Abstract

Little is known about how the health professions organize in low- and middle-income countries (LMICs). This is particularly troubling as health worker strikes in LMICs appear to be growing more frequent and severe. While some research has been conducted on the impact of strikes, little has explored their social etiology. This article draws on theory from organization and management studies to situate strike behavior in a historical process of sensemaking in Kenya. In this way, doctors seek to expand pragmatic, moral, and cognitive forms of legitimacy in response to sociopolitical change. During the first period (1963–2000), the legacy of colonial biomedicine shaped medical professionalism and tensions with a changing state following independence. The next period (2000–2010) was marked by the rise of corporate medicine as an organized form of resistance to state control. The most recent period (2010–2015) saw a new constitution and devolution of health services cause a fractured medical community to strike as a form of symbolic resistance in its quest for legitimacy. In this way, strike behavior is positioned as a form of legitimation among doctors competing over the identity of medicine in Kenya and is complicating the path to universal health coverage.

Achievement of universal health coverage (UHC) is directly tied to a health system's capacity to strengthen its health workforce (Cometto, Buchan, and Dussault 2020). Since 2004, the global health community has focused on addressing the inadequate supply, maldistribution, and imbalanced skill mix of human resources for health, particularly in low- and middle-income countries (LMICs) (Chen et al. 2004). This led to concerted efforts to demonstrate the magnitude of workforce challenges (WHO 2006) as well as systematic attempts to position solutions in a crowded UHC agenda (Chopra et al. 2008). While much of this work has raised the profile of health workforce development in LMICs, it betrays a technical understanding of a social problem (Campbell et al. 2013), which is among the “disappointing failures” in global health programming (Horton 2016). It is still unclear, for example, how the health professions organize and engage in the policy process in many LMICs. This is problematic as growing discontent among health workers increasingly leads to service delivery interruptions that threaten progress toward UHC (Russo et al. 2019).

Evidence is relatively scarce on strikes among health workers in LMICs. In a recent comparison of 70 strikes across 23 low-income countries, from 2009 to 2018, researchers found that strikes were becoming more frequent as a result of complaints about remuneration, dissatisfaction with sector governance/policy, and safety of working conditions (Russo et al. 2019). While striking health workers are hardly new (Wolfe 1979), they have traditionally been viewed as too disorganized to exert political influence on the policy process in LMICs (Walt 1994). This article questions the assumption and argues for its reappraisal. Furthermore, by understanding how health professionals engage in organizational sensemaking, I argue that recent strike activity is a key step in the pursuit of legitimacy in Kenya, a lower-middle-income country.

Human resources for health in Kenya are under considerable strain as a result of internal and external political economic forces. In 2014, the number of skilled health professionals in Kenya (17.86 per 10,000 population) was below the WHO minimum threshold (22.8 per 10,000 population) (WHO 2018). Doctors disproportionately practice in urban areas (MOH 2015). Health-worker migration persists with estimates as high as 8% of nurses and 51% of physicians practicing abroad in 2008 (Mwaniki and Dulo 2008). Moreover, of the health workers that remain, many are absent from their posts. In the most recent service delivery indicators report (2018), 61% of doctors and 55% of nurses were absent at the time of the survey. These absences were authorized for ancillary activities such as training, teaching, meetings, and workshops for 69% of absent doctors and 42% of absent nurses, suggesting systemic problems with health systems planning and management (MOH 2019). How these pressures are tied to organizing practices and their implications for the health sector are the subjects of this article.

Finally, since 2010, Kenya has experienced multiple strikes by health professionals that challenge the health system in complicated ways. These strikes occur amid institutional transformation, including the promulgation of a new constitution, formation of a senate, devolution, and expansion of social benefits. As I will show, there is historical precedence to strikes in the Kenyan health sector, but they appear to be growing more frequent and severe (Irimu et al. 2018). Evidence is mixed on the health effects of the most recent wave of strikes since 2010. Research from one rural coastal county, covering six strikes from 2010 to 2016, found no association between strike incidence and overall mortality, although the authors note the data underestimates this effect (Ong'ayo et al. 2019). Service delivery interruptions have been documented in a number of public referral hospitals (Irimu et al. 2018; Njuguna 2015), and though there is evidence that the health system absorbs these shocks in complex ways, health workers report feeling further demoralized by deteriorating health and financial conditions, often in already fragile service delivery settings (Waithaka et al. 2020). While health-worker strikes elsewhere have been characterized as ambiguous “environmental jolts” that trigger social processes of organizing (Meyer 1982), I argue that in Kenya these events are related to organizational sensemaking among health professionals as they seek legitimacy amid a health sector undergoing profound institutional change.

This article provides a social explanation of “what is going on here?” (Goffman 1974). By drawing from a body of work collectively known as the “sensemaking perspective” in organizational studies (Weick 1995), this research provides a basis for understanding the structure and agency of professional organizing in the Kenyan health sector. More specifically, by tying the struggle for legitimacy among a divided medical profession in Kenya to the legacy of colonial rule, this research explores unique organizing phenomena in the process of sensemaking. In this way, the research advances knowledge about health professional associations in LMICs as well as underappreciated features of the sensemaking perspective in organizational studies. Finally, by shifting the focus of health sector strikes from technical problem solving to social meaning making, this work can inform deliberative practices of workforce strengthening in Kenya and other LMICs encountering similar challenges.

