© Kamla-Raj 2019  J Soc Sci, 60(1-3): 9-20 (2019)
PRINT: ISSN 0971-8923  ONLINE: ISSN 2456-6756 DOI: 10.31901/24566756.2019/60.1-3.2244
Street-level Bureaucrats’ Coping Strategies and How They Affect
Public Service Delivery in Ghana
Daniel Dramani Kipo-Sunyehzi1, Philip K. Attuquayefio1 and James Kipo Sunyehzi2
1University of Ghana, Legon Centre for International Affairs, Legon-Accra, Ghana
2University for Development Studies, School of Business and Law, Wa Campus, Ghana
KEYWORDS Action. Behaviour. Bureaucrats. Coping Strategies. Policy Services
ABSTRACT Street-level bureaucrats (SLBs) are at the front of public social policy-making and implementation.
This paper examines actions, behaviours and SLBs coping strategies in social service delivery. It uses interviews,
documentation and observations with a comparative case study approach. It contributes to public social policy
implementation in developing world context. It adds to street-level bureaucracy debates that actions and behaviour
of SLBs are not only influenced by workload and working conditions but are influenced by their organisational
culture. It moves away from the traditional public bureaucracy perspective and brings a new dimension on SLBs
coping strategies within public-private organisational contexts. Findings suggest that organisational behaviour,
interests, resources and culture influence the coping strategies SLBs adopt in organisations, which affect their
clients’ access to social services. Ironically, findings suggest SLBs in private organisations seem more inclined
towards clients than their public counterparts. It concludes that the interest of clients should be paramount.
INTRODUCTION Research Objectives
Street-level bureaucrats (SLBs) directly or in- This research study explored the factors that
directly play crucial roles in the various stages of affect social service delivery at the local level and
policy cycle-agenda setting, formulation, decision how action, the behaviour of SLBs influence the
making, and implementation to evaluation implementation of a public social policy-National
(Howlett et al. 2009). Street-level bureaucrats are Health Insurance Scheme (NHIS) in Ghana.
public service workers or key actors in the policy  Some scholars argue that some actions of
process who interact on a daily basis with indi- SLBs diverge from the stated policy intentions-
viduals or clients (Edlins and Larrison 2018). There goals or objectives in developed and developing
is extensive literature on strategies or mechanisms countries (Lipsky 1980; Makinde 2005). Lipsky
SLBs adapt to cope with their work from earlier (1980, 2010) elaborated some conditions of work
scholarly works including Lipsky (1980, 2010) to that affect SLBs work outputs and outcomes.
recent works (Tummers and Rocco 2015; Tum- These include limited resources relative to work-
mers et al. 2015; Edlins and Larrison 2018; Peder- load, high demands for social services from cli-
sen et al. 2018). Also, recent literature on SLBs ents or the citizens, ambitious organisational
moves away from coping strategies of SLBs to
the point of accountability. The impact of ac- goals, or vague or conflicting goals and the in-
countability on SBLs (Murphy and Skillen 2018), voluntary nature of their clients (Lipsky 1980,
accountability from profit and non-profit orient- 2010: 27-28). Other recent scholars share similar
ed organisations perspectives (Lieberherr and views with Lipsky on conditions that compel
Thomann 2019) as well as informal accountability SLBs to adopt various coping strategies to cope
of SLBs towards their citizen-clients (Pivoras and with their work situations or manage their client’s
Kaselis 2019). demands on a daily basis (Bender et al. 2018;
Searcy 2018; Edlins and Larrison 2018; Pedersen
Address for correspondence: et al. 2018). Examples of some of the coping strat-
Daniel Dramani Kipo-Sunyehzi, PhD egies are ‘rationing services’ through ‘creaming’,
Research Fellow,
University of Ghana, worker bias against some clients and cases
Legon Centre for International Affairs and against organisational norms of non-differentia-
Diplomacy Ghana, tion (Lipsky 1980, 2010). Some include ‘discrimi-
P. O. Box LG25, Legon-Accra, Ghana nation’ against some groups based on race like
E-mail: dkipo-sunyehzi@ug.edu.gh ‘black’ or other colour on the provision of social
10 DANIEL DRAMANI KIPO-SUNYEHZI, PHILIP K. ATTUQUAYEFIO  AND JAMES KIPO SUNYEHZI
services (Einstein and Glick 2017; Searcy 2018). delivery in two cities (Accra/Kumasi) in Ghana
Some studies show SLBs controlling clients, or (Crook and Ayee 2006). They analysed the influ-
modifying policy goals (Ayee 1994; 2012; Ohe- ence of ‘organisational culture’ and attitude, ‘po-
meng et al. 2012). Also, changing clients’ percep- litically protected privatisations’ on SLBs ability
tions, attitudes, beliefs and behaviours on some to enforce environmental standards in communi-
services provision (Smith and Brownell 2018) ties. Similar studies look at behaviour, actions of
among other coping strategies or mechanisms of SLBs, politicians in policy-making and implemen-
SLBs. These coping strategies are largely nega- tation processes in Ghana and how such behav-
tive as they limit clients’ access to social services. iours, actions affect public service delivery (Ayee
On the contrary, some scholars like Nielsen 1994; Ayee 2012; Ohemeng and Ayee 2012; Ohemeng
argues that SLBs behaviour can be ‘positively et al. 2012).
