Doctors as street-level bureaucrats in a rural hospital in South Africa

Abstract

In the perspectives of implementation of policy, the top-down and bottom-up perspectives of policy-making dominate the discourse. However, service delivery and therefore the experience of the policy by the citizen ultimately depend on the civil servant at the front line to implement the policy. Lipsky named this street-level bureaucracy, which has been used to understand professionals working in the public sector throughout the world. The public sector in South Africa has undergone a number of changes in the transition to a democratic state, post 1994. This needs to be understood in public administration developments throughout the world. At the time of the study, the public sector was characterized by considerable inefficiencies and system failures as well as inequitable distribution of resources. The context of the study was a rural hospital serving a population of approximately 150 000. An insider-ethnography over a period of 13 months explored the challenges of being a professional within the public sector in a rural hospital in South Africa. Data collection included participant observation, field notes of events and meetings, and documentation review supplemented with in-depth interviews of doctors working at a rural hospital. Street-level bureaucracy was used as a framework to understand the challenges of being a professional and civil servant in the public sector. The context of a resource-constrained setting was seen as a major limitation to delivering a quality service. Yet considerable evidence pointed to doctors (both individually and collectively) being active in managing the services in the context and aiming to achieve optimal health service coverage for the population. In the daily routine of the work, doctors often advocated for patients and went beyond the narrow definitions of the guidelines. They compensated for failing systems, beyond a local interpretation of policy. However, doctors also at times used their discretion negatively, to avoid work or to contribute to the inefficiencies of healthcare delivery. While appearing to be in conflict, the merging of the roles of the health professional and the bureaucrat is required to be able to function effectively within the healthcare system. Being a doctor and being a civil servant are synergistic in daily work, and as a result it is difficult to neatly differentiate professional and civil servant roles in decision-making. It is in the discretion of both roles that considerable flexibility within the roles is possible. Such freedom to act is critical for being able to find local solutions and thereby improve healthcare services. The findings resonate strongly with studies from other parts of the world and offer a window into making sense of the local decision making of doctors. Street-level bureaucracy remains an important lens to view the work of healthcare professionals in the public sector. In the tension between the top-down policy-making and the bottom-up pressure, street-level bureaucracy acts as an important terrain for improving the implementation of services and therefore advocacy and health system improvement.