Theory and Methods

Sensemaking, a recurrent social process of understanding disrupted order, has been the subject of considerable research in organizational studies (Brown, Colville, and Pye 2015; Maitlis and Christianson 2014; Sandberg and Tsoukas 2015; Weick, Sutcliffe, and Obstfeld 2005). The emergence of this line of inquiry in the mid-90s marked an analytical shift from choice selection (decision making) to the intersubjective creation of meaning (sensemaking) (Maitlis and Christianson 2014). It has been associated with a variety of commensurable research traditions including those rooted in pragmatism (Hernes and Maitlis 2010), phenomenology (Sandberg and Tsoukas 2020), and postmodernism (Langenberg and Wesseling 2016). The work of organizational scholar Karl Weick is considered foundational; he explained sensemaking as a process that is: (1) grounded in identity construction, (2) retrospective, (3) enactive of sensible environments, (4) social, (5) ongoing, (6) focused on and by extracted cues, and (7) driven by plausibility rather than accuracy (Weick 1995). Thus, while sensemaking concerns the retrospective evaluation of specific episodes, actors are defined through their abilities to make sense of them in ways that enable action (Sandberg and Tsoukas 2015). The human ability to order flux through social meaning is responsible for the creation and perpetual recreation of organizations (Tsoukas and Chia 2002). Language is a fundamental feature of this social process, and, as such, discursive constructs are tied instrumentally to organizational stability and change (Vaara, Sonenshein, and Boje 2016). By focusing on sensemaking, this article illustrates profound transitions in the organization of the health professions in Kenya, whereby doctors construct narratives in pursuit of organizational legitimacy.

The sensemaking perspective has much in common with other post-positivist approaches in policy studies. Research in this tradition operates from the premise that humans are engaged and embedded in the social construction of multiple, but equally legitimate, interpretations of social reality, which are open to change and reinterpretation (Berger and Luckmann 1966). More recently, efforts have been made to understand how these concepts have been deployed in empirical research on the health policy process (Koon, Hawkins, and Mayhew 2016). Still, little research to date explores the political dynamics of the health workforce in LMICs from an organizational sensemaking perspective, which focuses more specifically on the construction of legitimate collective action.

In addition to processes of sensemaking, legitimacy is also a particularly useful construct in organizational settings. According to Suchman (1995: 577), “Legitimacy is the generalized perception or assumption that the actions of an entity are desirable, proper, or appropriate within some socially constructed system of norms, values, beliefs, and definitions.” Because legitimacy brings stability and order to the social world, it is an aspirational characteristic of organizations and institutions (Scott 2008). In organizational research, legitimacy has been characterized as pragmatic, moral, or cognitive in nature (Suchman 1995). Nascent organizations focus their attention on constructing pragmatic and moral legitimacy, turning their attention to cognitive legitimacy as the organization matures (Golant and Sillince 2007). Pragmatic legitimacy (audience self-interest) is pursued via strategic exchange, influence, and projecting a particular disposition (Suchman 1995). Moral legitimacy (normative approval) is constructed by seeking favorable evaluations about the organization and its endeavors (Suchman 1995). Cognitive legitimacy (comprehensible, taken-for-granted position) is present when an organization is culturally determined to be inevitable, necessary, or assumed (Suchman 1995). When organizations form, pragmatic legitimacy allows founders to mobilize resources from newly recruited constituencies for organizational development, while moral legitimacy facilitates investment on the basis of plausible outputs, their ethical validity, and alignment with social institutions (Golant and Sillince 2007). In this article, I demonstrate how members of a new medical union organize, amid institutional flux, in the quest for pragmatic, moral, and cognitive legitimacy.

Legitimacy is closely tied to concepts such as professional authority and autonomy in the sociological literature on health professions. Authority is understood as an ability to ensure compliance through some combination of status, claim, or (organizational) characteristic, which relies on both legitimacy and dependency (Starr 1982). According to Blau (1963: 308), “The distinctive feature of authority is a belief system that defines the exercise of social control as legitimate.” This is predicated on internal consensus, which, according to Starr (1982: 80), in early American medicine posed “perhaps the foremost obstacle to the collective authority of the medical profession . . . internally, divided, it was incapable of mobilizing its members for collective action or of winning over public opinion.” That divisions within health professions, especially medical professionals, pose legitimacy challenges to professional authority has been shown in various contexts, including Germany (Kuhlmann 2006), India (Sriram et al. 2018), Turkey (Agartan and Kuhlmann 2019), Mexico (Nigenda and Solórzano 1997), Taiwan (Lo 2002), and Zimbabwe (Mutizwa-Mangiza 1999). In LMICs, this was accentuated by the legacy of social stratification imposed by colonial regimes and institutionalized in postcolonial state bureaucracies (Johnson 1972). Still, there remains limited scholarship disentangling legitimacy, authority, and how these influence the political nature of the relationship between doctors and the state in LMICs (Chorev and Schrank 2017).

