IDEAS home Printed from https://ideas.repec.org/a/eee/socmed/v242y2019ics0277953619305453.html
   My bibliography  Save this article

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

Author

Listed:
  • Nunes, João
  • Lotta, Gabriela

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.

Suggested Citation

  • Nunes, João & Lotta, Gabriela, 2019. "Discretion, power and the reproduction of inequality in health policy implementation: Practices, discursive styles and classifications of Brazil's community health workers," Social Science & Medicine, Elsevier, vol. 242(C).
    • Handle: RePEc:eee:socmed:v:242:y:2019:i:c:s0277953619305453
    DOI: 10.1016/j.socscimed.2019.112551
    as

    Download full text from publisher

    File URL: http://www.sciencedirect.com/science/article/pii/S0277953619305453
    Download Restriction: Full text for ScienceDirect subscribers only
    File URL: https://libkey.io/10.1016/j.socscimed.2019.112551?utm_source=ideas
    LibKey link: if access is restricted and if your library uses this service, LibKey will redirect you to where you can use your library subscription to access this item
    ---><---

    As the access to this document is restricted, you may want to search for a different version of it.

    References listed on IDEAS

    as
    1. Pérez, L.M. & Martinez, J., 2008. "Community health workers: Social justice and policy advocates for community health and well-being," American Journal of Public Health, American Public Health Association, vol. 98(1), pages 11-14.
    2. Atinga, Roger A. & Agyepong, Irene Akua & Esena, Reuben K., 2018. "Ghana's community-based primary health care: Why women and children are ‘disadvantaged’ by its implementation," Social Science & Medicine, Elsevier, vol. 201(C), pages 27-34.
    3. Richard Crook & Joseph Ayee, 2006. "Urban Service Partnerships, 'Street-Level Bureaucrats' and Environmental Sanitation in Kumasi and Accra, Ghana: Coping with Organisational Change in the Public Bureaucracy," Development Policy Review, Overseas Development Institute, vol. 24(1), pages 51-73, January.
    4. Gale, Nicola & Dowswell, George & Greenfield, Sheila & Marshall, Tom, 2017. "Street-level diplomacy? Communicative and adaptive work at the front line of implementing public health policies in primary care," Social Science & Medicine, Elsevier, vol. 177(C), pages 9-18.
    5. Witmer, A. & Seifer, S.D. & Finocchio, L. & Leslie, J. & O'Neil, E.H., 1995. "Community health workers: integral members of the health care work force," American Journal of Public Health, American Public Health Association, vol. 85(8), pages 1055-1058.
    6. Michael Hill & Peter Hupe, 2003. "The multi-layer problem in implementation research," Public Management Review, Taylor & Francis Journals, vol. 5(4), pages 471-490, December.
    7. Gitte Sommer Harrits & Marie Østergaard Møller, 2014. "Prevention at the Front Line: How home nurses, pedagogues, and teachers transform public worry into decisions on special efforts," Public Management Review, Taylor & Francis Journals, vol. 16(4), pages 447-480, May.
    Full references (including those not matched with items on IDEAS)

    Citations

    Citations are extracted by the CitEc Project, subscribe to its RSS feed for this item.
    as


    Cited by:

    1. Patel, Gupteswar & Brosnan, Caragh & Taylor, Ann & Garimella, Surekha, 2021. "The dynamics of TCAM integration in the Indian public health system: Medical dominance, countervailing power and co-optation," Social Science & Medicine, Elsevier, vol. 286(C).

