Date of Award

Summer 8-31-2025

Document Type

Open Access Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Global Governance and Human Security

First Advisor

Courtenay Sprague

Second Advisor

Stacy VanDeveer

Third Advisor

Steve Striffler

Abstract

There has been insufficient attention by global health scholars to labor organizing by health workers, including when and why organizing occurs, what forms and strategies it takes and its implications for governance and policy. These questions are critical but largely absent in research on what has been called the “global health workforce crisis.” Kenya represents an important case study. A new constitution in 2010 expanded institutional spaces for labor organizing and decentralized governance of the health system. Both reforms had significant implications for the health workforce and strikes by health workers have been pervasive. In 2017, nationwide strikes by public sector doctors and nurses lasted for 100 days and 150 days, respectively, massively disrupting health services across the country.

This dissertation explored labor organizing by health workers, specifically doctors and nurses working in Kenya’s public health sector, including what motivates labor organizing efforts, the characteristics of organizing in the public health sector (including unionization, collective bargaining and strikes) and its impacts on working conditions, governance and policy. A political economy-based conceptual framework and Walt and Gilson’s health policy triangle guided the study approach and analysis. Three methods were employed: in-depth interviews in Kenya with 81 public sector doctors and nurses, labor union officials, and government health officials; a database of strikes that included 155 strike events by health workers using systematic searches of media reports; and primary and secondary document analysis.

Findings revealed that doctors and nurses increasingly viewed employment in Kenya’s public health sector as precarious, characterized by frequent delays in pay and benefits, understaffed and under-resourced facilities and employment on short-term contracts. The roots of this precarity were framed in highly political terms, including public corruption, poor accountability and de-prioritization of public health in newly decentralized spaces, and were perceived to threaten the public sector workforce and motivated labor organizing. Unions secured improvements in working conditions through collective bargaining and strike actions at local and national levels but organizing was highly contested by public employers and gains made through organizing were often insecure. The impacts of organizing on health governance and policy were subtle but important, and despite their limitations health workers’ unions emerged as legitimate actors in Kenyan health politics.

The dissertation makes three key contributions. First, it shows that health worker organizing in Kenya extends beyond wages and working conditions to challenge corruption, mismanagement and systemic neglect that operate across local, national and global political economies and that are rarely taken up in global health scholarship. Second, it demonstrates how unions have become vital political actors, using strikes, bargaining and public advocacy to claim justice, professional recognition and state accountability for public health. Third, it exposes both the challenges and opportunities of organizing within decentralized, resource‑constrained institutions, highlighting health workers’ agency in fragile governance environments. In doing so, the study captures a pivotal moment in Kenya’s health sector and offers a novel framework for viewing health systems as contested political arenas. The dissertation lays the groundwork for theory building and comparative research on the political economy of labor movements in public health sectors that can contribute to global health scholarship.

Comments

Free and open access to this Campus Access Thesis is made available to the UMass Boston community by ScholarWorks at UMass Boston. Those not on campus and those without a UMass Boston campus username and password may gain access to this thesis through Interlibrary Loan. If you have a UMass Boston campus username and password and would like to download this work from off-campus, click on the “Off-Campus Users” button.

Download

Share

COinS