motivated’ as SLBs are engaged in acts or ways Andersen (2004) looks at attitudes of front-
that seek to maximise or gain ‘job satisfaction’ line workers/SLBs in a public hospital (Bolgatan-
from such actions (Nielsen 2006: 861, 863). Niels- ga Regional Hospital) in Northern Ghana in rela-
en further argues that SLBs are not only just com- tion to the kind of treatment given to patients,
pelled to cope due to working conditions but are some received good treatment while those termed
also ‘enticed’ to cope (Nielsen 2006: 866). Fur- the ‘villagers’ received poor treatment. The study
thermore, SLBs are engaged in actions or practic- identified myriad of factors accounting for differ-
es like rule ‘bending’ or ‘breaking rules’ for cli- ential treatments for patients such as the ‘bu-
ents’ or patients’ interests, needs (Evans 2013; reaucratic aspects of hospital practice’, ‘bad atti-
Cooper et al. 2015; Assadi and Lundin 2018). Thus, tudes’ of hospital workers (SLBs) in relation to
SLBs adopt coping strategies that aim to increase working conditions, professionalism and the ‘so-
clients’ access to social services. cial identities’ of the health workers (SLBs). Oth-
Other scholars look at coping strategies of er factors analysed include resource deficiencies,
SLBs in service delivery differently not pessimis- poor working conditions, underpayment and un-
tic or optimistic but a blend of the two contrary derstaffing. These factors may explain why some
views, with the typology of coping strategies of health workers in Africa and Ghana, in particular,
SLBs. Some studies identified such typology of show some ‘bad attitudes’ towards patients at
coping strategies ‘moving towards clients’, ‘mov- health facilities. These studies also explain how
ing away from clients’ and ‘moving against cli- SLBs actions, behaviour and or discretion affect
ents’ (Tummers et al. 2015; Tummers and Rocco their clients’ access to healthcare services (hos-
2015). These typologies are manifested in the pitals/clinics (Andersen 2004; Aniteye and Mayhew
application of rules, including rule-bending, break- 2013; Atinga et al. 2018).
ing or rigid rule application in the provision or
allocation of social services including healthcare. Agency and Stewardship Theoretical
Other studies look at politics-bureaucracy dynam- Perspectives
ics in policy processes in a developing world con-
text of SLBs (Makinde 2005; Ayee 2012; Ohemeng Agency and stewardship theories provide the
and Ayee 2012; Ohemeng et al. 2012). explanatory frames for this study, not only at the
organisational level but at individual levels. In
Street-Level Bureaucrats Coping Strategies in this regard, the researchers look at individuals’
Ghanaian Context motivations for their actions, behaviour during
public social service delivery. The researchers
Crook and Ayee (2006) look at how street-lev- explore principal-agent or principal-steward the-
el bureaucrats adapt to ‘client-oriented’ ways of oretical perspectives. The research study thus
working with elements of flexibility, responsive- looks at the relationships in healthcare service
ness to clients or public needs as opposed to provision: contractual relationships between
‘rule-oriented’ ways of public service delivery. health service providers as agents/steward and
Their study focuses on Environmental Health National Health Insurance Authority (NHIA) as
Officers (SLBs) coping strategies. They adopted principal (organisational level). The relationship
a comparative case study approach to service at the individual level is between health workers
J Soc Sci, 60(1-3): 9-20 (2019)
STREET-LEVEL BUREAUCRATS COPING STRATEGIES IN GHANA 11
(SLBs) and patients/ clients (health insurance searchers attempted to analyse how the types of
beneficiaries). The second individual-level rela- coping strategies affect clients’ access to health
tionship is between the NHIA workers (agents) care services at hospitals and clinics and health
and beneficiaries (principal) in new public man- insurance office. The study’s analytical frame-
agement sense. The principal-agent theory is pre- work is illustrated in Figure 1.
mised on the principle that the ‘principal’ con-
tracts an ‘agent’ to perform some tasks. Studies
established that the agent while serving the prin-
cipal interest may have some other motives or Workload-SLBs Stress Coping
interests’ such as ‘self-interest’, ‘self-regarding’, strategies(Public and Types of Effect onPrivate Health Organisational Coping
‘self-seeking with aim of increasing or maximis- Cultre, ClientsService Interests, Strategies Access to
Providers) of SLBs
ing his or her own income, leisure, time at the Health CareWorking Services
expense of principal (Foss 1995; Petersen 1995; Conditions-resources.
Brinkerhoff and Bossert 2014; Kipo-Sunyehzi
2018; Baker 2019). The principal-agent theory is
‘empirically tested’ or used from the implementa- Fig. 1. Study analytical framework
tion lens of NHIS in Ghana. In this regard, this Source: Author
study explores the factors that affect principal-
agent relationships. The principal-agent theory METHODOLOGY
is based on the ‘economic model of man’ where
humans are seen as being ‘hyperrational’ and ‘op- This research study adopts mainly a qualita-
portunistic’ (Niskanen 1971; Eisenhardt 1989). Stud- tive method. It specifically adopts a case study
ies show that the principal-agent relationships have approach with ‘detailed and intensive analysis of
some problems or challenges. These include ‘mor- a single case’ (Bryman 2012: 66). The single case
al hazards’, ‘adverse selection’, ‘multiple princi- being the National Health Insurance Scheme
pals’ syndrome’ information asymmetries, ‘ethical (NHIS) as a ‘contemporary phenomenon’ (Yin
dilemmas’ et cetera (Foss 1995; Petersen 1995; 2014) in Ghana. A comparative study involves
Brinkerhoff and Bossert 2014; Baker 2019). the ‘study of numerous cases along the same
Stewardship theory serves as an alternative lines, with a view to reporting and interpreting
to agency theory. The agency theory as explained numerous measures on the same variables of dif-
earlier is based on ‘economic man’ while steward- ferent individuals’ (Greenstein and Polsby 1975:
ship theory is based on the ‘humanistic model of 8). A case may be individual, group or organisa-
man’ (Donaldson and Davis 1991). Humanistic in tion (Merriam and Grenier 2019). The researchers
the sense that the steward has a need or a task to compared four implementing organisations (two
achieve, he or she works towards it and is self- clinics and two hospitals) on public-private health
motivated rather than financially motivated. Stew- service providers’ basis. The rationale for using a
ardship theory, the steward motivation is extrin- comparative case study design/approach is to
sic towards a collective goal (Schillemans 2013). help discover similarities and differences in two
The steward does not shirk or engages in acts of ‘contrasting cases’ patterns in service provision,
self-seeking but exercises lots of trusts for the behaviours, attitudes towards clients. The re-
principle. Also, the steward is committed to the searchers used three criteria in the selection of
task of the principal. cases namely duration in operation, ownership
 The study analytical framework focuses on and categories of health care services provided
public and private sector organisations, their work in Tamale Metropolis of Ghana as in Table 1.
