The enactment of the 1988 Constitution aroused pessimistic interpretations regarding the chances of fulfilling its promises. Some considered that the institutions established or re-established by the constitution would make the country ungovernable. Furthermore, they also argued (and still argue) that the list of constitutionalized social policies did not fit into the government budget. Others, however, faced the challenge of designing a complex institutional architecture capable of putting into practice some of the constitutionalized social rights. The most challenging task was to provide universal access to public health services, previously limited to those who had formal jobs.
Academic research detailing the trajectory of health policy experts, explaining their activism and the challenges they faced is now available; hence it is here only enough to highlight its importance. Similarly, the reconstruction of similar health policy experiences, tested in other countries and in smaller territorial areas, and that led to the construction of the current model of healthcare, is also already mapped and analysed. What is still not known is, however, what happened to this institutional architecture, i.e. how and by whom health policy is implemented.
Gabriela Lotta's book faces this issue. The book's topic is the work of community health workers that make up the Family Health Strategy. The focus is on the bureaucracies that implement this strategy. Mainly based on the contribution of Michael Lipsky on the dilemmas of a public servant that comes in direct contact with the citizen at the time of implementing policies, the book begins with a review of the literature on the implementation of public policies and their agents, or street-level bureaucrats, as called by Lipsky. The main theories on public policies dealing with implementation, as well as the analyses already conducted on the Brazilian case, are also reviewed. It should be noted that although the first edition of Lipsky's book was published in 1980, the Brazilian literature analysing the street-level bureaucrats is still in its infancy.
This review is followed by a chapter detailing the role of community workers recruited by the program, highlighting their double commitments: to the state as public servants, and to the community in which they live and work. In this sense, the research goes beyond the classic literature on street level bureaucracy that only takes into account the role of civil servants in the provision of services when they directly interact with citizens. The experience of a public policy that turns a community resident into a state representative adds value to Lipsky's contribution.
Chapters 03, 04 and 05 are, in my view, the great contribution of this work. Chapter 03 deals with the details of the contexts and of the institutional and organizational factors of the selected Basic Health Units, identifying the factors and contexts that make the cases analysed closer or more distant from themselves, but mainly the discretion of bureaucrats. These factors are crucial and show how decisions made by community agents are adaptations of rules that enable them to implement the policy according to local conditions. Adaptations do not mean, however, actions that substantively contradict policy rules. In other words, values, beliefs and ideas contribute to operationalize the policy at the time of its implementation. In this sense, the book helps to prove one of the conclusions of the literature on implementation, which indicates the distance between the two stages of the policy process - formulation and implementation.
Chapter 04 adds relational factors to context and rules, showing the role of social networks in the implementation process, as well as their influence on the formation of vertical connections established in contact with both the community and other civil servants. Horizontal connections were also identified, mainly generating exchange of information among members of the community.
In the following chapter the author goes beyond network mapping, always static, as she properly claims, to identify the dynamic elements of the implementation process and the discretion of bureaucrats. It is about identifying the dynamics that influence the practices and the styles of interaction or intermediation used by street-level bureaucrats.
As expected, some comments should be made to the reader and/or to forthcoming editions. As the author herself acknowledges, the number of cases is small. However, this small number can be credited to the involvement of a single researcher in an ambitious research project. A larger team, using a similar methodology, as suggested by the author, can help to form and consolidate a research agenda on street-level bureaucrats. A second comment is related to the literature review and the details of the rules governing the program. Both seem very large and both the literature and the description of rules could be mentioned throughout the book, making it lighter and allowing a more pleasant reading.
The book has many merits. The main one is its contribution to the knowledge of the policy implementation phase, when public servants provide services. More than that, public servants are part of the community that receives their service. In this sense, Gabriela Lotta presents another important contribution to the growing literature on national policies that are locally implemented. It also contributes to the advancement of our knowledge about who an important part of the bureaucracy is and how it acts. The quality of Editora Fiocruz publications must also be highlighted. By mobilizing various methodologies and testing and expanding concepts and theories, the book delivers what it promises.
Publication Dates
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Publication in this collection
2016