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. Gore, Christopher D., 2018. "How African cities lead: Urban policy innovation and agriculture in Kampala and Nairobi," World Development, Elsevier, vol. 108(C), pages 169-180.
    2. Hildebrand Sean, 2015. "Coerced Confusion? Local Emergency Policy Implementation After September 11," Journal of Homeland Security and Emergency Management, De Gruyter, vol. 12(2), pages 273-298, June.
    3. Nava Ashraf & Oriana Bandiera & Edward Davenport & Scott S. Lee, 2020. "Losing Prosociality in the Quest for Talent? Sorting, Selection, and Productivity in the Delivery of Public Services," American Economic Review, American Economic Association, vol. 110(5), pages 1355-1394, May.
    4. Alan Kirschenbaum, 2021. "Reducing patient surge: community based social networks as first responders," Natural Hazards: Journal of the International Society for the Prevention and Mitigation of Natural Hazards, Springer;International Society for the Prevention and Mitigation of Natural Hazards, vol. 108(1), pages 163-175, August.
    5. Arima, Yuzo & Guthrie, Brandon L. & Rhew, Isaac C. & De Roos, Anneclaire J., 2009. "The impact of the First Steps prenatal care program on birth outcomes among women receiving Medicaid in Washington State," Health Policy, Elsevier, vol. 92(1), pages 49-54, September.
    6. Visram, Shelina & Walton, Nick & Akhter, Nasima & Lewis, Sue & Lister, Graham, 2020. "Assessing the value for money of an integrated health and wellbeing service in the UK," Social Science & Medicine, Elsevier, vol. 245(C).
    7. Nicola K Gale & Manbinder S Sidhu, 2019. "Risk work or resilience work? A qualitative study with community health workers negotiating the tensions between biomedical and community-based forms of health promotion in the United Kingdom," PLOS ONE, Public Library of Science, vol. 14(7), pages 1-19, July.
    8. Luljeta Pallaveshi & Ahmed Jwely & Priya Subramanian & Mai Odelia Malik & Lueda Alia & Abraham Rudnick, 2017. "Immigration and Psychosis: an Exploratory Study," Journal of International Migration and Integration, Springer, vol. 18(4), pages 1149-1166, November.
    9. Ilona Sips & Ahmad Haeri Mazanderani & Helen Schneider & Minrie Greeff & Francoise Barten & Mosa Moshabela, 2014. "Community Care Workers, Poor Referral Networks and Consumption of Personal Resources in Rural South Africa," PLOS ONE, Public Library of Science, vol. 9(4), pages 1-7, April.
    10. Na Tang & Muyu He, 2023. "The times make a hero: Street‐level policy entrepreneurship in major crisis responses in China," Review of Policy Research, Policy Studies Organization, vol. 40(4), pages 490-508, July.
    11. Greene, George J. & Reidy, Emma & Felt, Dylan & Marro, Rachel & Johnson, Amy K. & Phillips, Gregory & Green, Evelyn & Stonehouse, Patrick, 2022. "Implementation and evaluation of patient navigation in Chicago: Insights on addressing the social determinants of health and integrating HIV prevention and care services," Evaluation and Program Planning, Elsevier, vol. 90(C).
    12. Kellen Kiambati, 2020. "Influence of credit risk on shareholder market value of commercial banks listed in Nairobi Securities Exchange," International Journal of Research in Business and Social Science (2147-4478), Center for the Strategic Studies in Business and Finance, vol. 9(2), pages 107-117, March.
    13. Govind Gopakumar, 2009. "Developing Durable Infrastructures: Politics, Social Skill, and Sanitation Partnerships in Urban India1," Review of Policy Research, Policy Studies Organization, vol. 26(5), pages 571-587, September.
    14. Estelle D. Watson & Shabir Moosa & Dina C. Janse Van Rensburg & Martin Schwellnus & Estelle V. Lambert & Mark Stoutenberg, 2023. "Task-Shifting: Can Community Health Workers Be Part of the Solution to an Inactive Nation?," IJERPH, MDPI, vol. 20(17), pages 1-13, August.
    15. May, Anthony D. & Page, Matthew & Hull, Angela, 2008. "Developing a set of decision-support tools for sustainable urban transport in the UK," Transport Policy, Elsevier, vol. 15(6), pages 328-340, November.
    16. Judith Nalukwago & Rik Crutzen & Bart van den Borne & Paul Mukisa Bukuluki & Leonard Bufumbo & Richard Batamwita & Amos Zikusooka & Rachel Lenzi & Gretchen Thompson & Jane Alaii, 2018. "Adolescents Discussing Sexual Behaviors With Key Influencing Audiences," Global Journal of Health Science, Canadian Center of Science and Education, vol. 10(8), pages 1-91, August.
    17. Helle Ørsted Nielsen & Vibeke Lehmann Nielsen, 2023. "Different encounter behaviors: Businesses in encounters with regulatory agencies," Regulation & Governance, John Wiley & Sons, vol. 17(1), pages 61-82, January.
    18. Revilla, Ma. Laarni D. & Qu, Fangqi & Seetharam, K E & Rao, Bhanoji, 2021. "“Sanitation” in the Top Development Journals: A Review," ADBI Working Papers 1253, Asian Development Bank Institute.
    19. Kash, Bita Arbab & May, Marlynn Lee & Tai-Seale, Ming, 2007. "Community health worker training and certification programs in the United States: Findings from a national survey," Health Policy, Elsevier, vol. 80(1), pages 32-42, January.
    20. May, Marlynn L. & Contreras, Ricardo B., 2007. "Promotor(a)s, the organizations in which they work, and an emerging paradox: How organizational structure and scope impact promotor(a)s' work," Health Policy, Elsevier, vol. 82(2), pages 153-166, July.

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:eee:socmed:v:242:y:2019:i:c:s0277953619305453. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: Catherine Liu (email available below). General contact details of provider: http://www.elsevier.com/wps/find/journaldescription.cws_home/315/description#description .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.