Similar to professional authority, professional autonomy is related to legitimacy in complex ways, with some scholars blurring the distinctions. According to Elston (1991: 61), “Professional autonomy refers to the legitimated control that an occupation exercises over the reorganization and terms of its work.” Professional autonomy can be further distinguished based on its clinical (right to set standards and monitor clinical performance), economic (right to determine remuneration), and political (right to make policy decisions on health matters) dimensions (Elston 1991). Freidson (1970) assumed that clinical autonomy was relatively stable across contexts, but that economic and political autonomy varied considerably across countries. For this reason, some have called for a renewed focus on professional legitimacy/autonomy as a source of political power, which is largely overshadowed by research on clinical autonomy (Schlesinger 2002). Political autonomy is of interest in Kenya because legitimacy claims can be tied to broader systems of medical professionalism. Abbott contends that professions maintain a “strategic heartland monopoly” over core jurisdictions (i.e., clinical decision making), but that analysis of other jurisdictions in which they have vied for legitimacy is key to understanding how they evolve (Abbott 1988). Thus, the central aim of this analysis is to look at how different forms of legitimacy evolved in Kenya to compete for political autonomy or, rather, extend its jurisdiction beyond the “heartland” of clinical decision making into the realm of health sector policy and planning.

To accomplish this, four distinct sources of data were used. First, I reviewed the academic literature related to health workforce development in Kenya. Second, published reports, position papers, and government documents (2000–present) were identified and reviewed throughout the research process. Third, I conducted and analyzed 50 semistructured, in-depth key informant interviews. The interviews' location and tone, the nature of the dialogue, the characteristics of the interviewer, and reflections on physical space were all seen as important features of the data. This was captured through ethnographic field notes, which constitute my fourth dataset. Since the field notes were not systematically coded in the same way as the text of the interview transcript, these served as reference points throughout the course of analysis and interpretations of findings, but are not directly cited.

This research was a piece of a larger project on the politics of health finance reform in Kenya (Koon 2017). For this work, I conducted 50 interviews in English from May 2014 to March 2015 in Nairobi, Kenya. Interview participation was developed through an iterative snowball method (Bernard 2011) of identifying principal actors based on relevant documents and knowledge of their involvement in health policy discussions. Study participants were recruited via email, phone calls, and personal contact.

Interview participants were leaders of medical and nursing professional associations, unions, and regulatory bodies. Their insights, as well as those from other study participants including politicians, government officials, international stakeholders, and the private for-profit business community, form the empirical foundation of this research. Interviews were recorded, transcribed, and thematically coded, and emerging themes were analyzed using Dedoose analytical software. Secondary coding was pursued to more thoroughly analyze organizational processes among the health professions. Quotes are presented below anonymously from study participants, utilizing broad professional descriptors to protect their identity.

Reflexivity is an important part of all interpretive research but particularly in accounts of sensemaking (Vaara, Sonenshein, and Boje 2016). This research was conducted by a nonmedical, white male from a high-income country who spent approximately six months in rural and urban parts of Kenya (from 2006 to 2011) prior to initiating this research in 2014. The “outsider status” of the researcher was seen as both positive and negative: positive in the sense that many interview respondents agreed to participate and speak candidly as the researcher was perceived to not have a readily identifiable policy position; negative in the sense that often the researcher had to resort to “phased assertion” probes (Bernard 2011), whereby controversial opinions were challenged and emerging counterarguments tested during interviews. This provocative interview style was used to speed up elite interviews, discuss core sources of contested beliefs, and enable participants to differentiate themselves from the party line. As will be demonstrated, the Kenyan health sector was in the process of institutional transformation at the time of fieldwork, which presented an opportunity for understanding the politics of policy change. This was also determined to be a useful subject of empirical research by Kenyan Medical Research Institute-Wellcome Trust (KEMRI-WT), a local research institution with which the researcher was affiliated during data collection. Through interactions with other researchers at KEMRI-WT and presentations at international research conferences, peer-debriefing was pursued. Member checking was enabled through presentation of preliminary findings of the larger study to a select group of study participants. Thus, through triangulation of data sources, reflexivity, peer debriefing, and member checking, this research is consistent with the rigorous conduct of research in the social sciences (Marshall and Rossman 2011). The Institutional Review Boards of Amref Health Africa in Kenya and the London School of Hygiene and Tropical Medicine in England approved this study.

Findings

Sensemaking starts with chaos.

—Weick, Sutcliffe, and Obstfeld, “Organizing and the Process of Sensemaking”

The following section is divided into three parts with different sources of information. Narratives in organizational research are often composites, constructed by the researcher to interpret collective meanings of organizational members (Vaara, Sonenshein, and Boje 2016). In the first section, I describe organizational sensemaking and the quest for legitimacy among Kenyan physicians using secondary historical data from independence to the new millennium. In this period, independence from colonial rule was understood to be the trigger for organizational sensemaking, which resulted in an overreliance on pragmatic legitimacy at the expense of moral legitimacy, as the medical profession privatized, fragmented, and was constrained by the inadequate social institutions of a weak state. In the second section, I present findings from a companion analysis to argue that a failed health financing reform effort, underpinned by divisive electoral politics, led to political disarray that fragmented the medical profession's organizational claims to pragmatic legitimacy from 2000 to 2010. In the third section, I rely on primary data from organizational actors engaged in the active process of sensemaking and their understandings of legitimacy from 2010 to the present. In this period, the promulgation of a new constitution, devolution of health services, and expansion of social benefits triggered organizational sensemaking, through forms of symbolic resistance, but with unclear legitimacy implications given the changing identity of the state under broader institutional reforms. By looking at three distinct periods, I construct a broader narrative of professional medical organizing in pursuit of legitimacy in Kenya.

