Reconstructing Professional Legitimacy Under Institutional Complexity: Evidence from Global Health

The global health system has undergone profound institutional reconfiguration, marked by the rise of public-private partnerships (PPPs), philanthropic foundations, and new governance arrangements. While prior research has documented these structural changes, we know far less about how professionals working within this fragmented system experience and respond to institutional complexity, and how their responses cumulatively transform professional logics. Drawing on interviews with 25 global health professionals across multilateral organizations, PPPs, and international NGOs, we examine how everyday coping practices shape professional legitimacy and authority. Our analysis identifies three mechanisms through which professional logics evolve endogenously: elastic legitimation, whereby professionals gain credibility by acknowledging uncertainty rather than projecting mastery; moral tension work, through which professionals privately critique institutional arrangements while publicly complying with them; and constraint-as-authority, where professionals derive credibility from demonstrating awareness of institutional limitations. These mechanisms reveal how professional logics change not through deliberate institutional entrepreneurship but through the accumulated effects of routine professional practice. By theorizing professional logic evolution as an emergent, practice-driven process, this study contributes to institutional theory, research on professions, and global health governance. More broadly, it demonstrates the value of phenomenon-based, abductive theorizing for explaining surprising patterns of professional authority under conditions of institutional complexity.