schedule (roles and positions) in terms of the cas-  In addition, the researchers purposively se-
es they handle, their workload per day, work pres- lected a number of service providers termed SLBs.
sure and general working conditions. The re- Their actions, behaviours and attitudes matter
searchers looked at how such conditions may most since they are healthcare service providers.The choice of ‘purposive sampling’ (non-proba-
compel them to adopt coping strategies in deal- bility sampling technique) was to enable us to
ing with problems/challenges. Finally, the re- obtain insights into certain practices, context, time
J Soc Sci, 60(1-3): 9-20 (2019)
12 DANIEL DRAMANI KIPO-SUNYEHZI, PHILIP K. ATTUQUAYEFIO  AND JAMES KIPO SUNYEHZI
Table 1: Cases and the selection criteria the ethics of research including informed con-
Cases Owner- Years Types of sent of participants. They also obtained institu-
ship  of  services tional permissions from Ghana Health Service and
operation NHIA before we commenced the interviews in
Ghana.
West Hospital Public 18 5 services
SDA Hospital Private 11 5 services
H. Adams Clinic Private 26 4 Services RESULTS
Bilpeila Clinic Public 29 4 Services
NHIS Office Public 11 Registration/ The results focused on politics, working con-
Renewal ditions, action, behaviour and coping strategies
Note: SDA-Seventh Day Adventist; H.-Haj; Five (5) service of SLBs. The main research question is: to what
delivery areas at facilities- Out-patient, in-patient, extent and how does the behaviour of SLBs in-
diagnostics, pharmacies, theatre services. fluence implementation of NHIS? These are key
and in line with research questions on SLBs (Gray assumptions: the more positive attitude towards
2009). The selection of the SLBs in the study was the clients the better the health care services
based largely on their positions and units occu- provided them and vice versa. The other assump-
pied and the years of experience gain in the pro- tion is that the higher (more) the workload of
vision of healthcare services to NHIS clients. The SLBs the less positive attitude towards clients.
categories of SLBs were selected in facilities and The final assumption is that SLBs adopt coping
NHIS office are illustrated in Table 2. strategies to their advantage but at the expense
There was a triangulation of data sources, with of clients. These assumptions were analysed qual-
the rationale to increase the reliability and validi- itatively from fieldwork data gathered (empirical
ty of findings. In this regard, extensive documents observations).
including annual reports, attendance registers,
minutes of meetings, memoranda, charts among Politics
others were obtained in the field in addition to
direct observations of SLBs healthcare service On the issue of politics, the researchers found
provision. One-on-one in-depth interviews were that politics appeared to more in the early stages
conducted at facilities/NHIS office. The research- of the policy (agenda setting, formulation and
ers probed for more detailed responses from in- decision-making stages) than at the implementa-
terviewees (Gray 2009: 369-370; Bryman 2012: 469). tion stage. The researchers then tried to find out
This was done through the use of a semi-struc- the role of politics during the implementation of
tured interview guide with questions directed to NHIS in Ghana. SLBs in health facilities indicated
SLBs, their coping strategies and how they en- that politics may only exist in the NHIS office.
hance or inhibit healthcare services to clients. But NHIS officials responded that there is no
The fieldwork with SLBs took three stages: Sep- politics in their job. They found that politicians
tember-November 2012, February-July 2013 and and administrators of NHIS work together for
July- October 2014. The researchers adhered to mutual benefits and for the success of the policy(NHIS). Thus, politics appeared to have a mini-
Table 2: Participants (SLBs) and their sub-units for in-depth interviews
West Hospital SDA Hospital HAC Clinic Bilpeila Clinic NHIS Office
Out-patient (2) Out-patient (2) Out-patient (1) Out-patient (1) Manager (1)
In-Patient (1) In-patient  (1) In-patient (1) In-patient (1) Accounts (1)
Laboratory (1) Laboratory (1) Laboratory (1) Laboratory (0) MIS (1)
Diagnostic  (1) Diagnostic (1) Diagnostic (1) Diagnostic (1) PRO (1)
Pharmacy (1) Pharmacy (1) Pharmacy (1) Pharmacy (1) Data (1)
Total 6 Total 6 Total 5 Total 4 Total 5
Grand Total 26
Note: MIS- Information Management System      PRO- Public Relation Officer
J Soc Sci, 60(1-3): 9-20 (2019)
STREET-LEVEL BUREAUCRATS COPING STRATEGIES IN GHANA 13
mal role, the researchers only observed some aging attendances for registrations and renew-
forms of party politics in the area of transfer of als. While bad behaviours like insults, shouts,
health insurance workers particularly scheme rudeness, favouritism, disrespect towards clients
managers. Politics is a sensitive area. make some clients go to neighbouring districts to
access the same services like registration or re-
The Behaviour of SLBs at NHIS Office newal instead of Tamale Metropolis. One such
district a number of SLBs mentioned is Savelugu-
The researchers interviewed SLBs in NHIS Nanton district which served as an alternative for
office on registrations and renewals of member- dissatisfied clients. The SLBs indicated some bad
ship and how they cope with a large number of attitudes were exhibited unintentionally due to
clients who visit their office for services like reg- heavy workload, work pressure, congestions cou-
istrations and renewals. It is SLBs who determine ple with a limited number of staff to handle a large
clients who qualify for NHIS exemption policy number of clients in the office. The researchers
during registration. Five SLBs in the NHIS office observed some of these positive and negative
took part in the in-depth interviews on questions attitudes of SLBs in the NHIS office during field-
on the extent and how their behaviour affects the work. They also observed that in some cases some
implementation of NHIS. Four out of the five highly placed persons jumped queues to be of-
agreed that their behaviour had both positive and fered services promptly while the majority of cli-
negative effects on service delivery in areas such ents remained in the queue.
as clients’ registrations and renewals of member-
ship. Meanwhile one of them said their behav- The Workload of SLBs at NHIS Office
iour has only positive effects on service delivery.
