A leader’s attribute plays an important role in determining an organization’s future in terms of performance and success. Although organizations are affected by several factors both from the internal and external environment, such factors normally impact an organization through its leader [1-4]. It is against this background that several leadership styles and leadership theories have been developed and used with varying degrees of success. One such leadership style and leadership theory, which has attracted significant attention from researchers and scholars, recently, is servant leadership. Servant leadership style is increasingly being accepted and used across different fields and organizations, with its basic premises seen as effective in solving some of the organizational problems and issues [1]. In fact, Russell asserted that various scholars and practitioners now contend that servant leadership is an appropriate and effective leadership style for organizations [5]. Servant leadership emerged as a concept in the 1970s after Robert Greenleaf coined the phrase in his essay ‘The Servant as Leader’ [6]. Driving by the belief that poor leadership was a major contributing factor to the uprising in the 1960s, Greenleaf suggested that leaders need to serve their followers and that characteristic of great leaders is that they strive to become servants first [7]. Even though the emergence of the concept is recent, servant leadership is considered to have a deeper and stronger historical base than any other leadership style. According to Brewer, traces of servant leadership are evident in passages dating back to the 4th century B.C., especially those documented from China’s Lao-Tzu who lived in 570 B.C [8]. Additionally, the concept of servant leadership is evident in Jesus’s teachings to his disciples, which are documented in the New Testament Books of Mark and John [8]. Nevertheless, the literature on servant leadership that followed its emergence five decades ago focused on developed themes that could facilitate the operationalization of the concept of servant leadership, and as such, researchers have attempted to emphasize various characteristics of a servant leader [9-18]. Organizations that provide health care have a complex system, comprising of many stakeholders including hospitals, different clinics, primary health care centers and the management and staff of these facilities/institutions. The focus of the health care organizations is to provide the best health care services to the population that it is designated to cater. Nonprofit health care providing organizations (such as the Medical Services Department (MSD), also must focus on the efficient utilization of the available funds to provide the most optimum and best possible care to patients and a high patient satisfaction [17,19]. Poor results in the form of low patient satisfaction may decrease the patient’s perceived value of the medical care provided, thus affecting the patient's trust and adherence to treatment. More so, when the treatment is being provided free of charge as is the case in Saudi Arabia. Another important challenge for the health care providers is to improve the overall quality and value of health care. Trastalk have discussed in detail about the changing aspects of health care and the necessity of leadership in tackling the different issues of health care [19]. They suggest that the health care providers due to their unique understanding and interactions should be at the forefront as leaders. They must take the initiative to serve as leaders due to the important position they occupy in satisfying the patients who look forward for their guidance not only in diagnosis, assessment, advice, and treatment but also in taking informed decisions. In addition, a responsible health care provider working as a leader provides valuable guidance to his co- workers and health care providers and helps to maintain professional ethical and value driven standards. Furthermore, leadership from the health care provider is of importance in integrating the different stake holders in the care organization and for providing valuable insight and guiding the health care system in their endeavors to improve the value of care for the patients. Providing health care is a team work and leadership plays an important role within the care provider network [2]. In each group any individual can serve as a leader by displaying exemplary commitment to professional and ethical behavior as a part of his/her professional responsibilities [19]. Among the different leadership models that have been applied in health care industry, servant leadership is recognized as a very effective tool and is likely to gain a prominent place in future.

This paper attempts to examine and discuss the application of servant leadership in military healthcare system by focusing on Medical Services Department (MSD) of the Ministry of Defense in Saudi Arabia. Based on Spears’ model of servant leadership, there are 10 attributes of a servant leader [20]. Although several theories and models have provided different attributes of servant leadership, the work of Spears was used in this analysis as it is more comprehensive [20].

