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STREET-LEVEL BUREAUCRATS IN COMMUNITY-BASED HEALTH INITIATIVES: A CASE STUDY OF AGONA WEST

Yıl 2025, Cilt: 9 Sayı: 2, 468 - 498, 30.06.2025

İbrahim Abubakar Ahmed

https://doi.org/10.47525/ulasbid.1673515

Öz

This study examines how street-level bureaucrats (SLBs) implement community-based health initiatives (CBHIs) in Ghana's Agona West Municipality through the Community-based Health Planning and Services (CHPS) program. The researcher employed a mixed-methods approach to investigate SLBs' discretionary practices to manage resource constraints and conflicting demands, implementation challenges, and coping strategies. Data were collected from 60 SLBs through surveys, 20 SLBs through in-depth interviews, and 32 community members through focus group discussions.
Findings reveal that SLBs perform diverse roles, including service provision, health education, and surveillance, frequently expanding these roles based on community needs. They exercise significant discretion through service prioritization, protocol adaptation, and resource mobilization, particularly in resource-constrained rural settings. Implementation challenges include resource limitations, administrative burden, and policy-practice gaps. SLBs employ coping strategies such as task prioritization, creative resource mobilization, and community engagement.
This study contributes to street-level bureaucracy theory by demonstrating recursive relationships between challenges, discretion, and coping strategies in African healthcare contexts. The researcher recommends realistic policy design, reduced administrative burden, supportive supervision, and systematic learning from SLBs' innovations to strengthen community-based health systems.

Anahtar Kelimeler

Street-level bureaucrats community health policy implementation coping strategies health systems.

Etik Beyan

Ethical approval was obtained from the Agona Swedru Government Hospital Ethics Committee (GHS/C/SGH/2264) and Ghana Health Service Ethics Review Committee (GHS-ERC-006/03/24). All participants provided informed consent and could withdraw anytime. Personal identifiers were removed to ensure anonymity, and the study followed culturally sensitive practices.

Kaynakça

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TOPLUM TEMELLİ SAĞLIK GİRİŞİMLERİNDE SOKAK DÜZEYİNDEKİ BÜROKRATLAR: AGONA WEST'TE BİR VAKA ÇALIŞMASI

Yıl 2025, Cilt: 9 Sayı: 2, 468 - 498, 30.06.2025

İbrahim Abubakar Ahmed

https://doi.org/10.47525/ulasbid.1673515

Öz

Bu çalışma, Toplum Temelli Sağlık Planlaması ve Hizmetleri (CHPS) programı aracılığıyla Gana'nın Agona West Belediyesi’nde sokak düzeyindeki bürokratların (SDB'ler) toplum temelli sağlık girişimlerini (CBHI'ler) nasıl uyguladıklarını incelemektedir. SDB'lerin kaynak kısıtlamalarını ve çelişen talepleri, uygulama zorluklarını ve başa çıkma stratejilerini yönetmeye yönelik isteğe bağlı uygulamalarını araştırmak için karma yöntem yaklaşımı kullanılmıştır. Anketler aracılığıyla 60 SDB'den, derinlemesine görüşmeler aracılığıyla 20 SDB'den ve odak grup tartışmaları aracılığıyla 32 topluluk üyesinden veri toplanmıştır.
Bulgular, SDB'lerin hizmet sunumu, sağlık eğitimi ve gözetim dahil olmak üzere çeşitli roller üstlendiğini ve bu rolleri sıklıkla toplumun ihtiyaçlarına göre genişlettiğini ortaya koymaktadır. Özellikle kaynakların kısıtlı olduğu kırsal ortamlarda hizmet önceliklendirmesi, protokol uyarlaması ve kaynak seferberliği yoluyla önemli ölçüde takdir yetkisi kullanmaktadırlar. Uygulama zorlukları arasında kaynak sınırlamaları, idari yük ve politika-uygulama boşlukları yer almaktadır. SDB'ler görev önceliklendirme, yaratıcı kaynak seferberliği ve toplum katılımı gibi başa çıkma stratejileri kullanmaktadır.
Bu çalışma; Afrika sağlık sistemi bağlamlarında zorluklar, takdir yetkisi ve başa çıkma stratejileri arasındaki özyinelemeli ilişkileri göstererek sokak düzeyinde bürokrasi teorisine katkıda bulunmaktadır. Toplum temelli sağlık sistemlerini güçlendirmek için gerçekçi politika tasarımı, azaltılmış idari yük, destekleyici denetim ve SDB'lerin yeniliklerinden sistematik öğrenme önerilmektedir.

Anahtar Kelimeler

Sokak düzeyinde bürokratlar toplum sağlığı politika uygulaması başa çıkma stratejileri sağlık sistemleri.