The follow-up question was interesting, they tried Besides interviews and on-site direct obser-
to answer ‘how’ their behaviour affect the servic- vations at NHIS office, the researchers used doc-
es they provide to their clients. One of the four uments evidence extensively. They obtained Ta-
SLBs (line manager) made these comments on male NHIS annual reports from 2010 -2013. The
‘how’ their behaviour affect service delivery: reason for using 2010 onward annual reports was
 You can see the pressure yourself, look at to avoid the errors in the calculations for registra-
the congestions in the office and outside, all tions and renewals which were based on ‘cumu-
these people are there for either registration or lative membership’ for years before 2010. From
renewal of their membership cards. As profes- 2010 onward calculations were based on ‘active
sionals, we will always try our possible best to membership’ for NHIS clients. Having obtained
contain the pressure and stress of work to make the yearly attendances for registrations and re-
them happy. However, we sometimes lose con- newals, the researchers tried to divide each year
trol and say some things that may be unpleasant figure by the number of days in that year (365
to our dear customers (SLBs, 1-3#4). days for all but 366 days for 2012 leap-year) to get
The SLB with the contrary view that their be- workload per day. We then divided the workload
haviour has only positive effects has this to say: per day by the number of SLBs (staff) to get the
We are here because of subscribers; without workload per head. These simple calculations
them we will not be in employment or be here helped to have a fair idea on the workload per day
doing anything so their interest is for our inter- and workload per head (number of cases per each
est and their happiness is our happiness. We have SLB). These analyses are presented in Table 3.
no option than to behave well and relate well Table 3 shows that in 2010, the NHIS office
with all who come here for renewals or registra- recorded average daily registration attendances
tions (SLB#5). of 101 clients. On the number of clients who vis-
Interviews with SLBs in the NHIS office ited the NHIS office to renew their membership,
showed they were mindful of their behaviour to- the average daily renewals were 95 clients. This
wards clients. Thus, they indicated that positive shows NHIS office was overwhelmed with a total
actions, utterances and attitudes like a show of of 196 clients seeking both new registrations and
respect, kindness, politeness, smiles, timeliness renewals of their membership to NHIS. On total
in service delivery) have a direct effect of encour- workload per day in the NHIS office, data shows
J Soc Sci, 60(1-3): 9-20 (2019)
14 DANIEL DRAMANI KIPO-SUNYEHZI, PHILIP K. ATTUQUAYEFIO  AND JAMES KIPO SUNYEHZI
Table 3: Workload per day workload per head
Year 2010 SLBs 2011 SLBs 2012 SLB 2013 SLBs
Registration Attendance 37,201 1 1 33,976, 11 42,714 19 72,776 22
Average Daily Attendance 101 9 Reg- 94 8 Reg- 116 6 Reg- 199 9 Reg-
cases cases cases cases
Renewal Attendance 34,253 1 1 46,043 11 58,040 19 80,895 22
Average Daily Renewals 95 8 Ren- 127 11 Ren- 158 8 Ren- 221 10 Ren-
cases cases cases cases
Total Work Load Per Day 196 221 274 420
Total Work Load per Head 17 19 14 19
Source: Annual Reports: Tamale Metropolitan Mutual Health Insurance Scheme (TMMHIS) 2010-2013
an increasing trend from 196 to 221, 274, 420 for Table 4 results on coping strategies of SLBs
clients seeking registrations and renewals for show most SLBs (SLBs#2-5) were compelled to
2010, 2011, 2012, 2013 respectively. On the other adopt strategies due to workload as ways to ease
hand, the total workload per head handling both pressure and relax at the workplace. However, one
registrations and renewals of membership moved of them (SLB#1) view those coping strategies as
from 17 cases per head (SLB) in 2010 to 19, 14, 19 ways of making things work better and faster for
for 2011, 2012, 2013 respectively. There was a lit- clients at the workplace through rule-bending or
tle drop in a number of cases each SLB handled rule-breaking and work flexibility.
only in 2012.
The Behaviour of SLBs at Health Facilities
Coping Strategies of SLBs at NHIS Office during Health Service Delivery
Questions on ‘how’ SLBs cope with their Individual workers in organisations (public or
workload and ‘why’ SLBs behave in the way they private) are faced with a number of work-related
do in their workplace were asked and their re- issues and they are faced with everyday dilem-
sponses were analysed. The aim is to help identi- mas in the delivery of public services to citizens.