Organizing Doctors in Kenya (1963–2000)

Much can be explained by the legacy of colonial biomedicine in Kenya. The Kenyan Medical Association (KMA) started as the East African branch of the British Medical Association (BMA) prior to independence. The system of care developed by the Colonial Medical Service reflected a hospital-centric, largely urban service-delivery platform, common in Europe in the early twentieth century (Iliffe 1998). The expressed purpose of this care was to cater to the health needs of colonial administrators serving abroad (Beck 1970). The BMA was a primary vehicle for organizational sensemaking among colonial medical officers, maintaining strong links to their epistemic community and decreasing their social and intellectual sense of isolation by engaging with current medical research and standards of practice (through the British Medical Journal and the Kenya Medical Journal/East African Medical Journal, established in 1923) (Crozier 2007). Nevertheless, the BMA, founded in 1832, was also seen as a powerful trade union, setting fees, addressing collective needs, and providing political representation (Jones 1981). This was true of the East African branches as well, which aggressively lobbied to the Colonial Office through the BMA to improve terms of the East African Medical Service, particularly through targeted campaigns in 1919–21, 1925–26, and 1936 (Crozier 2007). Initially, membership was restricted to colonial medical officers, and little evidence exists of meaningful efforts to establish a domestic medical workforce (Beck 1970). This marginally changed during colonial administration, with governments in East Africa developing a handful of small training programs for African health care providers (with the notable exception of the Makerere Medical School in Uganda in 1924) (Iliffe 1998). Upon independence in 1963, health featured prominently in the nationalist agenda with the Kenya African National Union aspiring to provide free health care nationwide (Sama and Nguyen 2008). The domestic workforce grew rapidly, as did membership in the BMA chapter, which was renamed the Medical Association of Kenya in 1968 and eventually severed ties with the colonial BMA in 1973, when the KMA was formed (Iliffe 1998).

For much of its history, the remit of the KMA reflected the changing role of the state in Kenyan society. Membership was and continues to be open to physicians serving in both public and private sectors. This shaped sensemaking for an emerging medical profession in several important ways. For example, following independence, Kenya was an early pioneer of primary health care, establishing a vast network of health facilities across the country (Sama and Nguyen 2008). With an emerging market orientation and the growing influence of international development actors in the 1990s, the health system turned its attention to a privatized system of hospital medicine (Dahlgren 1994). In addition, population growth and poverty placed a great deal of strain on providers, and citizen demands for accountability led to widespread distrust of public services. Meanwhile, other segments of the health workforce became increasingly organized and threatened the primacy of medical providers in systems of care (Iliffe 1998). Thus, the KMA, constrained and threatened, turned inward, narrowly striving to cater to its more established membership.

The postcolonial narrative explains the profession's difficulty in disentangling itself from the state. In fact, professionalization was considered constitutive of African nationalism in the postcolonial era (Johnson 1972). As African medical training advanced, Iliffe (1998) argues, the sector's structural dysfunction can be attributed to postcolonial interpretations of the relationship between the emerging professions and the state. This is because the cognitive basis of legitimacy for the medical profession was only applicable to the colonial order. Thus, emerging medical professionals “possessed only the powerless trappings of professionalism” (Iliffe 1998: 3). This suggests two interrelated aspects that further reinforced patterns of organization across the profession following independence. First, it seems clear that the emerging cadre of health professionals understood that relations with the state were zero-sum and not symbiotic in nature (Iliffe 1998). Second, as Iliffe (1998: 5) poignantly observes, “What chiefly damaged the power and status of East African doctors after independence was not the power of the state, but the weakening of the state in the face of population, growth, economic crisis, and commercialization.” As we shall see, sensemaking as the basis of organizing is tied to political action that led to a destructive pattern of interaction between doctors and the state, which persists today.

Doctors making sense of a postcolonial order enacted strikes that failed to advance pragmatic legitimacy and likely damaged moral legitimacy. Three doctors' strikes were initiated in Nairobi but encompassed other urban areas in 1971, 1981, and 1994. There is some indication that these represent the first (1971) and the most severe (1994) strikes in sub-Saharan Africa at the time (Iliffe 1998). The strike of 1971 was initiated in Nairobi and eventually included all public sector doctors; the cause was ostensibly over poor pay and professional recognition. The strike of 1981 was organized by disgruntled junior doctors who wanted the KMA to be less of a disciplinary body and more of a union. The strike of 1994 lasted more than 100 days and was precipitated by the desire of younger doctors to register as union. These physicians were responding to a number of grievances including low pay, poor working conditions, deteriorating public status, and eroding professional authority (Iliffe 1998). These recurring themes will be discussed in greater detail in the third section of this article, on “unionizing doctors,” below.