Etik Beyan

Etik onay Agona Swedru Devlet Hastanesi Etik Komitesi (GHS/C/SGH/2264) ve Gana Sağlık Hizmetleri Etik İnceleme Komitesi'nden (GHS-ERC-006/03/24) alınmıştır. Tüm katılımcılar bilgilendirilmiş onam vermiş ve istedikleri zaman geri çekilebilmişlerdir. Anonimliği sağlamak için kişisel tanımlayıcılar kaldırılmış ve çalışmada kültüre duyarlı uygulamalar izlenmiştir.

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  • Olayinka, F., O'Connell, T. S., Morgan, C., Monzon, M. F., Oshin, T., Tampe, T., ... & Shearer, J. C. (2024, July). Applying a Primary Health Care Approach to Closing the Human Resource for Health Gaps for Immunization. In Healthcare (Vol. 12, No. 14, p. 1449). MDPI.
  • Openstax (2024). Community-Based Healthcare Initiatives. https://openstax.org/books/fundamentals-nursing/pages/4-5-community-based-healthcare-initiatives - Accessed Date: 21/12/2024).
  • Owusu, L., Tuwor, R. D., Ackam, N., Loglo, A., Agbavor, B., Agbanyo, A., ... & Phillips, R. O. (2023). Role and capacity needs of community based surveillance volunteers in the integrated management of skin neglected tropical diseases (skin NTDs): a qualitative study from central Ghana. BMC Public Health, 23(1), 1086.
  • O'Toole Jr, L. J., & Meier, K. J. (2010). Implementation and managerial networking in the new public governance. In The New Public Governance? (pp. 338-352). Routledge.
  • Okine, P. E. N. A. (2024). An evaluation of community health care service in Ghana: A case of the Community-Based Health and Planning Service (CHPS) compound in Ghana (Doctoral dissertation, Brunel University London).
  • Park, S. (2022). The construction of social inequity and the role of public bureaucracies. Journal of Policy Studies (JPS), 37(4), 1-15. https://doi.org/10.52372/jps37401
  • Plano Clark, V. L. (2017). Mixed methods research. The Journal of Positive Psychology, 12(3), 305-306. https://doi.org/10.1080/17439760.2016.1262619
  • Pool, R., Montgomery, C. M., Morar, N. S., Mweemba, O., Ssali, A., Gafos, M., ... & McCormack, S. (2010). A mixed methods and triangulation model for increasing the accuracy of adherence and sexual behaviour data: the Microbicides Development Programme. PloS one, 5(7), e11600. https://doi.org/10.1371/journal.pone.0011600
  • Portero de la Cruz, S., Cebrino, J., Herruzo, J., & Vaquero-Abellán, M. (2020). A multicenter study into burnout, perceived stress, job satisfaction, coping strategies, and general health among emergency department nursing staff. Journal of clinical medicine, 9(4), 1007. https://doi.org/10.3390/jcm9041007
  • Prem, V., Karvannan, H., Kumar, S. P., Karthikbabu, S., Syed, N., Sisodia, V., & Jaykumar, S. (2012). Study of nurses' knowledge about palliative care: a quantitative cross-sectional survey. Indian journal of palliative care, 18(2), 122. https://doi.org/10.4103/0973-1075.100832
  • Perry, H. B., Chowdhury, M., Were, M., LeBan, K., Crigler, L., Lewin, S., ... & Hodgins, S. (2021). Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All". Health research policy and systems, 19, 1-21.
  • Rifkin, S. B. (2014). Examining the links between community participation and health outcomes: a review of the literature. Health policy and planning, 29(suppl_2), ii98-ii106. https://doi.org/10.1093/heapol/czu076
  • Rivera, J. D., & Knox, C. C. (2023). Bureaucratic discretion, social equity, and the administrative legitimacy dilemma: Complications of New Public Service. Public Administration Review, 83(1), 65-77. https://doi.org/10.1111/puar.13550
  • Sakeah, E., Bawah, A. A., Asuming, P. O., Debpuur, C., Welaga, P., Awine, T., ... & Oduro, A. R. (2023). Impact of community health interventions on maternal and child health indicators in the upper east region of Ghana. BMC Pregnancy and Childbirth, 23(1), 298. https://doi.org/10.1186/s12884-023-05577-7
  • Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., ... & Jinks, C. (2018). Saturation in qualitative research: exploring its conceptualization and operationalization. Quality & quantity, 52, 1893-1907. https://doi.org/10.1007/s11135-017-0574-8
  • Sheikh, K., Ranson, M. K., & Gilson, L. (2014). Explorations on people centredness in health systems. Health policy and planning, 29(suppl_2), ii1-ii5. https://doi.org/10.1093/heapol/czu082
  • Sumah, A. M., & Baatiema, L. (2018). Decentralisation and management of human resource for health in the health system of Ghana: a decision space analysis. International journal of health policy and management, 8(1), 28. https://doi.org/10.15171/ijhpm.2018.88
