve
(PPHO) who was 35 years old male stated clearly and Conflicts?
truthfully that “we manage the quality of the services of
our organization by accreditation”. Effective conflict resolution plans strategies to resolve
miscommunication, discrimination, and personal
Currently, in the absence of an internationally
grudges delivering solutions. The keys to successful
accrediting health care organization, Somalia lost its
conflict management are to compromise and achieve
total quality in healthcare service. Therefore, to avoid
a win-win situation.
misguided national health development plans and
policy, it is essential to examine the deficiencies and How do Healthcare Leaders Manage Changes
gaps in the operation of the past health care systems on Health Care Service?
(World Health Organization, 2010), and to provide a
Healthcare leaders should make employees specialize
basic framework to ensure a functional and quality
in their own field of expertise and ensure changes
health care system from local accrediting organizations
that are done by experts, safe and effective. It is about
(Quality Improvement, 2011; Shridhara, 2007).
handling the complexity of the process of managing
Total quality management was a new dawn for the change that is best for the organization governed
accreditation in medical sciences and public health. by specialized members of staff.
In Somalia, an initiative was mentioned mainly
as a contribution to manpower public healthcare How do Healthcare Leaders Manage
institutions so that constant accreditation is achieved. Performance?
However, manpower was reduced by the economic This is done by developing clear job descriptions, using
downturn and political turmoil of the 1980s and civil an employee recruitment plan, and providing effective
war of the 1990s (Office of Auditor General, 2005). As new employee orientation, appraisals, and promotions
a result, experts in leading Somalia towards approval or salary increments. Fair and just judgments without
of international accrediting bodies did not happen discrimination are also expected.
(World Health Organization, 2016/ 2015a / 2015b).
Why is Structuring Organizations Significant
Conclusion and Recommendations
in Managing Health Care Service?
Conclusion
In order for an organization to have a good foundation
The explored leadership and management in Somalia on which standard operating procedures and routines
were (1) work specialization addressing change rests, structure is needed. Organizational structure
management, (2) departmentalization addressing
provides policies to individual members of the team
organizational structure, (3) chain of command
to get to participate in specific decision making
addressing leadership traits and styles, (4) span of
processes, and thus to what extent their views shape
control addressing performance management and
the organization.
conflict resolution, (5) centralization addressing
team working, and (6) formalization addressing How do Healthcare Leaders Make their Team
quality assurance and total quality management.. The Work?
answers to the research questions are also concluded
Teamwork is done by dividing labor among health care
as follows:
30 Open Access Journal of Nursing V1 . I2 . 2018
Leadership and Management in Public Health Setting in Somalia
professionals in a centralized way with means that no for donations from United Nations or World Health
single professional will face a dilemma in completing Organization. This is because scarcity of natural
their tasks alone. The healthcare leaders organize and resources and raw materials are still a problem in
motivate members of staff to work together to avoid Somalia. Internally displaced peoples are still in
ethical dilemmas. camps with limited resources to make a better living.
Why is Quality Assurance Significant in However, other gulf countries surrounded by deserts
Managing Healthcare Service? with limited raw materials have solved the problems
of limited resources through the advancement of
This is done by maintaining a high quality of health care science and engineering.
service and by constantly auditing the effectiveness of
the organizations. In order to maintain quality services That is why it is also recommended that managers and
provided, quality assurance is significant. leaders should focus on the science of technology for
artificial resources, however expensive. Nevertheless,
How does Total Quality Management Play a an organization will be confident that having globalized
Role in Managing Healthcare Service?
and internationalized high technology resources will
Total quality management must involve employees’ help provide quality services in public health sectors
suggestions and manpower.  In addition, accreditation to help refugees and internally displaced peoples live
must be achieved. Global and international visions a better life (Quality Improvement, 2011).
in leadership and management of health care
Globalization and internationalization has maintained
services are important to be included in total quality
economic growth on other countries and can also be
management so that access to healthcare services may
effective in Somalia. It is therefore recommended that
have quality.
globalization and internationalization be implied
Recommendations in the Somali public health care setting governed by
Primarily, for the Somali healthcare delivery system, leaders and managers with sound decision-making.
it is recommended to have a good policy system. Evidence reveals that women have more decision-
Somalia’s government has already declared drought making power and influence over aspects of their
as a national disaster, and the country is in the process political, social and managerial (O’Neil and Domingo,
of formulating its first national disaster management 2016). It is finally recommended that women be
policy. For this policy to be effective, Somalia needs empowered to lead and manage public health settings
a Somali-led integrated disaster information system in Somalia. Working towards regulating electoral
that identifies food insecurity and directs responses candidacy for Somali women could help alleviate
to poverty. 
challenges associated with poverty and misuse of
Another landmark of change in Somalia was the resources and give more access to financial supports
formation of a semi-autonomous refugee health unit from other high income countries. Therefore, women
(RHU) in the MOH to serve the refugees from Ethiopia are recommended to pursue political ventures and
in 1977, which attracted Bildhaan Vol. 7, bringing candidacy.
in a 192 massive foreign aid and expatriate health
A new concept for public health Somali leaders and
professionals (Population Reference Bureau, 2005).
managers is found on figure 1.
The RHU introduced sound health care planning and
effective operations, which positively influenced the Acknowledgements
overall MOH functions and operations (Population First of all, we would like to thank East Africa University
Reference Bureau, 2005; World Bank, 2015). The RHU for their support. Also, we would like to thank all the
refugees gained valuable help (Population Reference organizations and institutions that were mentioned in
Bureau, 2005). this study for allowing their leaders and managers to
It is therefore recommended to continue seeking be interviewed. And lastly, we would like to thank Edu
Open Access Journal of Nursing V1 . I2 . 2018 31
Leadership and Management in Public Health Setting in Somalia