While colonial notions of professionalism oriented doctors in Kenya, strikes illustrate the fractious nature of organizing within the profession. As Iliffe (1998: 181) notes, “The doctors were commonly divided, between private practitioners and state employees, professional leaders and discontented juniors, conservative upholders of inherited ethics and radical advocates of new ideas.” For these reasons perhaps, the KMA did not enact strikes, preferring to mediate disputes between the state and self-organizing practitioners. This also helps to explain to some extent the KMA's focus on pragmatic, at the expense of moral, legitimacy. Decades of overcrowding, undersupply, inconsistent remuneration, and generally poor working conditions likely caused many physicians to move into private practice, and eventually to emigrate (Iliffe 1998; Mwaniki and Dulo 2008). As a welfare organization for a cognitively legitimate, but pragmatically oriented profession, the KMA represented the interests of more established, senior members of the profession, often in private practice (Iliffe 1998). This largely persists today and is, I argue, both a source of instability in health service delivery and an obstacle in the quest for organizational legitimacy among Kenyan doctors.

The Rise of the Medical Entrepreneur in Kenya (2000–2010)

Political transitions in the early 2000s reflected sociocultural shifts that influenced the complex relationship between the state and the organizing medical profession in Kenya. The election of President Mwai Kibaki in 2002 signaled an end to four decades of single-party rule by the Kenya African National Union. This proved consequential for health professional organizing, in several important ways. First, the newly elected administration embarked on an ambitious program of social policy reform. This included universal primary education as well as a move to overhaul health financing through the expansion of social health insurance. Second, a group of private medical providers formed their own professional association, enhancing ties between the medical and business communities. Third, election-related violence and the constitutional crisis of 2007–2008 resulted in a coalition government that split the Ministry of Health into two entities, with heads appointed by each party. Each of these developments represents a window into organizational sensemaking processes that shape the identity and legitimacy of organizing medical professionals.

The political process surrounding the 2004 Bill on National Social Health Insurance has been analyzed in detail elsewhere (Koon, Hawkins, and Mayhew 2020). In summary, after a period of intense stakeholder engagement, the bill was rapidly approved by Parliament, but President Kibaki refused to sign it into law, and it was promptly dismantled. The bill proposed several changes to revenue generation, risk pooling, and purchasing, which, while technically sound (Carrin et al. 2007), were seen as a threat to doctors' political and economic autonomy. A group of private for-profit medical providers were able to convince the president and minister of finance that the bill was unaffordable, unsustainable, and politically harmful. In so doing, they signaled the emergence of corporate medicine as an organized form of resistance to state control.

Thus, the process of lobbying against the bill served as a trigger for deeper processes of organizational sensemaking among private for-profit medical entrepreneurs. As sensemaking is concerned centrally with group identity, the principal actors enacted a formal mechanism to expand newly acquired pragmatic legitimacy. According to one representative, the “KHF [Kenyan Healthcare Federation] was born out of this bill and this created this desire of having a common vehicle. . . . We have common interests, we need to be involved in advocacy, a bit of lobbying, we never had a platform.” The private for-profit health sector is diverse and includes an array of actors from medical suppliers, device manufacturers, pharmaceuticals, providers, health facilities, and insurance companies. It is notable that this new organization was tied more directly to the emerging Kenya Private Sector Alliance than to the KMA, potentially accelerating the corporatization of health care in Kenya. Moreover, anticipating comparable jurisdictional competition in other countries, members of the KHF proceeded to incubate similar organizations under the umbrella of the East African Healthcare Federation, with an eye to expansion in southern and West Africa. Thus, on an exclusively pragmatic basis, an influential segment of the medical profession pursued legitimacy with uncertain implications for professional autonomy.

The failure of the bill also highlighted the relative weakness of both the Ministry of Health (MOH, which designed and advocated for the bill) and the KMA (which supported it). Traditionally, health financing debates in Kenya take place within the stakeholder management board of the public insurer, the National Hospital Insurance Fund (NHIF). The KMA's position is so assured that it was one of the few organizations to survive recent legislative amendments to end institutionally guaranteed positions on NHIF's management board. By definition, the MOH's relationship with the NHIF is stronger, though more complicated on account of the NHIF's status as a parastatal. Nevertheless, despite both occupying key positions in the governance structure of the national insurer, the politics of the 2004 bill show the limits of their influence on policy making. Moreover, the emergence of an organized market-oriented segment of the health profession implies shortcomings with the KMA's ability to secure pragmatic and moral legitimacy and the MOH's ability to contain it.

The weakening of the state's bureaucratic machinery and the more general rise of clientism culminated in the contested 2007 election. This resulted in electoral violence and a subsequent power-sharing agreement between two dominant political (coalition) parties. According to Mueller (2008: 187), among the damaging conditions that gave rise to political disarray were “deliberately weak institutions, mostly overridden by a highly personalized and centralized presidency, that could and did not exercise the autonomy or checks and balances normally associated with democracies; and political parties that were not programmatic, were driven by ethnic clientism, and had a winner-take-all view of political power and its associated economic byproducts.” Thus, the organizational basis and ascendancy of medical entrepreneurs based on a pursuit of exclusively pragmatic legitimacy is both symptom and cause of deteriorating state control.

