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.

Highlights

  • Notwithstanding the constraints they encounter, health workers are in many respects powerful

  • Speaking to a burgeoning literature on the lives and experiences of community health workers (CHWs) (Oliver et al, 2015; Mlotshwa et al, 2015; Maes, 2017), we explore the role of CHWs in health policy implementation by looking at their practices; their discursive styles; and their classifications

  • This article analyzed the role of power in policy implementation

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Summary

Introduction

Notwithstanding the constraints they encounter, health workers are in many respects powerful. Domination supplements discretion in the SLB approach by enabling an examination of how power operates in the daily practice of bureaucrats: through attempts to shape the behaviour of policy beneficiaries; through injunctions to constitute subjects who are predisposed to think and act in certain ways; and by reinforcing unequal relations in society This has important implications for health policy analysis, since it reveals frontline health workers as nodes in the circulation of power relations that go beyond coercion, threat or punishment. Agency is shaped and limited by structural constraints, never fully determined Another added value for health policy analysis of combining the SLB approach with the notion of domination is that the former enables discussions of power to be firmly grounded on day-to-day practice, avoiding generalizations about how power works and what its effects are.

Context of health policy implementation in Brazil
Data collection and analysis
Practices: what CHWs do
Discursive styles: how CHWs interact
Classifications: how CHWs judge and categorize users
The power of CHWs: changing behavior
The power of CHWs: producing citizens
The power of CHWs: reproducing inequality
Findings
Conclusion
Full Text
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