International Journal of Health Policy and Management

International Journal of Health Policy and Management

Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level Bureaucrats

Document Type : Original Article

Authors
Sudha Ramani 1
Lucy Gilson 2, 3
Muthusamy Sivakami 4
Nilesh Gawde 1
1 School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
2 Division of Health Policy and Systems, University of Cape Town, Cape Town, South Africa
3 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
4 Center for Health and Social Sciences, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
10.34172/ijhpm.2020.206
Abstract
Background
In 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.

 
Methods
We 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.

 
Results
Doctors 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.

 
Conclusion
This 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.
Keywords
Street Level Bureaucracy
Policy Implementation
Primary Health
India
Doctors

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International Journal of Health Policy and Management
Volume 10, Special Issue on Analysing the Politics of Health Policy Change in LMICs
The HPA Fellowship Programme 2017-2019
July 2021
Pages 376-387

  • Received Date 05 February 2020
  • Revised Date 07 October 2020
  • Accepted Date 10 October 2020
  • First Published Date 28 October 2020
  • Published Date 01 July 2021