Another effect of the contested 2007 election and 2008 power-sharing agreement was the division of the Ministry of Health into the Ministry of Medical Services and the Ministry of Public Health. This was largely unpopular as it raised concerns about conflicting mandates, uncertain governance arrangements, and inefficiencies in resource allocation (Wamai 2009). The disarray also created a vacuum of leadership within the health sector in which professional authority, autonomy, and professional legitimacy were increasingly unclear. Thus, the unsettled nature of health professional regulation created fertile grounds for broader institutional reforms, which began to take shape during consultations for perhaps the largest political transformation since the transition from colonial rule, beginning in 2010.

Unionizing Doctors in Kenya (2010–2015)

In 2010, Kenya embarked on an ambitious program of large-scale institutional change. This included the adoption of an explicit rights-based constitution, the formation of a senate, and the devolution of health services to 47 newly delineated counties, beginning in 2013. The uncertainty surrounding constitutional reform was acutely felt by doctors, whose relationship with the state was ambiguously altered. The constitution (2010) guaranteed every person the right to “the highest attainable standard of health, which includes the right to healthcare services, including reproductive healthcare.” Doctors interpreted this to be responsible for two subsequent developments. First, in 2013, the newly elected National Rainbow Coalition pushed to increase health care utilization through free maternity care and removal of user fees, overwhelming an exasperated health workforce (Koon et al. 2017). Second, following devolution, public practitioners would become employees of county health departments, with unclear, politicized mandates (Kimathi 2017). Finally, for the first time, the constitution (2010) explicitly acknowledged every worker's right to fair remuneration, reasonable working conditions, forming/joining a union, collective bargaining, and striking. This removed a widely acknowledged institutional constraint on organizing in the health sector, which doctors interpreted as an invitation to enact change in their quest for legitimacy.

The Kenya Medical Practitioners Pharmacists and Dentists Union (KMPDU) explains its genesis in a particular way. While the historical record suggests that the KMPDU was formed through an activist group of junior doctors in 1994 (airing similar grievances) (Iliffe 1998), the current organization dates itself to 2009 when it started as a Facebook group (Mwenda 2012). As one founder stated, “The message went to social media, which is the easiest way to get people to agitate . . . Twitter and all these . . . it's very powerful.” Once the message was out, a small group of junior doctors awaiting posting met at a YMCA meeting hall in Nairobi. They were frustrated by the death of a colleague who was “working diligently and providing medical care which he can't afford. It was absurd.” Some relayed stories of colleagues losing their jobs while agitating for better working conditions. Others identified specific service delivery shortcomings such as a shortage of gloves in the country's second largest teaching hospital. In this way, origin stories constructed problems as systemic, locating their source in the interface between the profession and the state.

Much of the KMPDU's identity is ascribed by its distinctions from the KMA. According to a KMA leader, the main difference is the KMPDU “mainly comprises of our younger colleagues . . . so by law they are allowed to go and picket in the street and all that. . . . In the background we [the KMA] back them [the KMPDU] a lot in the boardroom.” In this reading, the relationship is described as “cordial,” even if privately KMA leadership thought the younger KMPDU doctors were naive. The view from the KMPDU was less generous: “When it [the KMPDU] was formed, starting off, there was a bit of antagonism, I must admit.” Another reported, “I must say that initially there was some kind of . . . suspicion.” According to them, the KMPDU tried to “explain to the older guys [the KMA]” with reasoned proposals, but there was silence. “And so, we told [the KMA] that something needs to be done. . . . Guys could not take it anymore.” In this way, sensemaking was as much about what the KMA was not, as what the fledgling organization was perceived to be. According to one leader in the health professions, the KMA was a “member's club of senior doctors who have their way through Afya House [Ministry of Health],” and they noted, “[the KMA] lost ground with the young doctors, that's the only mistake.” By analyzing sensemaking, this analysis suggests that the KMPDU arose through a deficiency of moral legitimacy, as a result of the KMA's overreliance on self-interested exchange with the state.

Aggrieved and impassioned younger doctors drew inspiration from established industrial organizers beyond the health sector. As one founder of the KMPDU explained, “We struggled to get legitimacy because we came in as young people, and we didn't have a lot of resources.” This exchange-oriented view of pragmatic legitimacy is commonplace in Kenyan labor movements. It also explains how the small group of doctors were enchanted by the Central Organization of Trade Unions (COTU), the powerful umbrella of 36 different labor unions in Kenya. As a founder explained, “[the COTU] supported us in conceiving the idea of forming the union because at the beginning we were just doing demonstrations.” In this telling, the charismatic secretary general of the COTU encountered junior doctors in the streets and advised them that they should have a “legal foundation.” The COTU then showed them “the steps of forming a union.” He continued, “Yes, actually COTU gave us the resources to use . . . if it's a lawyer, if it's a negotiator, they supported us fully.” Another founder explained the extent of this relationship, “[the COTU secretary general] is my mentor, he is my father figure in the trade union movement. Whenever I have a problem, he is the first person I run to.” Despite this assistance, the KMPDU would, “struggle to gain legitimacy.” Others saw this as natural, “It takes time for a union to stabilize because there is a lot of politics, there is a lot of . . . teething problems.” As one founder pointedly observed, relations between the KMA and the KMPDU were tenuous: “I think the union fears to lose its autonomy and the KMA fears to be swallowed by the union.” In this way, dormant fissures within the medical profession were exposed by institutional change, which permitted new forms of organizing and resistance.

