Organizing under constraint: Paradox navigation in public health systems

ISSUE: Public health systems aim to deliver care that is effective, inclusive, efficient, and culturally responsive. However, they operate under persistent constraints such as limited funding, staff shortages, and aging infrastructure that generate enduring paradoxical tensions that frontline and middle-level actors continuously navigate to keep the health system functioning. CRITICAL THEORETICAL ANALYSIS: While existing research acknowledges that paradoxical tensions are persistent and experienced across organizational levels-from top-level managers to frontline health care workers, the theory on how they are managed beyond senior leadership remains thin. I introduce and theorize the concept of composite arrangements. This conceptchallenges the assumption that the health care system remains functional only through structural reform and explains how low-discretion actors in the public health system sustain continuity, adaptability, and legitimacy. INSIGHT/ADVANCE: I advance understanding of paradox management in health care by shifting the focus from a leader-centered perspective to a distributed, ongoing process embedded in the everyday practices of actors with limited discretion. By introducing the concept of composite arrangements, I show how those with limited discretion to shape structure or policy can maintain the effectiveness of public health systems despite ongoing paradoxical tensions. PRACTICE IMPLICATIONS: I outline practical ways to address paradoxical tensions through composite arrangements when actors have limited discretion. In addition, I explain how public health organizations can strengthen these arrangements by fostering organizational cultures that embrace paradox amid resource scarcity to sustain the health system's functioning.