Characteristics of Servant-Leaders

Listening: Listening is one of the key characteristics of a servant leader. Being a good listener is considered a valuable attribute of successful people. According to Spears, good listening is a learned skill, which can be valuable in terms of obtaining information and finding meaning in what is being spoken [21]. In the military, leaders are often compelled by the desire to do things their own way, owing to the strong chain of command. However, sometimes, there are other alternatives and better approaches of accomplishing a task and listening and evaluating the views of followers can lead to discovery of a better way of completing task in an efficient manner [22]. Listening and engaging followers can also be important for a servant leader in making them understand that their value as part of a team or organization is accepted and appreciated.

Empathy: Showing empathy is also a key attribute of a servant leader as effective leadership requires that one connects and understand the followers. Spears noted that empathy starts with understanding that it is the responsibility of a leader to not only manage a group, but also understand the group is made up of individuals [21]. As such, a servant leader should be able to have personal connect with each follower and treat every individual as productive and having something to offer to organizational cause. With reference to servant leadership in the military, Maxwell noted that an empathic military leader is not one who stands before a platoon and all that he sees is a platoon, but one who stands before a platoon and sees it as comprising of 44 individuals with specific aspirations, desire to live, and desire to do good [23]. Gustaveson adds that empathy is quite valuable attribute for leaders in the context of military environment where followers are sometimes overworked, face numerous family problems, and experience housing issues among other challenges [22]. Thus, the ability empathize with followers is a quite effective approach to making followers understand that a leader recognizes their concerns [24].

Healing: According to Northouse, healing refers to making one whole. In other words, leaders can heal their followers, and in particular, servant leaders are seen as a force of transformation through their abilities to recognize the fragility of human heart and that life brings different challenges to the work environment [21,24]. Gustaveson argues that this attribute is quite important in the context of military leadership as it promotes safe work environment, especially because most people in the military operate in dangerous environments [22]. While this attribute may seem less important in the context of military leadership as healing is a role preserved for healthcare providers, it remains essential in promoting effective leadership in the military because through this attribute a leader is able to express genuine concern in assisting their followers overcome personal challenges.

Awareness: This attribute is about the extent to which a leader understands the organizational environment through a global perspective. Ability to understand one’s environment, particularly in terms of ethical and moral issues, allows a leader to effectively ascertain conflicts of interests. Essentially, a servant leader should be able to establish values within the organization in order to strengthen the ability to manage subordinates [8]. According to Spears servant leadership encourages this unique and special attribute [21]. It makes it possible for leaders to effectively put themselves in other’s shoes, understand how they impact others, and comprehend their own objectives and desires [8,24]. In the context of military leadership, this is a unique attribute that defines a successful leader as those who have awareness demonstrate strong ability to fit into the larger organizational picture and can adjust their own objectives and behaviors to meet the common goal [22].

Persuasion: Persuasion is another key characteristic servant leader that makes servant leadership a valuable necessity in the military. While authoritarian leaders often make decisions based on their title or position, servant leaders strive to build broader consensus among group members through persuasion to achieve change [8]. Spears adds that the ability to persuade members of a team to accept a majority view without employing coercion is an essential element of teamwork [21]. Even though goals and objectives may be achieved using positional authority in military organizations or any other organization, such an approach erodes individual performance of followers. This is because without persuasion, a leader creates a work environment in which followers do not understand their value.

Conceptualization: In servant leadership literature, conceptualization is defined as the ability of a leader to recognize and comprehend how things fit into the big picture [22]. This attribute significant in enabling a leader to respond to issues and challenges in the context of organization’s overall objective. In other words, a leader should not just concentrate on the minor issues and problems at hand but need to be ready to see where everything fits into the larger picture in order to be able to adjust and respond to larger issues. Gustaveson argues that this attribute relates to military leadership, just as the attribute of healing, because an understanding of external issues that may affect an individual’s performance is important in preventing hazards not just to those individuals, but also to other organizational members [22].