If sensemaking was triggered by constitutional reform and individuation from the KMA, and facilitated by experienced labor organizers, registration of the union was enacted as a plausible outcome. As one KMPDU founder stated, “We had the constitution in 2010, that is when the union was formed, and . . . we have a totally different landscape of governance in the country and we wanted to sensitize not just ourselves but policy makers and health care personnel.” This account belies an ordered rendering of a complicated process. In another story, the same individual observes that following the new constitution, “we started by engaging the government by asking what are the labor laws, what does it take to register a union? . . . Let's go ahead and do it.” Another founder agreed: “It was never planned, it simply happened.” The interpretation of permissible organizational conduct enacted formal processes of legitimation. In this way, legally ambiguous attempts at formally registering a union in the past were deemed irrelevant in the context of broader institutional change.

Organizing doctors symbolically exercised institutionally conferred authority through the KMPDU to call for a strike that further solidified an emerging professional identity and attempted to augment pragmatic, moral, and even cognitive legitimacy. First, the initial strike was constructed pragmatically as part of both the process and outcome of sensemaking. As one leader explained, “Actually we had that industrial action happen within . . . three months of the union being registered.” He described this as formative in a crowded organizational landscape: “Not just KMA alone, but . . . we captured the imagination of everybody . . . even the media was caught unaware.” Much of this was motivated by self-interested exchange with the state to incrementally adjust salaries and improve working conditions. While the former was achieved through a 100% raise, the proposed steps to strengthen the work environment are reported to have fallen flat. Still, this was understood to be a key moment in recruiting financial and human resources to the KMPDU's cause, an important step in building pragmatic legitimacy.

To a much lesser extent, strike action was tied to doctors' quest for moral (normative) legitimacy. According to one KMA leader, “The health people are generally meant to serve. . . . Doctors are undervalued generally, especially here in Kenya.” As mentioned, sensemaking was tied to concrete examples of poor working conditions that negatively affected the health of patients in addition to the well-being of junior doctors. There are other indications of how doctors interpreted and enacted strikes to ethically validate the emerging organizational narrative. One was through a surprising, albeit tepid, endorsement by the KMA. “We had those elderly [KMA] professors, you know, telling us that we were doing the right thing . . . on the right track . . . they were right with us. . . . We had a very good support from KMA national office. I mean they didn't go out into the streets to demonstrate . . . but the message and the sufferings were going down to the younger doctors.”

Finally, the initial decision to strike was situated within a broader narrative of cognitive legitimacy for the fledgling medical union. The KMPDU's members understood an outcome of strikes was political autonomy to establish a new professional order in which they were actively engaged in workforce development. As one leader explained, “So, one thing that came out in this strike is that there was a very big difference in the influence and change in philosophy or ideology . . . in KMA. It triggered in them to think on ways in which they can engage the government.” Another emphasized that this was down to changing individual decisions: “How do you get the other party to understand your value and therefore translate [this in] to policy? . . . You know, when people agitate and they are called into the streets, they are bound to listen.” Enacting the transition from interpretation to action, an early KMPDU organizer shared, “The moment we triggered . . . things changed.” In this way, strikes harnessed institutional flux, reconstituting the professional identity of many junior doctors and positioning them as legitimate participants in policy and planning.

Discussion

This analysis offers a number of practical and theoretical insights. This work helps explain recent workforce policy developments in Kenya, demonstrate social dynamics of organizational sensemaking among doctors, and elucidate the basis of organizational legitimacy in the context of the sociology of the health professions. In explaining these phenomena, a richer picture of the sociopolitical dimensions of health workforce development comes into focus.

Strikes among doctors in Kenya have produced both positive and negative effects. As mentioned, withholding medical care is ethically dubious and harmful to citizens seeking care. On the other hand, strikes have wrenched free a number of important concessions, such as salary increases and debate over poor working conditions. Moreover, these may generate secondary effects such as increasing health-worker productivity and engagement, further raising quality of care. The KMPDU has continued engaging in key workforce development issues such as the Health Act of 2017, a related drive to establish a national health commission, and other, more tangential, issues related to health financing strategy. The implications for the KMA, whose weak grasp of moral legitimacy was exploited by the KMPDU, is unclear; yet, the identities of both are enmeshed. While much organizational sensemaking is an effort to assert control in the chaotic process of devolution, doctors continue to make sense of uncertainty in consequential ways. For example, though they initially failed at inserting the proposed health services commission (a body responsible for consolidating the confusing health professions regulatory landscape) into the Health Act of 2017, it was commissioned in 2019 following an assessment by a multisectoral presidential task force (BBI 2019). Arguably, much sensemaking continues to be in service of expanding pragmatic and cognitive legitimacy, at the peril of moral legitimacy, which animated its origins. This is particularly evident in the increasingly severe and frequent strikes, often in coordination with other health professionals (Irimu et al. 2018). It is plausible that insufficient moral legitimacy will further erode public trust in health services and eventually damage the KMPDU's tenuous pragmatic and established cognitive legitimacy. The struggle for organizational legitimacy and political autonomy amid deteriorating state control has also been documented in Zimbabwe (Mutizwa-Mangiza 1999) and, to a lesser extent, Nigeria (Alubo 1986). In summary, strike behavior as a key organizational process and outcome of sensemaking is a risky path to universal health coverage.

