In brief: Street-level bureaucracy theory

One of the most enduring questions in health policy analysis is why policies are often implemented in unintended ways; why implementation “on the ground” looks different to the intentions of top-level policy makers or the objectives of official policy documents.

Part of the answer lies in the working environments and mind-sets of street-level bureaucrats: front-line workers or policy implementers such as nurses, teachers and police officers.

This guidance note, courtesy of the Health Policy and Systems Division of the University of Cape Town, summarises the theory of street-level bureaucracy. It is intended to be used as a teaching resource, with the aim of introducing students to street-level bureaucracy theory and stimulating them to read further. It can work well with CHEPSAA’s module Health Policy Analysis or any other discussion of the behaviour of front-line health policy implementers.

This summary was developed in the context of work that synthesised the literature on street-level bureaucracy, as well as other aspects of the health policy analysis literature in low- and middle-income countries. This open access work can be accessed here.

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Community Health Funds

This case study encourages students to interrogate the strengths and weaknesses of the voluntary community health fund (CHF) model. Based on the results of a health systems analysis of the performance of the CHF, students are asked to use systems thinking to test how accurately they can anticipate the problems experienced in implementation and then to propose modifications to the CHF model that might mitigate shortcomings or take advantage of synergies elsewhere in the system.

This case study address issues around health care access, quality and equity; the facilitation of stakeholder involvement; politics and power; as well as accountability and trust.

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Lay Boards

This case study tells the real-life stories of two health facility governing committees in the same district. In Village A, the committee is highly accomplished and well-functioning. In Village B, the committee lacks drive and effectiveness.

By juxtaposing the well-functioning and poorly functioning committees, this case study raises questions about the value and limitations of including the voice of the population in the governance of health systems and the value of effective stakeholder processes. It helps students to understand the behaviours associated wit the success or failure of the committees and seeks to support students’ thinking about how to develop more effective community participation.

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The Patients’ Rights Charter in South Africa

This case study reflects on the implementation of the Patients’ Rights Charter in South Africa, a policy that had symbolic and political significance because it signalled a move away from the inequitable and inadequate health services that were provided to the majority of the population before the country’s transition to democracy in 1994. The Patients’ Rights Charter gave patients certain rights, but also stipulated that they had certain responsibilities in how they accessed health care and engaged with the health system.

Various aspects of this experience are highlighted in this case study, including how the Patients’ Rights Charter was introduced into the health system, the outcomes that were achieved, how the policy change was perceived and managed by health system managers and health workers, and how the policy’s structure of rights vs. responsibilities provided a resource for some frontline actors who resisted its implementation.

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Health Facility Committees and Financial Management Structures in Kenya

This case study is set in the Kenyan context and examines two policies. First, direct facility funding, through which facilities receive funding directly into their bank accounts, in part to address the problem of funding from higher levels in the health system that does not flow through to facilities. Second, health facility committees, which is about broadening community participation in public health service delivery. Health facility committees are also involved in managing the funds received through direct facility funding.

In exploring the implementation of these policies, this case study covers the relationships between health workers and health facility committees and the relationships between the wider community and the health facility committees.

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