fy some coping strategies and the rationale be- The individual workers in public organisations
hind such strategies in healthcare service provi- whom Lipsky termed ‘SLBs are employees of or-
sion. Five (5) SLBs in the NHIS office responded ganisations who are expected to ‘pursue organi-
to these questions on coping strategies and their sational goals’ which sometimes conflict with their
reasons. The following coping strategies were ‘individual goals’ (personal goals). The organi-
identified as presented in Table 4. sations in which they work are controlled by man-
Table 4: SLBs coping strategies in NHIS office in the implementation of NHIS in Tamale
SLBs Coping strategies Reasons for coping strategies
SLB#1 Rule bending to enrol more clients To make things work faster for
  Separation of clients to meet special needs   insurance subscribers
SLB#2 Separate those on official duty from others To differentiate subscribers
  Senior officials, high class from others   For faster services
SLB#3 Strictly first come first served basis To make work easy
  Principles of equality and fairness   To relax a bit at work
  No payment for the past/present no services   To rigidly apply the rules
SLB#4 Applying eligibility criteria in line to Acts To make sure clients do the right things
  The right amount of cedis before all services   before serving
SLB#5 Inspection of temporary chits, cards receipts of payments, It helps to take some form of  rest
invoices, break time   from work pressure
Some sit outside the pavilion, some sit inside   To ease work frustration
Source: Fieldwork Interview Data: 2012-2014 at NHIS Office, Tamale-Ghana
J Soc Sci, 60(1-3): 9-20 (2019)
STREET-LEVEL BUREAUCRATS COPING STRATEGIES IN GHANA 15
agers (who may be administrators, medical direc- may resort to harsh words if clients go contrary to
tors, physician assistants as the case of hospi- their rules. This was what one SLBs said on be-
tals and clinics). The managers are overly con- haviour towards their clients in the public clinic:
cerned with what is to be delivered (outputs) in We consider the health needs of clients first
organisations. Thus, the workers (SLBs) are ex- and always try our best to meet such needs. But
pected to show their professional skills and com- at some points, things do not work well and we
petencies in the delivery of social services to their turn to shout at them or say something that our
clients (Lipsky 1980, 2010). In this regard, the fo- clients may not be happy but we have to do that
cus is on SLBs in the four selected hospitals and to bring order and sanity in the ward or at the
clinics. The researchers first looked at their be- OPD (SLBs1-3#4).
haviour in the workplace. Secondly, they looked The researchers also solicited the views of
at their workload (number of cases per day, per SLBs in private hospital on their behaviour to-
head). Thirdly, the researchers explored the issue wards their clients. The six SLBs in their units
of how they cope with their work in terms of work- shared their opinions, views and experiences on
load and the rationale for such coping strategies. how their behaviour affects clients’ access to
The researchers asked the SLBs (the health health care services: consultation (out-patient
workers) at the four facilities how their behaviour department), diagnostic (ultra-scan), laboratory
affects their clients’ access to health care services. tests, pharmacies and in-patient (admission) ser-
The Private clinic three (3) SLBs answered vices. Most of them linked organisational culture
this question while two declined on the grounds to their behaviour, where they see themselves as
they were not comfortable to share their behav- doing services for humanity with godliness. This
iours towards clients. All the three-sounded pos- phrase was frequently used: ‘service to God is
itive and said they did all their best to always be service to mankind’. This was explained in the
nice to their clients to encourage them to attend context of religion like services to human beings
their clinic to access health care services. They are services offered to God. As such health ser-
said that fostering good human relations with cli- vices must be done well for an ‘eternal reward’. A
ents was important. They indicated their job ori- senior SLB in-charge of the ward (in-patient de-
entation at a private clinic is to promote these partment) in the private hospital has this to say:
virtues towards clients: friendliness, fairness, and Can we pay for the air we breathe? All these
the spirit of cooperation with clients in the imple- natural things are provided free for the comfort
mentation of NHIS in Tamale Metropolis. This of humanity by God. As such we ought to use
summarises three SLBs views who commented whatever we have wisely and properly to serve
on behaviour in a private clinic: our fellow humans and our reward may not only
We are here because of our clients, without be on earth but heaven for the good services to
them, there will be no work, no money and we human beings (SLBs2-6#1).
will have no option than to stop the operation of The six SLBs in public hospital shared their
the clinic in Bayanwaya (SLB1, 3#2). experiences and said they were constrained by
Public clinic four SLBs interviewed on their many problems or number of challenges from pro-
behaviour towards clients answered the ques- curement procedures to bureaucratic bottlenecks,
tion. They were interesting responses from the absenteeism of some workers, meagre salaries,
four SLBs (health workers) in the public clinic. promotion issues among others. These notwith-
The workers indicated they were all profession- standing, they still try all their best to promote
als: physician assistants, general nurses or mid- the interest of clients before their own. The six
wives or other paramedics and they allow their SLBs indicated that their clients sometimes blame
professional codes of conduct to guide their prac- them for use of bad language, neglect of duty,
tices. They also indicated that they were sup- rudeness or impoliteness but they discountedthose accusations and indicated that their clients’
posed to be friendly to their clients but in some statements were mere perceptions as a result of
cases, there is the need for clients to know their misinformation. This is what SLB said in a public
limits in such friendliness during health care ser- hospital on their behaviour towards clients dur-
vice delivery. They further indicated that they ing health care service delivery:
J Soc Sci, 60(1-3): 9-20 (2019)
16 DANIEL DRAMANI KIPO-SUNYEHZI, PHILIP K. ATTUQUAYEFIO  AND JAMES KIPO SUNYEHZI
Those of us in the public hospital, we are attendance for healthcare) relative to its staff
well trained and well-disciplined health profes- strength (number of SLBs) than public clinic (with
sionals, we are regulated by our various coun- fewer clients but more SLBs).
cils, this made us be mindful of misconduct to- There is a paradox, SLBs in both public and
ward our patients. If there are shouts or some private hospitals complained of heavy workload
form of insults in the labour ward you should but it turns that those with the most clients and
understand the situation ok and not generalised the smallest number of SLBs is the private hospi-
it (SLB1-5#6). tal, which turns to complain less and is most friend-
Even though the quote above was made by ly and polite towards their clients than a public
the sixth SLB, but most shared similar views from hospital. On the part of the two clinics, their SLBs
the interview the researchers had with them on complained less about the workload compared to
how they behave towards their clients. They in- those in the hospitals. It was interesting to ob-
dicated that bad language was not part of the serve that some public clinic officials complained
practice of the public officials (SLBs) but a mere about the workload on some days particularly, on
perception. Wednesday but such a complain on some days
was not noted in private clinic (which has fewer
The Workload of SLBs at Health Facilities SLBs but with more workload).
