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

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  • 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.

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  • 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
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    References listed on IDEAS

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    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. repec:bla:devpol:v:24:y:2006:i:1:p:51-73 is not listed on IDEAS
    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.
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    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).

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