Negotiating reform from within: workforce governance and the expatriate-Saudi interface in the SHSTP era

Saudi Arabia's Health Sector Transformation Program (SHSTP), introduced under Vision 2030, aims to improve health system performance while increasing the participation of Saudi nationals in the healthcare workforce. Although expatriate healthcare professionals continue to play a central role in service delivery, little is known about how workforce reform is experienced and governed within mixed Saudi-expatriate healthcare settings during this period of transformation.

This paper presents a secondary analysis of data collected as part of a broader doctoral study examining implementation of the SHSTP. The analysis draws on 53 semi-structured interviews with physicians (n = 30) and patients (n = 23), alongside a review of relevant policy and strategic documents. Data were analyzed using reflexive thematic analysis informed by an adapted Health Policy Analysis Triangle, with particular attention to actors, implementation processes, technology, and organizational culture.

Five interrelated themes were identified. First, collaborative professional cultures supported mutual learning and adaptation during reform. Second, authority was often negotiated between formal managerial structures and expertise-based influence. Third, leadership roles were reshaped by new accountability expectations and digital performance systems. Fourth, participants described ongoing capacity and competency challenges, highlighting the importance of mentoring and professional development. Finally, concerns about retention and motivation were linked to appraisal practices, contractual uncertainty, and professional identity. Across all themes, reform emerged as an ongoing organizational process shaped by everyday professional interactions rather than the straightforward implementation of policy directives.

Workforce reform under the SHSTP is shaped by everyday professional relationships, leadership practices, and organizational dynamics. Strengthening mentorship, leadership development, transparent appraisal processes, and knowledge-retention mechanisms may support workforce stability while advancing localization goals. These findings contribute to a deeper understanding of workforce governance in health systems undergoing large-scale reform.