Beyond the Front-Line: the Coping Strategies and Discretion of Lithuanian Street-Level Bureaucracy During COVID-19

This article presents the results of a project funded by the Research Council of Lithuania: ‘Public policy solutions and their improvement to overcome the COVID-19 crisis in Lithuanian municipalities: solution tools and service delivery.’ The research methodology is based on street-level bureaucracy theory and ongoing qualitative research in the form of interviews with social workers and doctors. Interviews were conducted in the Lithuanian municipalities which became the first COVID-19 hotspots in March-April 2020. The aim is to identify the response and coping strategies of street-level bureaucracy. The findings of current research suggest that the workload of street-level bureaucrats increased, the situation changed very rapidly, and there was a constant need to adopt rules and even recommendations issued by the ministry. Fear of COVID-19 infection, a lack of accurate information, uncertainty, and the possibility of allowing staff with children to leave the workplace led to staff shortages. This in turn motivated the administration and the remaining employees to look for suitable coping strategies.

Frontline healthcare workers’ experiences in implementing the TB-DM collaborative framework in Northern Ghana

Background Over the past decade, global health policy has increased its focus on measures to halt further increase in tuberculosis (TB) incidence and management of diabetes mellitus (DM). However, the vertical management of these two diseases have not achieved much in addressing the adverse effects of the rising tuberculosis-diabetes co-epidemic. This necessitated the World Health Organisation and the International Union Against Tuberculosis and Lung Disease to develop a framework to manage this dual disease burden. TB-DM co-epidemic is a public health concern in Ghana, adversely threatening the country’s fragile health systems. Since frontline healthcare workers are critical in health policy implementation, this study used Lipsky’s theoretical framework of street-level bureaucracy to explore their experiences in implementing the collaborative framework at the health facility level in Ghana. Methods This qualitative study was conducted between July to September 2019 using an exploratory design. Data was generated using a semi-structured interview guide designed to elicit information on knowledge of TB-DM comorbidity as well as systems for co-management. Twenty-three in-depth interviews were conducted among purposively selected frontline healthcare workers (doctors, nurses, TB task- shifting officers, TB institutional coordinators and hospital managers) from three health facilities in the Northern Region of Ghana. The lead author also conducted observations and document reviews, in order to fully address the study objectives. Thematic analysis was guided by the Lipsky’s theoretical framework of street level bureaucracy. Results The findings revealed three main themes and six sub-themes. Main themes were Prioritisation of TB/HIV co-infection while negating TB-DM comorbidity, Poor working conditions, and Coping mechanisms, whereas sub-themes were Low knowledge and awareness of TB-DM comorbidity, Limited awareness of the collaborative framework, High workload in TB & DM Clinics, Multiple roles, Inadequate training, and Space shortage. Conclusions Frontline healthcare workers had limited knowledge of TB-DM comorbidity and the collaborative framework, which, in turn adversely affected the effectiveness in implementing the framework. The effective implementation of the framework begins with raising awareness about the framework through in service training amongst the frontline healthcare workers. Additionally, an integrated screening tool to detect both TB and DM would help achieve early detection of TB-DM comorbidity.