This analysis adds important insight into the processes of organizational sensemaking. By focusing on “environmental jolts” (Meyer 1982) or other events that “trigger” (Sandberg and Tsoukas 2015) sensemaking, this analysis provides a social foundation for professional identity. Whether through the KMA's postcolonial transition, the formation of the KHF in opposition to health financing legislation, or the founding of the KMPDU upon constitutional reform, a divided medical profession plausibly reordered disrupted norms. The example of the KMPDU is instructive as origin stories are essential in identity construction. Not only did members interpret so plainly the use of social media in organizing amid institutional flux, they also used emotion to convey deeply felt experiences of injustice. In this way, the Kenyan experience helps fill an important gap in the sensemaking literature related to the role of larger institutional contexts, emotions, politics, and technology on sensemaking processes (Sandberg and Tsoukas 2015).

The focus of this work on legitimacy raises important questions about its organizational substance. If organizational legitimacy is simply the degree of cultural support for an organization (Scott 2008), this work questions Freidson's assumption that legitimacy is universally conferred as opposed to inherited or seized. As Mutizwa-Mangiza (1999) argues, colonial medicine was “parachuted into Africa” and rests on a rational-legal value structure that was poorly assimilated with preindustrial values. The shift to independence marked a return to administration based on recognition of the individual as opposed to their bureaucratic or professional standing. Patronage as a prohibitive force in medical organizing is further accentuated through clientist political settlements that exercise state control. I argue that this is tacitly understood by Kenyan doctors, trained in Western systems of education, and these value conflicts are a pervasive source of frustration, which potentially explains high absenteeism and emigration. Whether through the evolution of professional associations, the emergence of powerful medical entrepreneurs, or the realization of a union, organizational legitimacy in Kenya is a fleeting, incomplete, and competitive aspiration. For this reason, disaggregating organizational legitimacy into its pragmatic, moral, and cognitive forms may prove instructive.

Legitimacy also requires differentiation from other concepts in medical sociology. This work concerns an aspect of professional authority, the organizational basis of legitimacy. The relationship between professional autonomy and organizational legitimacy is illustrated in more complicated ways by the Kenyan experience. In some ways, the KMA has retained a degree of clinical autonomy for the medical profession, leading to a particular type of cognitive legitimacy. Cognitive legitimacy positions sensemaking as an outcome based on a common understanding of organizational activities, not cool calculation of means and ends (Golant and Sillince 2007). Standards of practice, licensure, and education are all firmly within its core jurisdiction. However, like the KMPDU and the KHF, the KMA pursues pragmatic legitimacy to advance economic autonomy, primarily through their entrenched position in health financing governance. All three professional bodies, however, seek and compete for political autonomy, with only the KMPDU moderately focused on moral legitimacy as a means to this end. The central focus of pragmatic legitimacy and political autonomy among a divided profession, however, precipitated symbolic political behavior, such as strike action, that became more pronounced as institutional constraints were lifted and the KMPDU formed. A unifying theme of each of these forces is the dynamic nature of the medical profession and its impressive ability to (re)organize.

Conclusion

This analysis shows that the organizational basis of sensemaking is helpful for understanding social problems in the health sector in LMICs. This also contributes fresh insight to the growing body of evidence concerning health professional movements as well as sensemaking and legitimacy in organizational studies. In Kenya, the powerful legacy of colonial biomedicine explains both the profession's endogenous division and exogenous friction with the state. This is further complicated by the corporatization of health care, which crystallized with the formation of a new market-oriented health professional association, led by disenchanted medical entrepreneurs. Seismic institutional change in the health sector triggered an intense sensemaking process in which a new medical union was created that immediately sought to expand its legitimacy through industrial action. In this way, service delivery interruptions are explained by deeper social divisions, constitutive of the postcolonial state-making enterprise in a rapidly changing democratic society. Further research is needed to understand how the complexities of organizing in the health sector shapes the political and social life of Kenyans, and the progressive attainment of universal health coverage globally.

Acknowledgments

The author acknowledges the financial support of the Research Traveling Award at the London School of Hygiene and Tropical Medicine as well as the generosity of the Health Economics Research Unit at the Kenyan Medical Research Institute-Wellcome Trust for hosting him during fieldwork. Thanks also to the guest editors and other participants of the American Political Science Association workshop that preceded this special section. Finally, the author appreciates the study participants who graciously offered their time and thoughts during this research.

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