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

Autor(es)

Nunes, Joao ^[1] ; Lotta, Gabriela ^[2]

Afiliação do(s) autor(es)

^[1] Univ York, Dept Polit, York YO10 5DD, N Yorkshire - England

^[2] Getulio Vargas Fdn, Dept Publ Management, Av Nove Julho 2029, Sao Paulo - Brazil

• Tipo de documento: Artigo Científico
• Fonte: SOCIAL SCIENCE & MEDICINE; v. 242, DEC 2019.
• Citações Web of Science: 0

Resumo

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 comunitarios de saude, 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 Unico de Saude, 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. (AU)

• Processo FAPESP: 17/24750-0 - Burocratas de nível de rua: o uso da discricionariedade e seu impacto na inclusão, exclusão e (re)produção das desigualdades
• Beneficiário: Gabriela Spanghero Lotta
• Modalidade de apoio: Auxílio à Pesquisa - Regular