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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.

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. [ABSTRACT FROM AUTHOR]

Highlights • Interface bureaucrats are key actors in climate policy implementation. • Discretionary implementation practices re-shape climate adaptation interventions. • Studies of pragmatism can offer new insights in everyday environmental governance. Abstract When climate change policies are implemented in practice, they travel through the hands of a range of practitioners who not only mediate but also potentially transform climate interventions. This article highlights the role of a group of actors whose practices have so far received little attention in the study of climate change governance, namely the public servants who are responsible for the everyday implementation of national climate change policies and associated programmes on the ground. Situated at the frontline of the state and often engaging directly with citizens, these "interface bureaucrats" occupy a complex position in which they must balance their role as representatives of the state with the need to accommodate the pressures, interests and practical challenges associated with everyday policy implementation. In this article we examine how interface bureaucrats in Zambia seek to navigate this role as they go about implementing national climate change adaptation policies in practice, and what this means for the nature and outcome of these interventions. We identify key dilemmas of the interface bureaucrats in our study areas, namely (i) intervening with limited reach, (ii) implementing generic policies, and (iii) managing conflicting interests. We show how they address these dilemmas through highly pragmatic practices involving informal agreements with community members, discretionary adjustments of official policies, and negotiation of contested interventions. As a result, the nature and outcomes of climate change adaptation interventions end up differently from the official policies and the underlying governance interests of the central state. Our findings suggest a need for greater attention to the role of interface bureaucrats as everyday climate policy makers and point to the significance of pragmatism and compromise in the interaction between state actors and citizens in environmental interventions. [ABSTRACT FROM AUTHOR]

As an independent researcher, registered social worker and erstwhile long-term, long-distance carer, the care of older people and protection of elders from abuse had been constant professional and personal foci for me for many years. Commissioned to review a case involving the serious abuse of an elder where official safeguarding procedures had not been used, I puzzled why this had been managed 'informally' by social services and partner agencies (i.e. outside adult safeguarding procedures), with vague unspecified 'monitoring' (AEA 2006). Why was there this apparent gap between policy intention and implementation? That question led to research on which this essay is based. [ABSTRACT FROM AUTHOR]

Title. Child health promotion in the United Kingdom: does health visitors’ practice follow policy? Aim. This paper is a report of a study to assess to what extent national child health promotion policy is reflected in health visitors’ practice across the United Kingdom. Background. Community or public health nurses are often key providers of child health promotion programmes for well children. Over the last decade, national United Kingdom policy concerning universal preventive health services for preschool children has changed rapidly. Health promotion contacts are increasingly targeted to those with the highest health needs. Method. A survey was conducted in 2005 of health visitors’ Child Health Promotion Programme practice. A postal questionnaire exploring local practice and policy was sent to a random 10% sample of Registered Health Visitors. Respondents were from all four countries of the UK although predominantly (90%) from England. Nominal data were analysed by frequencies and associations between key variables. The chi-square test was used for comparisons between groups of respondents, with a statistical significance level of P < 0·05. Findings. A 64% response rate ( n = 1537) was obtained, with 1043 questionnaires from current practitioners. While three-quarters of respondents stated that the number of routine contacts recommended in local policy had decreased since revision of the Child Health Promotion Programme, 39% stated that targeted contacts had increased. Just over a third agreed that contact should be targeted to children with identified needs after 1 year of age. Conclusion. As child health promotion programmes play a major part in well-child care internationally, it is important to take into account diversity in practice, and potential conflicts between professional values and policy. [ABSTRACT FROM AUTHOR]

This study investigates the implementation of a recent health management information systems (HMIS) policy reform in Uttar Pradesh, India, which aims to improve the quality and use of HMIS data in decision-making. Through in-depth interviews, meeting observations and a policy document review, this study sought to capture the experiences of district-level staff (street-level bureaucrats) who were responsible for HMIS policy implementation. Findings revealed that issues of weak HMIS implementation were partly due to human resources shortages both in number and technical skill. Delays in recruitment and the presence of inactive staff overburdened existing staff and weakened the implementation of HMIS activities at the block- and district-levels. District staff also explained how inadequate computer literacy and limited technical understanding further contributed to low HMIS data quality. The organizational culture was even more constraining: working within a very rigid and hierarchical organization was challenging for district data staff, who were expected to manage day-to-day HMIS activities, but lacked the discretion and authority to do so effectively. Consequently, they had to escalate minor issues to district leadership for action and were expected to follow their supervisors' directives– even if they contradicted HMIS policy guidelines. High performance pressures associated with achieving top district rankings deviated focus away from HMIS data quality issues. Many district-level respondents described their superiors' "fixation" with becoming a top-ranking district often resulted in disregard for the quality of data informing district rankings. Furthermore, the review of district rankings only partially encouraged district-level leadership to investigate reasons for low-performing indicators. Instead, low district rankings often resulted in punitive action. The study recommends the importance of incorporating the perspectives of district staff, and recognizing their discretion, and authority when designing policy implementation processes, and finally concludes with potential strategies for strengthening the current HMIS policy reform. • Well-designed policies are insufficient for successful HMIS policy implementation. • Attention needs to be paid to organizational cultural factors. • Strict organizational hierarchy and punitive work culture weaken HMIS implementation. • Incorporating perspectives of policy implementers is critical for HMIS policy design. [ABSTRACT FROM AUTHOR]