Foresight: Foresight refers to the ability of a leader to learn from past experiences and influence future outcomes based on those experiences. It involves avoiding repeating the same mistakes made in the past and provides a means of determining the future impact of a decision [25]. This is a key characteristic of not just servant leadership, but also other types of leadership because leaders are usually held accountable for organizational problems and failures [26]. This is more important in the context of military leadership where failure can be costly in terms of deaths and destruction; hence the ability of a military leader to recognize past failures and successes and use such experiences to avoid future problems is invaluable.

Stewardship: This is about a leader personally holding himself or herself accountable to the success or failure of their organization. Essentially, this attribute of servant leadership involves accountability, honesty, and being ethical, which makes stewardship important in a military setting. It also promotes partnership and not patriarchy and encourages leaders to distribute ownership and responsibility [27,28]. In the context of military setting, leaders are operating like stewards since they are placed in positions of trust and service and can only effectively by being accountable, honest, and ethical. In fact, stewardship theory holds that an agent has collectivist and not an individualistic management perspective and his primary motivation is to promote the interests of the organization and the principal over his personal interests [29].

Commitment to the growth of people: Commitment to the growth of followers is also a key element of effective leadership in the context of military. Military leaders are bound by rank structure to train their subordinates in order to do the job or become leaders in future [22]. Not only does this require that every individual in the organization is treated in a unique manner; it is also essential that individual differences among followers are understood and recognized in order to promote their personal and professional development [22,24]. In the context of military setting, followers are expected to learn a lot of things by themselves; however, they are unlikely to progress if they are forced to do tasks without being offered guidance.

Building community: Building community is the last but equally valuable characteristic of servant leadership [12,20]. It is important because it allows leaders to be sensitive to what influences the organization and workforce. In the military, building of various levels of community is necessary from the country level to the military, specific command, and to the smallest military unit [22]. A servant leader will strive to help his followers develop a sense of unity and create an environment in which they feel connected, which can be achieved with the use of outdoor activities or informing followers about the value and purpose of their role. Gustaveson notes that this idea already exists in the military setting as exemplified by promotions of esprit de corps through codes of honor and conduct, oaths, and pledges [22].

Implementing servant leadership at military organization

MSD and its patient experience challenge: Medical Services Department (MSD) of Saudi Arabia’s military is the second largest healthcare provider in the country with more than 34 hospitals and 160 primary healthcare clinics, several outpatient facilities, and field hospitals focused on helping the military achieve its objectives and missions in the Kingdom and overseas [30,31]. In 2013, the MSD offered healthcare services to more than 7,498,000 patients across the Kingdom [30]. The country’s healthcare has comparatively improved in recent decades and years as compared to the 1980s [32]. Significantly, the improvement is attributed to the government’s efforts to prioritize healthcare services and increase allocation for healthcare services every year [33]. Notably, Saudi Arabia’s healthcare services efficiency was recently ranked 16th by Bloomberg in terms of healthcare costs per capita, life expectancy, and healthcare expenditure as a proportion of GDP [34]. Despite the above positives, the healthcare system in the Kingdom is still plagued by several challenges. For instance, the healthcare sector remains underfunded as compared to the group of high-income countries which Saudi Arabia is part of. In addition, the sector is also constrained by an inadequate number of doctors (i.e., 9.4 doctors per 10,000 people compared to G20 average of 27.1 doctors per 10,000 people) and low bed capacity (i.e., 22 beds per 10,000 people which is below the G20 average of 56) [35]. Additionally, with the expected population of the country expected to surpass 39 million people by 2030, there will be more pressure on the country’s healthcare system, including MSD, which provide healthcare services to military personnel as well as civilians [30,36]. Moreover, the change in disease patterns with an increase in non-communicable disease (i.e., chronic diseases, such as cancer, cardiovascular disease, diabetes, and hypertension) resulting from lifestyle changes is also another challenge for the MSD [36,37].

