The need for world-class, responsive, leadership and management for healthcare systems cannot be over-emphasized. The healthcare system is challenged by persistent increase in the demand for health care services, driven by rapid population growth and a high incidence of non-communicable diseases (NCDs).¹ Additional demographic pressure such as a rising elderly population, as well as socioeconomic reforms, liberal urbanization, and lifestyle changes, significantly impact the overall health status of the population.^2,3 These conditions have also resulted in the need for innovative and adaptive leadership and management across health institutions to navigate these complex challenges effectively.³ The Kingdom of Saudi Arabia (KSA) and the Kingdom of Bahrain (KB) are monarchies and are currently undergoing a significant transformation from a government-controlled healthcare system to a more self-sustained, autonomous model.⁴ The magnitude and complexity of this transformation require effective leadership at all levels of management (senior, middle and frontline).

Effective healthcare leadership depends on the ability of managers at all levels to translate strategy into coordinated action.^5-8 Among these tiers, middle managers (MMs) serve as the vital bridge between strategic leadership and frontline service delivery. MMs are individuals positioned between senior executives and frontline staff who are responsible for interpreting strategy, coordinating operations, and guiding teams. Senior and frontline managers refer respectively to strategic decision-makers (e.g., deans, CEOs) and those reporting to MMs (e.g., clinical or administrative supervisors). MMs operationalize institutional goals, ensure communication across hierarchical levels, and maintain team performance under complex and evolving healthcare conditions. ^9-12The competency of healthcare middle managers has been recognized as a decisive factor influencing organizational quality, staff satisfaction, and patient outcomes.^9,11,12

In the management and leadership literature, skills are task-specific abilities that can be learned or developed (e.g., communication or problem-solving).¹³ Traits and personal characteristics refer to enduring personal dispositions such as integrity, confidence, or adaptability that influence behavior across situations.¹⁴ Competencies, in contrast, represent the integrated combination of knowledge, skills, attitudes, and traits that together enable effective performance in a specific role or context.^15,16 Thus, in this study, the term competency is used as an overarching construct that encompasses both technical skills and personal traits required for successful middle management in healthcare.

In the Kingdom of Saudi Arabia (KSA) and the Kingdom of Bahrain (KB), national visions and policy reforms have emphasized health-system autonomy, efficiency, and quality improvement. These reforms demand managers who can navigate new governance structures and lead teams through change.^17,18 Yet, despite the critical role of MMs in implementing these transformations, there remains a gap in understanding what competencies define successful middle management in these settings. Existing research in these regions has focused largely on senior leadership development or physician management training,^17,18 with little exploration of the competency expectations across hierarchical levels or comparative perspectives between countries.

This study aimed to identify and compare the perceptions of senior, middle, and frontline managers regarding the core competencies required for successful healthcare middle managers in Bahrain and Saudi Arabia. The study also sought to explore how these competencies align or differ across hierarchical levels and how the findings can inform the design of competency-based training and development programs for MMs. Understanding these perceptions provides valuable insights into leadership development, capacity building, and workforce planning, and offers a foundation for designing targeted training and competency frameworks tailored to the evolving needs of the region’s healthcare systems. This paper presents the findings of that inquiry and offers recommendations for practice and policy related to healthcare leadership development.

The findings from the interview reveal seven major personal traits required as prerequisite for MMs: personality, agility, attitude, managerial skills, work ethics, mental ability and interaction. Personality had the highest scores while agility had the lowest. In literature, personality constructs are identified as being critical to both senior and MMs.¹⁹ The attainment of competency is determined by three factors - personal characteristics, job demands and organizational environment.²⁰ Personal characteristics encompass variables such as the individual’s capability, morals, vision and personal philosophy.

