{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T18:41:08Z","timestamp":1792694468467,"version":"4.5.0"},"reference-count":26,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T00:00:00Z","timestamp":1789689600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>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\u2013expatriate healthcare settings during this period of transformation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      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                      <jats:italic>n<\/jats:italic>\n                      = 30) and patients (\n                      <jats:italic>n<\/jats:italic>\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.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1902847","type":"journal-article","created":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T05:38:30Z","timestamp":1789709910000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Negotiating reform from within: workforce governance and the expatriate\u2013Saudi interface in the SHSTP era"],"prefix":"10.3389","volume":"14","author":[{"given":"Ahmed","family":"Alshehri","sequence":"first","affiliation":[{"name":"Healthcare Management and Medical Informatics Department, College of Health Sciences, Umm Al-Qura University","place":["Makkah, Saudi Arabia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Asaad Abdulrahman","family":"Abduljawad","sequence":"additional","affiliation":[{"name":"Department of Public Health, College of Health Sciences, Umm Al-Qura University","place":["Makkah, Saudi Arabia"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,18]]},"reference":[{"key":"B1","volume-title":"Global Strategy on Human Resources for Health: Workforce 2030","year":"2016"},{"key":"B2","volume-title":"Vision 2030: Kingdom of Saudi Arabia","year":"2016"},{"key":"B3","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s40985-019-0112-4","article-title":"Healthcare human resource development in Saudi Arabia: emerging challenges and opportunities\u2014a critical review","volume":"40","author":"Al-Hanawi","year":"2019","journal-title":"Public Health Rev."},{"key":"B4","doi-asserted-by":"publisher","first-page":"11786329221121214","DOI":"10.1177\/11786329221121214","article-title":"Healthcare transformation in Saudi Arabia: an overview since the launch of Vision 2030","volume":"15","author":"Alasiri","year":"2022","journal-title":"Health Serv Insights."},{"key":"B5","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/1478-4491-1-1","article-title":"Human resources for health policies: a critical component in health policies","volume":"1","author":"Dussault","year":"2003","journal-title":"Hum Resour Health."},{"key":"B6","doi-asserted-by":"publisher","first-page":"308","DOI":"10.1093\/heapol\/czn024","article-title":"\u2018Doing' health policy analysis: methodological and conceptual reflections and challenges","volume":"23","author":"Walt","year":"2008","journal-title":"Health Policy Plan."},{"key":"B7","doi-asserted-by":"publisher","first-page":"423","DOI":"10.1016\/S1048-9843(02)00120-0","article-title":"Distributed leadership as a unit of analysis","volume":"13","author":"Gronn","year":"2002","journal-title":"Leadersh Q."},{"key":"B8","doi-asserted-by":"publisher","first-page":"273","DOI":"10.1111\/padm.12175","article-title":"Understanding hybridity in public organizations","volume":"93","author":"Denis","year":"2015","journal-title":"Public Adm."},{"key":"B9","doi-asserted-by":"publisher","first-page":"61","DOI":"10.46328\/ijres.v6i1.639","article-title":"The institutional isomorphism in the context of organizational changes in higher education institutions","volume":"6","author":"Cardona Mej\u00eda","year":"2020","journal-title":"Int J Res Educ Sci"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.4135\/9781036234386","author":"Green","year":"2018","journal-title":"Qualitative Methods for Health Research"},{"key":"B11","volume-title":"A Global Health Strategy for 2025\u20132028: Advancing Equity and Resilience in a Turbulent World: Fourteenth General Programme of Work","year":"2025"},{"key":"B12","author":"Patton","year":"2015","journal-title":"Qualitative Research & Evaluation Methods: Integrating Theory and Practice"},{"key":"B13","volume-title":"Street-Level Bureaucracy: Dilemmas of the Individual in Public Service","author":"Lipsky","year":"2010"},{"key":"B14","doi-asserted-by":"publisher","first-page":"201","DOI":"10.1080\/2159676X.2019.1704846","article-title":"To saturate or not to saturate? 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