|Year : 2018 | Volume
| Issue : 4 | Page : 270-273
Street-level bureaucracy in tobacco control: A qualitative study of health department in district Jalandhar, Punjab
Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
|Date of Submission||26-Mar-2018|
|Date of Acceptance||26-Nov-2018|
|Date of Web Publication||21-Dec-2018|
Dr. Shaveta Menon
215 Urban Estate Phase 2, Jalandhar - 144 022, Punjab
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The implementers of the tobacco control policy in the field have been neglected by the policymakers. They are the ones who have first-hand knowledge and their experiences in the field are not being used to bring about changes in the area of tobacco control. Objective: The objective of this paper is to critically examine how Michael Lipsky's concept of street-level bureaucracy can be used to address tobacco control in the health department in district Jalandhar of Punjab. Methods: Semi-structured interview schedules were used to interview Senior Medical Officers/Nodal Officers and Health Supervisors/Sanitary inspectors in four out of ten Community Health Centers and District hospital in Jalandhar. Data so collected were subjected to the process of inductive analysis and themes developed within the framework given by Lipsky. Results: The street-level bureaucrats (SLBs) were not given adequate training, and various organizational resources for tobacco control are missing in the district. There are threats and challenges which are faced by them in the field, and they do not exercise decision-making power to handle these barriers for effective implementation of the tobacco control program. Conclusion: The government needs to be inclusive in the process of policymaking meaning that it can be more accommodative of the suggestions given by the SLBs and provide them with discretionary powers to exercise their role efficiently.
Keywords: Community health centers, senior medical officers, street-level bureaucracy, street-level bureaucrats, tobacco policy
|How to cite this article:|
Menon S. Street-level bureaucracy in tobacco control: A qualitative study of health department in district Jalandhar, Punjab. Indian J Community Med 2018;43:270-3
|How to cite this URL:|
Menon S. Street-level bureaucracy in tobacco control: A qualitative study of health department in district Jalandhar, Punjab. Indian J Community Med [serial online] 2018 [cited 2019 Jun 24];43:270-3. Available from: http://www.ijcm.org.in/text.asp?2018/43/4/270/248201
| Introduction|| |
Tobacco control policy is being increasingly recognized in political science and policy research due to some unique reasons. Thus, investigating tobacco policy implementation models and outcomes has been a continuing concern worldwide. These policy outcomes result from a complex interplay between government and nongovernment actors at different intensities. However, the classic problem in policy implementation is that the top-down approach is followed more than the bottom-up approach. The bottom-up approach emphasizes that the work of those delivering these services is obscurely political in nature. The implementers meet various challenges in the field which vary from undefined problems, uncertain objectives, and sometimes contradictory goals. The aim of this paper is to critically examine how Michael Lipsky's concept of street-level bureaucracy can be used in the health department to address tobacco control in district Jalandhar of Punjab.
| Methods|| |
The paper follows the street-level bureaucracy approach given by Michael Lipsky. Lipsky defines street-level bureaucrats (SLBs) as the public service workers who interact directly with the citizens in their course of job and have substantial discretion in the execution of their works. In short, they are mediators of the legitimate relationship of the citizens to the state. The problems which these SLBs face arise from the lack of organizational and personal sources, physical and psychological threats, and conflicting role expectations. He also notes that some of the SLBs are untrained and inexperienced. Therefore, the ambiguity of goals and under training, as well as nature of the job make it difficult for the SLBs to perform their job efficiently. As far as tobacco control policy is concerned, it is seen as a regulatory policy in which the regulation is a prescription by the government which must be complied with intended targets and failure to do so involves penalty. Thus, Lipsky's theory will help to understand the nature of job and challenges faced by SLBs in district Jalandhar.
The study is exploratory in nature and was conducted in four out of ten Community Health Centers (CHCs), namely, Noormahal, Kala Bakra, Lohian and Shahkot, and District hospital in Jalandhar district. The purposive sample consisted of Senior Medical Officers (SMOs)/Nodal officers and Sanitary Inspectors/Health Supervisors one each in the four CHCs and District Hospital, responsible for field visits for tobacco control program.
Two separate semi-structured interview schedules were used for in-depth exploration of the work duties of the SLBs, namely, the SMOs/Nodal officers as well as the health supervisors/sanitary inspectors. The major questions were centered on the nature of their duties, the barriers faced in implementing tobacco control policy in the field, resources, and experience with the clients in the field.
Data collection was iterative in nature where the first step of contact with the SLBs was formal, researching their place in tobacco control program. The second time it was more detailed about their personal experiences in executing their duties and problems they face in executing the same in the field. Data was collected in a period of 2 months from January 2017 to February 2017 for which prior appointments were fixed, and permission through consent forms was taken from the authorities. The interviews were conducted in Punjabi Language and were audio recorded by the researcher.
Data was recorded, and the verbatim was translated in English and transcribed before subjecting it to the process of inductive thematic analysis. Transcripts were read and coded manually. Categories were developed which were later merged into broader themes. The themes were identified, analyzed, and patterns reported in the data so obtained. The researcher acknowledged her own theoretical positions and values in relation to the qualitative research.
| Results|| |
The research findings have been divided into four major parts. Each of these parts is highlighted through the framework established by Lipsky. The various parts represent the nature of the job and problems faced by the implementers of tobacco control in the district.