Employee motivation at MSD: In addition to patient-related challenges and problems at MSD, the organization also face employee related issues and problems. It is reported that despite having some of the best resources and significant funding, Saudi Arabia’s military engages in poor recruitment and training [38]. Although this could be attributed to low funding of the healthcare systems and programs of MSD by the Saudi Arabian government, there is a possibility that the type of leadership employed by the military leadership to manage the organization has contributed to the reduced level of employee motivation and engagement at MSD [30]. In other words, command and control leadership is associated with low efficiency and reduced level of employee motivation due to the disconnect between the leaders and the followers [39]. The leadership is often preoccupied with the problems and issues that affect them while paying little or no attention to the problems and issues faced by the followers [25]. These organizational challenges and employee issues call for the implementation of servant leadership in order to enhance the efficiency of MSD and employee satisfaction.

Introducing servant leadership at MSD: Introduction of the concept of servant leadership at MSD can be essential in alleviating the challenges and problems faced by the military in its efforts to meet healthcare needs of its military personnel and Saudi Arabian people. It is worth noting that MSD is typically a large, complex organization owing to the number of health facilities it runs. Additionally, as a department in the military, it is hierarchically structured with a topdown, command and control kind of leadership. The presence of a topdown, command and control leadership does not imply that the leaders at MSD have no attributes and characteristics of servant leadership discussed earlier. Additionally, it is not accurate to suggest that the command and control leadership employed at MSD leads to low levels of employee engagement at the organization [40]. Essentially, all military organizations are known to have command and control leadership but employee engagement that results in emotional connection to the organizational mission and team is usually quite high [22,40]. In other words, elements of servant leadership relating to attributes of listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to the growth of people, and building community [21] could be evident at MSD. Nevertheless, any effort to introduce servant leadership at the organization would be daunting and challenging because organizational members are always resistant to change. Besides, the leadership at MSD are used to the command and control leadership model and to a culture focused primarily on excellence on healthcare delivery and a specific way of doing things [13], making it challenging to successfully implement this leadership model. Nevertheless, the leaderships and organizational members can be made to understand the need of shifting MSD’s operating culture and leadership approach.

Implementing the concept: Building awareness: Successful introduction and implementation of servant leadership at MSD would require awareness building. Drawing on a case study of Cleveland Clinic, which had a military-like command and control leadership before a servant leadership was implemented in 2008 [40], an external consultancy group with significant knowledge and experience in servant leadership can be used to facilitate the implementation of this leadership style at MSD. This would involve building awareness of servant leadership among leaders of every unit and function within MSD through several activities including servant leader- focused coaching, and servant leader initiation program [40]. Furthermore, as illustrated in Jennings and Stahl-Wert [41], the following key steps could be explored and implemented by the leadership of MSD to encourage servant leadership: Upending the top-down pyramid to ensure that leaders and followers support and serve each other in the organization; Building on collective strengths through recognition and leveraging of each member’s strengths; Creating a strong and compelling vision shared by every member of the organization in order to encourage members to develop a common goal of achieving it; Training and coaching each member of the organization to practice servant leadership; Raising the bar by motivating organizational members to commit to greater goals and empowering them to achieve those goals.

This paper has tried to discuss the concept of servant leadership and its relevance and effectiveness to MSD for Armed Forces, Saudi Arabia. By providing a detailed analysis of servant leadership and its applicability to the military context, it has been argued that characteristics of servant leadership are quite relevant and applicable to the context of military setting. In fact, all the ten characteristics of servant leadership are readily traceable in the military leadership where, despite the strong chain of command and hierarchy, military leaders must share power, place the interests and needs of others ahead of their own and help followers develop and perform efficiently as much as possible. From this perspective, servant leadership has been found suitable and appropriate as a way of promoting the performance and efficiency of MSD. It is suggested that servant leadership be introduced and implemented at the organization through awareness building in order to eliminate change resistance and enhance acceptability of this style of leadership at the organization.