Discretion, power and the reproduction of inequality in health policy implementation

Practices, discursive styles and classifications of Brazil's community health workers

Bibliographic Data

ID4597524
AuthorsJoão Nunes (0000-0002-0118-0993, University of York, corresponding author), Gabriela Lotta (0000-0003-2801-1628, Fundação Getulio Vargas)
Year2019
Volume242
Pages112551
Publication date2019-12-01
Peer ReviewedYes
Open AccessYes
TypeARTICLE
VenueSocial Science & Medicine (JOURNAL)
Journal identifiersISSN: 0277-9536 • E-ISSN: 1873-5347
PublisherElsevier BV (PUBLISHER)
DOI10.1016/j.socscimed.2019.112551
PMID31622914
OpenAlexW2973058487
LanguageEN
Citations received21
References cited52

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

Conceptualization · Context (archaeology · Disadvantaged · Discretion · Economic growth · Economics · Empowerment · Geography · Inequality · Political science · Public health · Public relations · Scarcity · Sociology · Workforce · Community Health and Development · Global Maternal and Child Health · Global Public Health Policies and Epidemiology · Law · Medicine · Nursing · Health Policy