Discretion, power and the reproduction of inequality in health policy implementation: Practices, discursive styles and classifications of Brazil's community health workers

Abstract

This article explores the mobilization of power by health workers during policy implementation, showing how in a context of discretion and resource scarcity they can reproduce inequalities in access to health services. The argument innovates theoretically by supplementing the ‘street-level bureaucracy’ literature, which emphasizes frontline worker discretion, with a conceptualization of power as domination encompassing the shaping of behavior, the constitution of subjects and the reproduction of inequality. Empirically, the article focuses on Brazilian community health workers (agentes comunitários desaúde, CHWs). CHWs are a neglected but highly important segment of the health workforce that traditionally functions as a link between the health system and disadvantaged groups. The article examines how Brazilian CHWs act as street-level bureaucrats mobilizing power in their interactions with users. They operate within a severely under-resourced public health system, the Sistema Único de Saúde, which places constraints upon their action and forces them to make allocation decisions with little training and support. The article highlights the ways in which inequalities in access to health services are reproduced (inadvertently or not) through the practices, discursive styles and classifications of CHWs. Methodologically, the paper is based on ethnography with 24 CHWs and interviews with 77 other CHWs in Brazil.

Community health workers reveal COVID-19 disaster in Brazil

“…The value of CHWs stems from their local knowledge and daily contact with families. 5 , 6 This proximity to communities is also vital for ground-level outbreak surveillance 7 and risk communication, as seen with the outbreak of Zika virus disease. 8…”

Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level Bureaucrats

“…2,3 Many of the organizational and local socio-political factors elicited in this study -resource constraints, structural deficits, issues with organizational culture and relationships, and lack of connect with the community -have been noted in other empirical studies on frontline policy implementation that involve doctors, 13,14 as well as other cadres of frontline staff. [7][8][9][10][11][12][36][37][38] In our findings, the set of 'professional' factors play out strongly, and these interact in various ways with 'organizational' factors to shape doctors' actions. Although one other study has noted these interactions, as well as the challenges that doctors face in dealing with the duality of being a professional (a clinician) as well as a bureaucrat, 14 most SLB studies underplay the influence of professional factors over frontline worker actions.…”

“…'Coping' has always been a central concept in SLB theory, [1][2][3] and some empirical LMIC literature does touch on how frontline health staff 'cope' by adopting certain attitudes and actions (such as rationing, distancing from patients and categorising patients) during policy implementation. 7,9,10,12,15 However, the knowledge base is still limited and more studies that systematically categorise coping behaviours and elicit nuanced accounts of these behaviours are needed from LMIC health contexts. In this study, the consideration of coping at various levels-as specific instances, as strategies that surround these instances, and also as aggregated adaptive processes (adapted from Tummers and colleagues' framework 32 )has enabled a systematic and detailed understanding of doctors' coping behaviours in primary healthcare settings.…”

“…workers and managers) in such settings. [7][8][9][10][11][12] However, within LMIC literature, medical doctors working at the frontlines of care delivery have been less frequently been examined using SLB theory (some recent exceptions being Karadaghi and Willott, 13 Gaede, 14 Kelly 15 ). In this paper, we have explicitly focussed on understanding the perspectives of medical doctors.…”

Understanding the role of lady health workers in improving access to eye health services in rural Pakistan – findings from a qualitative study

“…It appears that many secondary-level providers were unaware of the LHW programme and their referrals. LHWs spent considerable time completing the slips, which ultimately did not have a required level of authority [ 27 , 28 ]. As advocated by several participants in this study, improved engagement and communication between LHWs and hospital-based healthcare providers will be necessary to ensure that the referral pathways work effectively, and the referred patients receive the care they need.…”