  • Schwarz, D., Kim, J. H., Ratcliffe, H., Bell, G., Awoonor-Williams, J. K., Nimako, B., ... & Bitton, A. (2019). The status of Ghanaian community health workers' supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey. Gates Open Research, 3, 1468. https://doi.org/10.12688/gatesopenres.12979.2
  • Teram, E., & White, H. (1993). Strategies to address the bureaucratic disentitlement of clients from cultural minority groups. Canadian Journal of Community Mental Health, 12(2), 59-70. https://doi.org/10.7870/CJCMH-1993-0018
  • Teye, J. K., Yaro, J. A., & Bawakyillenuo, S. (2015). Local farmers' experiences and perceptions of climate change in the Northern Savannah zone of Ghana. International Journal of Climate Change Strategies and Management, 7(3), 327-347. https://doi.org/10.1108/IJCCSM-05-2014-0066
  • Thomann, E., & Lieberherr, E. (2023). Bringing street-level bureaucrats' behaviour into policy evaluation. In Handbook of Public Policy Evaluation (pp. 391-407). Edward Elgar Publishing. https://doi.org/10.4337/9781800884892.00035 Tierozie, C. (2011). Impact assessment of the community-based health planning and services initiative in the Berekum municipality (Doctoral dissertation).
  • Tummers, L. L., Bekkers, V., Vink, E., & Musheno, M. (2015). Coping during public service delivery: A conceptualization and systematic review of the literature. Journal of Public Administration Research and Theory, 25(4), 1099-1126. https://doi.org/10.1093/jopart/muu056
  • Tummers, L., & Bekkers, V. (2014). Policy implementation, street-level bureaucracy, and the importance of discretion. Public Management Review, 16(4), 527-547. https://doi.org/10.1080/14719037.2013.841978
  • Universiteit, P. A.-V., & 2017, undefined. (2016). ACCESS TO HEALTHCARE THROUGH NHIS; FACTORS LIMITING ENROLMENT OF THE POOR UNTO THE NATIONAL HEALTH INSURANCE SCHEME IN. Bibalex.Org. http://bibalex.org/baifa/Attachment/Documents/aOac5ijpgw_20180415123208956.pdf
  • Van Belle, S., & Mayhew, S. H. (2016). Public accountability needs to be enforced-a case study of the governance arrangements and accountability practices in a rural health district in Ghana. BMC health services research, 16, 1-14. https://doi.org/10.1186/s12913-016-1836-1
  • Wak, G., Oladokun, S., Manye, A., Awine, T., Komesuor, J., & Aborigo, R. (2025). Effect of Household Dynamics on Infant Mortality in the Kassena_Nankana Districts of Rural Northern Ghana, 1999-2018. Child Indicators Research, 1-18.
  • World Health Organization. (2016). Framework on integrated, people-centred health services. Geneva: World Health Organization, 2019.
  • World Health Organization. (2018). WHO guideline on health policy and system support to optimize community health worker programmes. World Health Organization.
  • Wu, X., Wang, H., Yuan, X., Huang, S., & Luo, D. (2015). Design and implementation of recursive model predictive control for permanent magnet synchronous motor drives. Mathematical Problems in Engineering, 2015(1), 431734. https://doi.org/10.1155/2015/431734
  • Wak, G., Oladokun, S., Manye, A., Awine, T., Komesuor, J., & Aborigo, R. (2025). Effect of Household Dynamics on Infant Mortality in the Kassena_Nankana Districts of Rural Northern Ghana, 1999-2018. Child Indicators Research, 1-18. https://doi.org/10.1007/s12187-024-10212-8
  • Wagenaar, H. (2019). Discretion and street-level practice. In Discretion and the quest for controlled freedom (pp. 259-277). Cham: Springer International Publishing. https://doi.org/10.1007/978-3-030-19566-3_17
  • Yin, Robert K. (2017). Case study research and applications: Design and methods. Sage Publications.
  • Zulu, J. M., & Perry, H. B. (2021). Community health workers at the dawn of a new era. Health Research Policy and Systems, 19, 1-5.
Toplam 105 adet kaynakça vardır.

Ayrıntılar

Birincil Dil İngilizce
Konular Politika ve Yönetim (Diğer), Halk Sağlığı (Diğer)
Bölüm Araştırma Makalesi
Yazarlar

İbrahim Abubakar Ahmed 0000-0002-1621-2951

Gönderilme Tarihi 10 Nisan 2025
Kabul Tarihi 21 Haziran 2025
Erken Görünüm Tarihi 21 Haziran 2025
Yayımlanma Tarihi 30 Haziran 2025
Yayımlandığı Sayı Yıl 2025 Cilt: 9 Sayı: 2

Kaynak Göster

APA Abubakar Ahmed, İ. (2025). STREET-LEVEL BUREAUCRATS IN COMMUNITY-BASED HEALTH INITIATIVES: A CASE STUDY OF AGONA WEST. Uluslararası Anadolu Sosyal Bilimler Dergisi, 9(2), 468-498. https://doi.org/10.47525/ulasbid.1673515

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