Street-Level Bureaucracy Underutilized in Pacific Island Countries to Implement Health Reforms Effectively.

Street-level bureaucracy is a social theory developed by Michael Lipsky that tries to explain the way in which front line public service workers interpret and implement government policies.

The theory is based on the notion that the hard and dirty work of the state is done by the front line workers. The theory assumes 3 things:

  1. Demand from clients will always be more than resources. Governments appear to provide limited resources for public servants to achieve increasingly higher output and provide limited resources despite increase in demand for government services.
  2. Personal discretion by government front line workers. Government employees appear to prioritise the easier task and leave the complex task to be attempted later. As a result complex tasks will keep moving down the priority ladder.
  3. Personal discretion at how the policy is implemented, as long as it achieve its outcome.

This theory has implications for individual employees and systems. Lipsky predicted that because the demand from clients will never be met, increasing staff and budget will not decrease workloads of public servants. Instead he predicted that increasing capacity will expand government services at the same level of service at a higher volume.

I think Street-Level Bureaucracy can be used to understand and explain how and why health plans and health sector reforms do not appear to gain traction in Pacific Island Countries. Studies done in the UK show that GP doctors use their discretion on how clinical guidelines are used. Although they like guidelines and support their implementation, how guidelines are used is up to the doctors. I think same phenomenon is or maybe happening in Pacific Island countries. We just don’t know because little or no research has been done into this aspect of health sector reform reviews.


About rodney itaki

Medical doctor and public health specialist from Papua New Guinea.
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