(Hospitals/Clinics)
Coping Strategies of SLBs at Health Facilities
The researchers looked at a number of clients (Hospitals/Clinics)
that attended each facility in relation to the num-
ber of SLBs. The aim is to find out which facility This question was asked of SLBs in the hos-
SLBs has more workload (clients’ attendance) as pitals and clinics: ‘how do you manage to cope
in Table 5. with your workload and other challenges at the
Table 5 shows the private hospital (SDA) had workplace? The aim of the question is to solicit
higher average daily attendances from 2009 to views, opinions and experiences of SLBs at the
2012 compared to its public hospital (WH) coun- local level who are directly involved in day to day
terpart for the same period except in 2013. By im- implementation of NHIS. In this regard, we used
plication, private hospital SLBs might have expe- largely in-depth interviews and a few direct ob-
rience more daily workload than the public hospi- servations. The various coping strategies SLBs
tal SLBs. The overall picture is that the private mentioned during interviews at health facilities
hospital had more workload (daily clients’ atten- are summarised in Table 6.
dance) with less staff in handling the large num- Table 6 shows that the public hospital SLBs
bers of clients while the public hospital experi- coping strategies are ways to make clients do
enced fewer daily clients’ attendance (less work- what is right or to calm them if they put up un-
load) but with more SLBs. On the other hand, the friendly behaviour while waiting for health ser-
private clinic had more workload (more clients’ vices. The clients are either put away or made to
Table 5: Facilities yearly out-patient department attendance and number of SLBs
Facilities                      Yearly OPDS attendance SLBs
2009 2010 2011 2012 2013    Size
Public Hospital (WH) 42,046 47,460 54,067 55,659 66,758 184
Average Daily Attendance 115 130 148 152 183
Private Hospital (SDA) 42,444 55,058 84,711 81,593 59,750 112
Average Daily Attendance 116 151 232 223 164
Public Clinic (BC) 4,565 3503 4,292 4549 3914 23
Average Daily Attendance 13 10 12 12 11
Private Clinic (HAC) 14,621 18,678 20,226 18,598 - 17
Average Daily Attendance 40 51 55 51 -
Source: Fieldwork Data: Health Facilities Out-Patient Department Attendance Records, 2009-2013
J Soc Sci, 60(1-3): 9-20 (2019)
STREET-LEVEL BUREAUCRATS COPING STRATEGIES IN GHANA 17
Table 6: SLBs coping strategies at health facilities during health service delivery
Health facilities Coping strategies Reasons for coping str.
Public Hospital Shout to calm patients, uniform staff first Creaming/no need to spend more
(West Hospital) Rules application as in Acts/Regulations   time, for conformity
Private Hospital Client-oriented practices (friendliness) Use of funs, jokes for relaxation
(SDA Hospital) Non-discrimination-service to God-Man To make clients happy
  To serve clients better
  To stop clients complains
Public Clinic Use of shift to ease pressure at the workplace To relax a bit from the stress
(Bilpeila Clinic) Politeness to clients but sometimes shouts To calm them by shouts
Private Clinic Clients attendance as a source of a revenue No discrimination
Haj Adams Clinic Flexibility, politeness and Friendliness To offer more services
Source: Fieldwork Interview Data: 2012-2014 at Health Facilities (Hospital/Clinics), Tamale-Ghana
act appropriately during health service delivery. tion among clients based on social status, work
The private clinic SLBs coping strategies seem to or tribal connotations or location (against ‘villag-
be friendly and moving towards clients and use ers’), rigid application of rules among others.
of humour or funs to make clients happy. The These coping strategies simply suggest SLBs
public clinic SLBs coping strategies seem to be ‘moving away’ or ‘moving against’ their clients.
both moving towards clients and moving away These findings are consistent with the views of
from clients through politeness and shouts while earlier scholars like Lipsky (1980, 2010) and other
private clinic SLBs do not adopt creaming or dis- recent works/findings (Tummers and Rocco 2015;
crimination as they are moving towards clients. Tummers et al. 2015; Einstein and Glick 2017; Ed-
lins and Larrison 2018; Pedersen et al. 2018; Searcy
DISCUSSION 2018; Smith and Brownell 2018). However, the
SLBs in the private organisations (private hospi-
Results showed SLBs in public and private tal and clinic) exhibited largely positive attitudes
hospitals exercised discretion in the provision of towards their clients despite the higher workload
healthcare services to their clients, similar empir- per day, workload per head.
ical observations among SLBs in NHIS office. The  The findings on the SLBs in the private or-
SLBs in NHIS office exercised enormous discre- ganisation are consistent with other studies find-
tion in the selection and application of the eligi- ings on positively motivated coping strategies of
bility criteria on exempt group members (persons SLBs (Nielsen 2006; Evans 2013; Cooper et al.
exempted from payment of the premium). The re- 2015; Assadi and Lundin 2018). The private hos-
sults are consistent with Lipsky theorisation that pital behaviour was largely influenced by their
SLBs exercise so much discretion as not only organisational culture rooted in their religious
policy implementers but as ‘actual policymakers’ practice: ‘service to God is service to Mankind’.
through their choices and interpretations of policy Private hospital SLBs adopted more clients-ori-
(Lipsky 1980, 2010; Makinde 2005; Kipo-Sunyehzi ented practices like politeness, friendliness where
2018). they put the interest of clients above all other
  The empirical evidence supports the as- interests. Also, the private hospital SLBs were
sumption that: the more the workload of SLBs, found with the practices like ‘rule-breaking’, ‘rule
the less positive attitude towards clients. These mending’ to meet the health needs of their cli-
observations were mainly noted among SLBs in ents. Similar findings were found among the SLBs
public organisations (public hospital, clinic and in the private clinic. Results suggest the private
NHIS office). The public SLBs largely exhibited clinic SLBs actions, behaviour and coping strate-
more negative attitudes towards their NHIS cli- gies were financially motivated- to attract more
ents during social service delivery. These strate- clients to their clinic to increase attendance. Thus,
gies include creaming (prompt services to some attract more claims from NHIA.