Job demands includes factors such as career stage, interests, roles, responsibilities and duties. The organizational environment refers to elements such as job culture, climate of the organization, and the economic, political, societal, ecological, and spiritual environment.²⁰ The personal characteristics such as capability, morals, vision, personal philosophy as identified in the literature align with, or are closely related to, the personal traits identified in this study: agility, attitude, managerial skills, work ethics, mental ability and interaction.²¹

The sub-themes identified under the personal traits included Integrity, Organization, Time management, Task management, Leadership quality, Teamwork, Decision-making, Vision, Good communication, Active listening, Patience, Knowledge, and Flexibility. These attributes are also supported in the literature.^22,23 As observed by Katz, effective leadership involves three types of personal skills - technical, human and conceptual.¹³ Technical skills refer to the knowledge and abilities related to a specific type of work, activity, specialization, or area of competency.²⁴ Human skills involve the knowledge and ability to work effectively with people, encompassing competencies such as effective communication, relationship building, fostering team cooperation, creating an atmosphere of trust and psychological safety, and demonstrating sensitivity and concern for the welfare of subordinates.²⁵ The managerial competences of time management and task management identified in this study are also supported by literature.^26,27 The social qualities required for MMs were identified as humility, good communication, active listening, good work ethics, the ability to motivate, lead and being a good team player. Good communication and relationship-building skills have been discussed as essential personal competences for MMs.¹³ Similarly, social judgment skills- reflecting sound understanding of people and social systems have also been recognized in the literature as critical competencies for successful MMs.²⁷

Under leadership qualities required for successful MMs in a medical university or health care organization, our study found a mix of traits and skills which were often used interchangeably by participants. This included self-confidence, a desire to grow, being organized, integrity, communication, vision, knowledge, teamwork, time and task management. As also noted in the literature, effective leadership skills are essential for fostering conditions conducive to teamwork, improving operational outcomes, and ensuring the smooth flow of information.²⁸ Specifically, transformational leadership skills have been linked to managerial behavior and managerial effectiveness during transformation.^22,23 Additionally, managers who adopt a learning-oriented style have been found to demonstrate high competence in their roles,²⁹ particularly within the domain of middle management. Human, technical and conceptual skills have also been identified as important,¹³ although these constructs intercept with already discussed elements such as communication, knowledge, and relationship building.

Problem-solving skills, including the ability to recognize a problem, collect information, and create work plans for problem-solving,²⁷ are a core set of managerial skills. Knowledge, defined as the accumulation of information and the possession of a mental framework in which information is organized, is also identified as a vital tool in the middle manager’s portfolio.²⁷ The literature further outlines leadership competencies for physicians.³⁰ These include team management with the aim of enhancing quality of care through a focus on value, efficiency, and safety,³¹ as well as change management, which is based on the understanding that change is inevitable in the medical sector and that leaders must be equipped to respond effectively to shifting circumstances.^32-34

Given that the aim of the study was to identify the differences in the perceptions of frontline, middle and senior managers on the competences required for successful MMs, aggregation of the data based on hierarchical management position is a central to achieving this aim. By analyzing both thematic trends and individual items emerging from the data, the study reveals several insightful patterns. For example, in looking at the findings on personal traits required for MMs, a trend emerged in the data in which senior management tends to emphasize certain traits such as personality, agility, attitude, managerial skills, work ethics, and mental ability more, compared to frontline-level managers. This pattern may reflect senior management’s supervisory role over MMs³⁵ granting them a broader perspective. According to them, these qualities enable MMs to implement strategic decisions and fulfill organizational objectives effectively. On the other hand, the frontline management prioritizes interaction and attitude more than both middle and senior management.  This emphasis likely reflects the relational dynamics required for MMs to effectively guide, support, and collaborate with frontline staff.³⁵ Confirming this interpretation, sub-themes identified under interaction and attitude were good communication, active listening, and patience, which are attributes that subordinates would appreciate in a senior. These findings suggest that MMs should have a set of personal traits that would allow them to work effectively with both senior and frontline-level management, serving as a vital bridge between strategic leadership and operational execution.

