Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level Bureaucrats
BackgroundIn this study, we use the case of medical doctors in the public health system in rural India to illustrate the nuances of how and why gaps in policy implementation occur at the frontline. Drawing on Lipsky’s Street Level Bureaucracy (SLB) theory, we consider doctors not as mechanical imple...
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| Format: | Article |
| Language: | English |
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Kerman University of Medical Sciences
2021-07-01
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| Series: | International Journal of Health Policy and Management |
| Subjects: | |
| Online Access: | https://www.ijhpm.com/article_3942_8fbeebac93696212afcd432c2d352c29.pdf |
| _version_ | 1811158824064647168 |
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| author | Sudha Ramani Lucy Gilson Muthusamy Sivakami Nilesh Gawde |
| author_facet | Sudha Ramani Lucy Gilson Muthusamy Sivakami Nilesh Gawde |
| author_sort | Sudha Ramani |
| collection | DOAJ |
| description | BackgroundIn this study, we use the case of medical doctors in the public health system in rural India to illustrate the nuances of how and why gaps in policy implementation occur at the frontline. Drawing on Lipsky’s Street Level Bureaucracy (SLB) theory, we consider doctors not as mechanical implementors of policies, but as having agency to implement modified policies that are better suited to their contexts. MethodsWe collected data from primary care doctors who worked in the public health system in rural Maharashtra, India between April and September 2018 (including 21 facility visits, 29 in depth interviews and several informal discussions). We first sorted the data inductively into themes. Then we used the SLB theoretical framework to categorise and visualise relationships between the extracted themes and deepen the analysis. ResultsDoctors reported facing several constraints in the implementation of primary care- including the lack of resources, the top-down imposition of programs that were not meaningful to them, limited support from the organization to improve processes as well as professional disinterest in their assigned roles. In response to these constraints, many doctors ‘routinized’ care, and became resigned and risk-averse. Most doctors felt a deep loss of professional identity, and accepted this loss as an inevitable part of a public sector job. Such attitudes and behaviours were not conducive to the delivery of good primary care. ConclusionThis study adds to empirical literature on doctors as Street Level Bureaucrats in lower and middle income countries. Doctors from these settings have often been blamed for not living up to their professional standards and implementing policies with rigour. This study highlights that doctors’ behaviours in these settings are ways through which they ‘cope’ with their loss of professional identity and organizational constraints; and highlights the need for appropriate interventions to counter their weak motivation. |
| first_indexed | 2024-04-10T05:30:50Z |
| format | Article |
| id | doaj.art-fff129e4a2284bcb86c4f34004ae7f16 |
| institution | Directory Open Access Journal |
| issn | 2322-5939 |
| language | English |
| last_indexed | 2024-04-10T05:30:50Z |
| publishDate | 2021-07-01 |
| publisher | Kerman University of Medical Sciences |
| record_format | Article |
| series | International Journal of Health Policy and Management |
| spelling | doaj.art-fff129e4a2284bcb86c4f34004ae7f162023-03-07T09:08:18ZengKerman University of Medical SciencesInternational Journal of Health Policy and Management2322-59392021-07-0110Special Issue on Analysing the Politics of Health Policy Change in LMICs37638710.34172/ijhpm.2020.2063942Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level BureaucratsSudha Ramani0Lucy Gilson1Muthusamy Sivakami2Nilesh Gawde3School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, IndiaDivision of Health Policy and Systems, University of Cape Town, Cape Town, South AfricaCenter for Health and Social Sciences, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, IndiaSchool of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, IndiaBackgroundIn this study, we use the case of medical doctors in the public health system in rural India to illustrate the nuances of how and why gaps in policy implementation occur at the frontline. Drawing on Lipsky’s Street Level Bureaucracy (SLB) theory, we consider doctors not as mechanical implementors of policies, but as having agency to implement modified policies that are better suited to their contexts. MethodsWe collected data from primary care doctors who worked in the public health system in rural Maharashtra, India between April and September 2018 (including 21 facility visits, 29 in depth interviews and several informal discussions). We first sorted the data inductively into themes. Then we used the SLB theoretical framework to categorise and visualise relationships between the extracted themes and deepen the analysis. ResultsDoctors reported facing several constraints in the implementation of primary care- including the lack of resources, the top-down imposition of programs that were not meaningful to them, limited support from the organization to improve processes as well as professional disinterest in their assigned roles. In response to these constraints, many doctors ‘routinized’ care, and became resigned and risk-averse. Most doctors felt a deep loss of professional identity, and accepted this loss as an inevitable part of a public sector job. Such attitudes and behaviours were not conducive to the delivery of good primary care. ConclusionThis study adds to empirical literature on doctors as Street Level Bureaucrats in lower and middle income countries. Doctors from these settings have often been blamed for not living up to their professional standards and implementing policies with rigour. This study highlights that doctors’ behaviours in these settings are ways through which they ‘cope’ with their loss of professional identity and organizational constraints; and highlights the need for appropriate interventions to counter their weak motivation.https://www.ijhpm.com/article_3942_8fbeebac93696212afcd432c2d352c29.pdfstreet level bureaucracypolicy implementationprimary healthindiadoctors |
| spellingShingle | Sudha Ramani Lucy Gilson Muthusamy Sivakami Nilesh Gawde Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level Bureaucrats International Journal of Health Policy and Management street level bureaucracy policy implementation primary health india doctors |
| title | Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level Bureaucrats |
| title_full | Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level Bureaucrats |
| title_fullStr | Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level Bureaucrats |
| title_full_unstemmed | Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level Bureaucrats |
| title_short | Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level Bureaucrats |
| title_sort | sometimes resigned sometimes conflicted and mostly risk averse primary care doctors in india as street level bureaucrats |
| topic | street level bureaucracy policy implementation primary health india doctors |
| url | https://www.ijhpm.com/article_3942_8fbeebac93696212afcd432c2d352c29.pdf |
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