clients), rationing of clients (go and come back  Results showed mixed feelings on the as-
next day) and services (long waiting), discrimina- sumption that SLBs adopt coping strategies to
J Soc Sci, 60(1-3): 9-20 (2019)
18 DANIEL DRAMANI KIPO-SUNYEHZI, PHILIP K. ATTUQUAYEFIO  AND JAMES KIPO SUNYEHZI
their advantage but at the expense of clients. they seeking healthcare services at the facility. It
The empirical findings, observations did not sup- concludes that financial motivation is an influen-
port this assumption fully, it was noted some SLBs tial factor to the positive attitudes exhibited by
in both public and private organisations (health SLBs in private organisations than those exhibit-
facilities) adopted some coping strategies that ed by their counterparts in the public sector. The
were in favour of their clients (access to health findings in this research study will hopefully as-
services in the health facilities-hospitals and clinics sist policymakers, health insurance authority and
and NHIS office). policy practitioners to be mindful of the impor-
However, the assumption is partly right in the tance of every policy process. An error in one
behaviour exhibited by SLBs in the three public affect all, a wrongly selected agent may do more
bureaucracies (NHIS office, public hospital and harm to the principal than good.
clinic) and their coping strategies were typical of
Lipsky theorisation. As their SLBs actions, be- RECOMMENDATIONS
haviours and coping strategies were out of job
frustration, workload and stress. The public bu- This study though largely qualitative provides
reaucracies SLBs coping strategies were more useful grounds for future studies in Ghana on
towards agency (self-interest against principal SLBs actions, behaviour and their coping strate-
interest) than stewardship (more trust, loyalty and gies along north-south dimensions. It is also
promoting principal’s interest). The reason being hoped future studies may utilise quantitative
the SLBs were more of protecting their interest methods like surveys and across-countries stud-
against clients’ interest (principal). These find- ies on SLBs coping mechanisms from gender lens
ings concur with other studies findings (Donald- instead of organisational theory-based. Future
son and Davis 1991; Foss 1995; Petersen 1995; studies may also investigate more into this ‘sen-
Brinkerhoff and Bossert 2014; Kipo-Sunyehzi sitive’ area of the politics in the implementation
2018; Baker 2019). of NHIS in Ghana or elsewhere.
Contributions to Knowledge on how Street-Level LIMITATIONS
Bureaucrats Work/Coping Strategies
This study may suffer from geographical lim-
This research study contributes to the exist- itation but the findings are transferable from one
ing literature in policy implementation in devel- context like Northern Ghana to Southern Ghana,
oping world context. It adds to how SLBs work and from Ghana to other countries with similar
and their working conditions in a developing settings.
world context, specifically on the coping strate-
gies SLBs adopt from public-private organisation- REFERENCES
al perspectives. Besides stress, it identifies other
factors like organisational culture, interests, re- Andersen HM 2004. Villagers: Differential treatment in
sources and politics as ‘influencers’ in the deliv- a Ghanaian hospital. Social Science & Medicine,
ery of public services to their clients in Ghana. 59(10): 2003-2012.Aniteye P, Mayhew SH 2013. Shaping legal abortion pro-
vision in Ghana: Using policy theory to understand
CONCLUSION provider-related obstacles to policy implementation.
Health Research Policy and Systems, 11(1): 23.
This research study concludes that despite Assadi A, Lundin M 2018. Street level bureaucrats, rule
the more workload of SLBs in the faith-based pri- following and tenure: How assessment tools are used
vate hospital, SLBs appeared more friendly, cour- at the front line of the public sector. Public Adminis-tration, 96(1): 154-170.
teous and client-oriented than their counterparts Atinga RA, Agyepong IA, Esena RK 2018. Ghana’s com-
in public health facilities. The religious practice munity-based primary health care: Why women and
of ‘service to God is service to mankind’ played a children are ‘disadvantaged’ by its implementation.
key role in terms of their organisational culture.  Social Science & Medicine, 201: 27-34.
The rationale was to make their clients happy, Ayee JR 1994. An Anatomy of Public Policy Implemen-tation. The Case of Decentralisation Policies in Gha-
reduce their complaints and frustrations while na. Aldershot: Avebury.
J Soc Sci, 60(1-3): 9-20 (2019)
STREET-LEVEL BUREAUCRATS COPING STRATEGIES IN GHANA 19
Ayee JRA 2012. Politicians and bureaucrats as genera- Lieberherr E, Thomann E 2019. Street-level bureaucra-
tors of public policy in Ghana. In: F Ohemeng, J Ayee cy research and accountability beyond hierarchy.  Re-
(Eds.): The Public Policy Making Process in Ghana: search Handbook on Street-Level Bureaucracy, 1-
How Politicians and Civil Servants Deal with Public 17.
Problems. Lewiston: The Edwin Mellen Press, pp. Lipsky M 1980. Street-Level Bureaucracy: Dilemmas
19-50. of the Individual in Public Services. New York: Rus-
Baker RM 2019. The agency of the principal-agent sell Sage Foundation.
relationship: An opportunity for HRD. Advances in Lipsky M 2010. Street-Level Bureaucracy: Dilemmas
Developing Human Resources, 21(3): 303–318. of the Individual in Public Service. 30th Anniversary
Bender K, Begun S, Durbahn R, Ferguson K, Schau N Edition. New York: Russell Sage Foundation.