Expectations about job performance
The SMO/Nodal officers along with the Health/Sanitary inspectors are responsible for the implementation of the tobacco control program in their respective blocks. The job of the health inspectors in the program is confined to collection of fines and on the spot counseling. Although the SLBs are supportive of their role in tobacco control, they have not been trained in detail about the tobacco control program. Some are disengaged from the requirements of an inclusive policy on tobacco control. The workforce has become exhausted due to caseloads from other health programs, and there are no meaningful interactions with clients. They are of the view that the political determination of the policy restricts those issues which need to be prioritized. They are structured in a way that they have to deal with these conflicts within themselves. Moreover, they have limited control over their job, and their job expectations are ambiguous.
In the words of a health inspector,
We have not been provided any formal training on tobacco control; however, intermittent notices are provided to health department to speed up the drive against tobacco control. We have to visit the field for vector control program and other health programs which leaves us with a lot of workload and paperwork.
Availability of resources (organizational and personal)
The SLBs said that although offenders are fined, the activities related to behavior change communication are missing due to lack of resources. The pamphlets or flyers which can be used to educate people are outdated in nature and lack creativity. Moreover, there is no clear demarcation of the budgetary allocation for various departments working for tobacco control. These institutions are working in their limited capacity and using the already work loaded workforce to address the issues relating to tobacco. The government is trying to project that the present workforce is capable of multitasking and handling different issues and problems of diverse programs together. This is a shallow claim by the government required the kind of activities and full-time dedication demanded by the tobacco control program. To make the problems worse, there is a lack of interdepartment coordination because tobacco control is seen primarily as the responsibility of the health department. This has led to the dilution of the comprehensiveness of the program which is considered a shared responsibility of various other departments.
Threat and challenge to authority (physical and psychological)
When SLBs raid tobacco kiosks for any kind of sale discrepancies, they face confrontation because kiosk holders tell them to find those who produce and market tobacco products. The SLBs said that they collect fine and try to be rational with those fined, but sometimes, violence also takes place and police has to intervene. To provide protection to the officers, two constables from police force are provided to these health teams. The SLBs feel that the government needs to tighten their noose around the big offenders rather than concentrating on those at the point of sale.
In the words of another health inspector,
Practically in the field, we encounter problems as people protest when we find them. The constant question which is always asked is that why the production of these tobacco products is not banned and there is no point fining them.
Using discretion to carry out their duties
As far as discretion to carry out their duties is concerned, the SLBs devised a mechanism to develop strategies for the duties considered important to them. While their work structure did not give them enough space to engage in counseling the tobacco users as well as sellers, they resorted to on the spot counseling of the offenders. Moreover, it was for them to decide whether the first-time offenders should be left after a warning or they should be fined. The SLBs demanded more power to be vested in the hands of those who work in the field and have a first-hand experience of the local problems being faced in implementing the tobacco control program.
| Discussion|| |
Tobacco being low on priority is a concern not only for India but also for other developing as well as developed countries. The impact of the tobacco policy in Australia was considered insignificant due to the improper translation of tobacco policy into practice as it was considered a low priority issue. Studies from developed and developing countries suggest similar barriers of scarcity of human resources and Information Education and Communication (IEC) material which hampers the effective implementation of the tobacco control program. The SLBs are the ones who experience a gap between the legislative policies and managers on one side and high workload on the other end. The SLBs in district Jalandhar are not clear about the nature of duties entrusted to them as their involvement is not limited to the tobacco control program. It has been argued that improvement in policymaking and implementation can be brought out by clarifying policy goal. However, the policymakers fail to see that these local service deliverers are in a better position to provide service delivery because they choose to ignore the knowledge and expertise these individuals have. It is important to bear in mind that Lipsky's model is based on a critique where it says that the service deliverers, street bureaucrats as he calls them, ultimately determine the policy. This is a major argument by those who believe in the bottom-up approach of policymaking. It is argued that policy implementation occurs at two levels. He says that first is at the macro implementation level where actors at the center devise a plan, second at the micro implementation level where the local actors react to macro level plans, develop their own plans, and implement them. Those at the center can indirectly influence the plans at the local or micro level. However, if those at the local level are not given liberty to adapt the program to local needs, the plan is likely to fail.
This translation of policy into intended effort requires time, money, and resources. Lipsky goes onto argue that SLBs work under discouraging environments which is visible in the study field where proper resources are not available to the implementers. The lack of resources financial or otherwise is a great set back to their efficiency and working. He also points out that the commands and the associated rigidness associated with it, a feature of top-down approach, also makes it difficult for the bureaucrats to attend to their duties regularly. This results in their demotivation and discouragement and hence they are not able to implement the policy sincerely. The SLBs in the study pointed out that other departments consider that tobacco control is primarily associated with the health department. The main partner agencies in case of tobacco control are the education department, police department, and the municipal department in the field. This left them demotivated and disillusioned about the course of action the tobacco control is taking. The actors involved work within constraints setup by various partner agencies; hence, the increased workload on the health department in the district. Moreover, the SLBs have not been provided special training for the tobacco control activities in the district, and no specifically tailored IEC material is made available. A similar study done in the six districts of Andhra Pradesh resulted in the discussion about nonutilization of the workforce in the health system for tobacco control activities.
