This article contributes to the literature on legitimacy by highlighting its paradox and constraints. While an optimal level of legitimacy-seeking behaviours may be necessary for organizational effectiveness, an excessive focus on legitimacy may lead to stakeholder mismanagement and have the opposite effect. These insights emerged from a longitudinal qualitative study of large-scale changes in public-sector health care in a Canadian province (1994-2002). In 1994, subordinate health care organizations underwent government-driven reforms to promote market-based logics of efficiency and cost reduction. Initial (...) years post reforms were characterized by a singular focus on government-driven priorities and inattention to other stakeholders. However, instead of giving benefits of legitimacy, these behaviours led to anger and activism from non-institutional stakeholders such as staff and community due to a decline in quality and patient satisfaction. Eventually, greater attention to stakeholder concerns ended the stand-off. These findings also elaborate Suchman's (Academy of Management Review 20(3), 571-610, 1995) framework on legitimacy and explain that legitimacy may occur for reasons other than institutionalization of values and be temporary in nature. (shrink)