2018. My own best friend: Homeless youths’ hesi- Makinde T 2005. Problems of policy implementation
tance to seek help and strategies for coping indepen- in developing nations: The Nigerian experience. Jour-
dently after distressing and traumatic experiences. nal of Social Science, 11(1): 63-69.
 Social Work in Public Health, 33(3): 149-162. Merriam SB, Grenier RS (Eds.) 2019. Qualitative Re-
Brinkerhoff DW, Bossert TJ 2014. Health governance: search in Practice: Examples for Discussion and Anal-
Principal-agent linkages and health system strength- ysis. San Francisco, CA: John Wiley and Sons.
ening. Health Policy and Planning, 29(6): 685-693. Murphy M, Skillen P 2018. Exposure to the law: Ac-
Bryman A 2012. Social Research Methods. Oxford: countability and its impact on street-level bureaucra-
Oxford University Press. cy.  Social Policy and Society, 17(1): 35-46.
Cooper MJ, Sornalingam S, O’Donnell C 2015. Street- Nielsen VL 2006. Are street-level bureaucrats compelled
level bureaucracy: An underused theoretical model for or enticed to cope? Public Administration, 84(4):
general practice? Br J Gen Pract, 65(636): 376-377. 861-889.
Crook R, Ayee J 2006. Urban service partnerships, street NiskanenW 1971. Bureaucracy and Representative
level bureaucrats’ and environmental sanitation in Government. Chicago: Aldine/Atherton.
Kumasi and Accra, Ghana: Coping with organisation- Ohemeng F, Ayee J 2012. Public policy making: The
al change in the public bureaucracy. Development Ghanaian context. In: F Ohemeng, J Ayee (Eds.): The
Policy Review, 24(1): 51-73. Public Policy Making Process in Ghana: How Politi-
Donaldson L, Davis JH 1991. Stewardship theory or cians and Civil Servants Deal with Public Problems.
agency theory: CEO governance and shareholder re- Lewiston: The Edwin Mellen Press, pp. 19-50.
turns. Australian Journal of Management, 16(1): 49- Ohemeng F, Carroll B, Ayee J 2012. The Public Policy
64. Making Process in Ghana: How Politicians and Civil
Edlins M, Larrison J 2018. Street-level bureaucrats and Servants Deal with Public Problems. Lewiston: The
the governance of unaccompanied migrant children. Edwin Mellen Press.
Public Policy and Administration, 1-21. Pedersen LH, Hjelmar U, Bhatti Y 2018. What does the
Einstein KL, Glick DM 2017. Does race affect access to minister do? On the working conditions of political
government services? An experiment exploring street leaders. Public Administration, 96: 259–275.
level bureaucrats and access to public housing.  Amer- Petersen T 1995. The principal-agent relationship in
ican Journal of Political Science, 61(1): 100-116. organisations. In: P Foss (Ed.): Economic Approaches
Eisenhardt KM 1989. Agency Theory: An assessment to Organisations and Institutions: An Introduction.
and review. The Academy of Management Review, Aldershot: Ashgate Publishing Limited, pp. 187-212.
14(1): 57-74. Pivoras, S, Kaselis M 2019. The impact of client status
Evans T 2013. Organisational rules and discretion in on street-level bureaucrats’ identity and informal
adult social work. British Journal of Social Work, 43: accountability. Public Integrity, 21(2): 182-194.
739-758. Schillemans T 2013. Moving beyond the clash of inter-
Foss P 1995. Introduction: on the economics of institu- ests: On stewardship theory and the relationships be-
tions and organisations. In: P Foss (Ed.): Economic tween central government departments and public
Approaches to Organizations and Institutions: An agencies. Public Management Review, 15(4): 541-
Introduction. Aldershot: Ashgate Publishing Limited, 562.
pp. xiii-xiv. Searcy Y 2018. Right back like we left something: Ex-
Gray DE 2009. Doing Research in the Real World. Lon- amining the commodification of Blackness in social
don: Sage Publications. services to address racial disparities - the case of
Greenstein FI. Polsby NW 1975. Strategies of Inquiry. Hartford. Social Work in Public Health, 33(5): 280-
California: Addison-Wesley Publishing Co. 288.
Howlett M, Ramesh M, Perl A 2009. Studying Public Smith M, Brownell G 2018. Knowledge, beliefs, atti-
Policy: Policy Cycles and Policy Subsystems. Ox- tudes, and behaviors regarding sickle cell disease: Im-
ford: Oxford University Press. plications for prevention. Social Work in Public
Hupe P, Hill M, Buffat A 2016. Understanding Street- Health, 33(5): 299-316.
Level Bureaucracy. Bristol, UK: Policy Press. Tamale Metropolitan Mutual Health Insurance Scheme
Kipo-Sunyehzi DD 2018. Principal-agent problems in 2010. NHIS Annual Reports-2011-2013. Tamale:
implementation of Ghana’s health insurance scheme. Government of Ghana.
 Journal of Operations and Supply Chain Manage- Tummers LL, Bekkers V, Vink E,  Musheno M 2015.
ment, 11(2): 59-74. Coping during public service delivery: A conceptual-
J Soc Sci, 60(1-3): 9-20 (2019)
20 DANIEL DRAMANI KIPO-SUNYEHZI, PHILIP K. ATTUQUAYEFIO  AND JAMES KIPO SUNYEHZI
ization and systematic review of the literature. Jour- Yin RK 2014. Case Study Research: Design and Meth-
nal of Public Administration Research and Theory, ods. Thousand Oaks, California: Sage Publications
25(4): 1099-1126. Inc.
Tummers L, Rocco P 2015. Serving clients when the server
crashes: How frontline workers cope with e government Paper received for publication in April, 2019
challenges. Public Administration Review, 75(6): 817-827. Paper accepted for publication in June, 2019
J Soc Sci, 60(1-3): 9-20 (2019)