Figure1. New concept on Somalia’s public health leadership and management

Punay for editing the final written research. Available at: https://www.snapsurveys.com/
blog/qualitative-vs-quantitative-research
References [5] Duttweiler, M. (2008), Priority Setting
[1] Adeyoyin, S., Agbeze-Unazi, F., Oyewunmi, O., Resources: Selected Background Information
Adegun, A., and Ayodele, R.O. (2015). “Effects of and Techniques Ithaca, NY: Cornell University
Job Specialization and Departmentalization on Cooperative Extension. Available online at http://
Job Satisfaction among the Staff of a Nigerian staff.cce.cornell.edu/administration/program/
University Library”. Library Philosophy
documents/priority_setting_tools.pdf
and Practice (e-journal). 1295. http://
digitalcommons.unl.edu/libphilprac/129 [6] HEATHFIELd, S. (2015). Performance
[2] Burns, N., & Grove, S.K. (2015). The practice Management. Available at: https://www.
of nursing research: appraisal, synthesis and thebalance.com/performance-management-
generation of evidence. Missouri: Saunders 1918226
Elsevier. [7] Office of Auditor General (2005), “Health System
[3] Centers for Disease Control, “Population-Based Strengthening in Africa. Sustainable Access to
Mortality Assessment—Baidoa and Afgoi, Treatment and Care for the Achievement of the
Somalia, 1992,” MMWR 41, no. 49 (1992): 913– Millennium Development Goals.” Meeting of
917. Experts, Addis Ababa, 10–12 October 2005.
[4] DeFranzo, S. (2015). What’s the difference [8] O’Neil, T. and Domingo, P., (2016). ‘Women and
between qualitative and quantitative research?
32 Open Access Journal of Nursing V1 . I2 . 2018
Leadership and Management in Public Health Setting in Somalia
power: Overcoming barriers to leadership and AS28.
influence’. London: Overseas Development [18] West, M.A., Topakas, A., and Dawson, J.F. (2014).
Institute. Climate and culture for health care performance.
[9] Population Reference Bureau (2005), “Country In B. Schneider and K. M. Barbera (eds.), The
Profiles: Somalia,” 2005. WHO-EMRO, “Country Oxford Handbook of Organisational Climate and
Profiles: Somalia,” 2004. Available at http:// Culture. (pp. 335- 359). Oxford: Oxford University
www.who.int/Earth/Trends Press.

[10] Quality Improvement (2011). Report: U. S. [19] World Bank (2015). World Development Report.
Department of Health and Human Services Investing in Health. Washington D.C.: Oxford
Health Resources and Services Administration. University Press.
Geneva: UN [20] World Health Organization (2015a), Health
[11] Shridhara, B. K. (2007), “Total quality Facilities Overview, Somalia. Somalia National
management (text and cases)”, India 2007. 4th Development Plan 2017-2019. Geneva: WHO
edition Gunjan Patel: Himalaya publishing. Pub.
[12] Somalia World Fact Book (2005). Online at [21] World Health Organization (2015b) “Facts and
http://www.cia.gov/cia/publications/factbook. Figures from the World Health Report.” The
[13] United Nations Entity for Gender Equality and World Health Report, Geneva: WHO. Available at
the Empowerment of Women (2012). Somalia http://www.who.int/whr/en
Humanitarian Strategy 2012-2015. Geneva: [22] World Health Organization (2016). WHO
UNDP, p. 11. received financial contributions to supports its
[14] United Nations Development Programme (2012). humanitarian work in Somalia from the Central
Somalia Human Development Report 2012: Emergency Response Fund. Geneva: WHO Pub.
Empowering Youth for Peace and Development. Available at http://www.who.int/emergencies/
Geneva: UNDP, p. 54 response-plans/2017/somalia/en/

[15] United Nations Development Programme [23] World Health Organization (2017). Somalia
(2001). “National Human Development Report— crisis. Update and funding request. Geneva:
Somalia” Geneva: UN Pub. WHO Pub. Available at http://www.who.int/
emergencies/response-plans/2017/somalia/
[16] Weber, D. (2010). Transformational leadership
somalia-funding-request_may2017.pdf?ua=1
and staff retention: an evidence review with
implications for healthcare systems. Nursing [24] World Health Organization (2010). U.S.S.R.,
Administration Quarterly, 34 (3): pp.246-258. 6–12 September 1978 Declaration of Alma-Ata.
[17] Welch, C. E., & Grove, P. L. (1991). An overview of Available at http://www.who.int/publications/
quality assurance. Medical Care, 29(8): pp.AS8– almaata_declaration_en.pdf

Citation: Regidor-111 Dioso, Abdirisak Mohamed Artan, et al. Leadership and Management in Public
Health Setting in Somalia. Open Access Journal of Nursing. 2018; 1(2): 21-33.
Copyright: © 2018 Regidor-111 Dioso, Abdirisak Mohamed Artan, et al.. This is an open access article
distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Open Access Journal of Nursing V1 . I2 . 2018 33