Multiple interpretations are possible when examining the individual attributes identified in the study. For example, both senior and frontline management identified the ability to motivate and ability to lead as one of the most significant characteristics for MMs. While fewer frontline-level managers focused on such attributes, top management highlighted concern and consideration for subordinates as important characteristics. In contrast, frontline management valued interactivity as a key trait for MMs. Representing a mix of all competencies identified by the three levels of management, the management as a whole acknowledges concern for employee well-being, relationship, communication, and being active as crucial competences. Such findings indicate that differences occur in the ways in which respective middle manager skills, competencies or traits may be perceived across the three levels of management, even when all the perceptions and all the items are necessary for successful MMs.

One important competency frequently highlighted in the literature as essential for physician leadership, but notably absent from the study’s findings is cross-cultural sensitivity. In the modern global context, there is strong emphasis on leadership that values diversity, since physicians and nurses tend to interact with patients and families from diverse cultural and social backgrounds.³⁵ Accordingly, the current thinking is to instill a strong sense of appreciation for diversity among medical students.³² It is likely that this competency was not considered a priority by the research participants in KSA and KB as against competences required for MMs in a global sense.

This study has several strengths. Participants had an average of six years' experience in their current roles, reflecting substantial expertise across senior leadership, middle, and frontline management in healthcare. The sample included 22% from senior management, 37% from middle management, and 41% from frontline management, with the majority representing middle and frontline management. Additionally, participants were nearly evenly split between the medical sector and the broader healthcare sector, supporting the generalizability of findings across both domains. Their roles spanned healthcare delivery, administration, teaching, leadership, research, training, and residency, demonstrating a diverse and rich base of experience informing the study’s insights. The educational background of respondents was also analyzed to contextualize the study's findings.¹⁹ distinct fields emerged, all within the broader domain of Medical Sciences, including Surgery, Internal Medicine, Family Medicine, Neurology, Neuroscience, Anatomy, Pathology, Radiology, Orthopedic Surgery, Geriatrics, Genetics, Nutrition, Public Health, Epidemiology, and areas such as Hospital Management and Healthcare Governance. The wide disciplinary spread contributes to a rich pool of knowledge and expertise, enhancing the relevance and applicability of the study’s insights.

There are several limitations to this study. All participants were over 31 years old, with the majority in the 41–50 age bracket, and 62% were male. These factors may introduce gender and age-related bias. As with most qualitative research, there is potential for subjective bias during data collection and interpretation. To mitigate this, a structured and well-defined coding process was used, which enhanced consistency and reduced human error. Additionally, the study focused on senior, middle, and frontline-level managers in the Kingdom of Saudi Arabia and Kingdom of Bahrain, limiting the generalizability of findings to other regions.

The findings from this study are useful for understanding perceptions on the leadership and management competencies required for MMs. Since MMs have to work effectively with both senior frontline-level managers in order to successfully deliver organizational goals, an understanding of the perceptions of competencies required for successful MMs across all three levels of management is strategic for successful transformations. The findings may, thus, be applied in the design and delivery of training programs for MMs in health and medical education. The findings from this study also have implications for further research as a portfolio of skills, traits, and competences have been identified for middle management that can be further explored to understand their individual impacts or benefits. Adopting such frameworks can professionalize middle-management roles and enhance continuity between strategic and operational leadership across healthcare organizations globally.

Middle managers play a pivotal role in translating institutional strategy into effective practice. In Bahrain and Saudi Arabia, success in these roles requires a balanced integration of ethical integrity, technical proficiency, interpersonal competence, and adaptability. Embedding these competencies into leadership-development programs can strengthen healthcare governance, improve communication across managerial tiers, and enhance system responsiveness to reform.

These competencies align with global leadership standards and thus hold relevance for healthcare organizations worldwide. Developing structured, competency-based training frameworks around these domains can enhance leadership capacity, improve organizational performance, and inform future comparative research across regions.