Interestingly, Lipsky stated that the SLBs enjoy discretion in determining the policy implementation at the local levels. The term discretion has been seen by some authors to have a positive impact through which SLBs can customize their decisions according to the specific situations which come their way. They have been rightfully called as street-level policy entrepreneurs who can adopt policy innovations to improve the implementation process. To adhere to the wishes of the government, the SLBs utilize the policy instruments in an effort to urge, bribe, coerce, or convince policy targets. That is why on spot fines are done in the tobacco control program for offenders to implement the policy effectively. These results might be explained by the fact that in bureaucracies client interaction is considered less important as that seen in street bureaucracies where client assessment is much pronounced. In addition, the top-downers see the policy implementation as a purely implementation process and fail to see the political aspects associated with it or try to ignore them.
| Conclusion|| |
The evidence from the study highlights the unexplored area of SLBs in the tobacco control program. A key policy priority, therefore, should be to make tobacco control policy more inclusive which voices the opinion of the SLBs involved in the program. This study adds to the existing body of tobacco control which will help the policymakers devise a robust mechanism through which more power is vested in the hands of those who have direct interaction with the clients. It also opens avenues for the public health experts to use social science theories in addressing issues of policy formulation as well as an implementation which can make the program a greater success.
Limitations of the study
The researcher faced problems in getting responses from the respondents as most of them wore the veneer of consensus but their body language told otherwise, which were recorded as unsaid responses. It was not possible to investigate the SLBs across all the ten CHCs in the district; hence, the limitation of a small sample.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cariney P, Studlar DT, Mamudu HM. Global Tobacco Control Power Policy Governance and Transfer. New York: Palgrave Macmillan; 2012.
Matland RE. Synthesising the implementation literature: The ambiguity conflict model of policy implementation. J Public Adm Res Theory 1995;5:145-74.
Lipsky M. Street Level Bureaucracy: Dilemmas of the Individual in the Public Service. New York: Russell Sage Foundation; 1980.
Sanyanga W. Implementation and regulation of the tobacco products control act 83 of 1993 by street level bureaucrats (and the tobacco control amendment act of 1999) in relation to selling of tobacco products to underage people. In: The Pietermaritzburg Central Business District as a Case Study. Pietermaritzburg: University of KwaZulu-Natal; 2005.
Howlett M, Ramesh M. Studying Public Policy: Policy Cycles and Policy Subsystems. Toronto : Oxford University Press; 1995.
Braun V, Clark V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77-101.
Panda R, Mathur MR, Divya P, Srivastava S, Ramachandra SS. Health system preparedness for tobacco control: Situational analysis of existing health programs in Andhra Pradesh, India. Asian Pac J Cancer Prev 2012;13:5969-73.
Robertson JA, Conigrave KM, Ivers R, Usher K, Clough AR. Translation of tobacco policy into practice in disadvantaged and marginalized subpopulations: A study of challenges and opportunities in remote Australian indigenous communities. Health Res Policy Syst 2012;10:23.
Ayres CG, Griffith HM. Perceived barriers to and facilitators of the implementation of priority clinical preventive services guidelines. Am J Manag Care 2007;13:150-5.
Thankappan KR, Pradeepkumar AS, Nichter M. Doctors' behaviour & skills for tobacco cessation in Kerala. Indian J Med Res 2009;129:249-55.
] [Full text]
Winter SC. Implementation. In: Peters BG, Pierre J, editors. The Sage Handbook of Public Policy. London: Sage Publications; 2006. p. 151-66.
Kickert JM, Klijn EH, Koppenjan JF. Managing Complex Networks: Strategies for the Public Sector. Thousand Oaks: Sage Publications; 1997.
Berman P. The study of macro – And micro-implementation. Public Policy 1978;26:157-84.
Palumbo Dennis J, Steven MM, Wright P. Measuring Degrees of Successful Implementation. Eval Rev 1984;8:45-74.
Anderson EJ, editor. The study of public policy. In: Public Policy Making. Boston: Houghton Mifflin Company; 1997. p. 1-34.
Bardach E. Getting Agencies to Work Together: The Theory and Practice of Managerial Craftsmanship. Washington DC: Brookings Institution Press; 1998.
Arnold G. Street-level policy entrepreneurship. Public Manage Rev 2015;17:307-27.
Hessing M, Howlett M. Canadian Natural Resource and Environmental Policy: Political Economy and Public Policy. Canada: UBC Press; 1997.
Keiser L. Understanding street-level bureaucrats' decision making: Determining eligibility in the social security disability program. Public Adm Rev 2010;70:247-57.
Baier V, March JG, Saetren H. Implementation and ambiguity. Scand J Manage Stud 1986; 2:197-212.