Bureaucracy on public health policy.

The use of private intermediaries may also impede result development. Intermediaries may have negative feelings about the program and thus act inefficiently. Outcome may be hampered because the coordination of various program elements is made more difficult if private middlemen enter the scene between government and clients. Implementation research must be credited for the discovery of the influence on program results of the third subcomponent of the larger administration factor: street-level bureaucracy. Michael Lipsky’s famous book Street-Level Bureaucracy has been particularly influential in this respect.

According to Lipsky (1980:3), street level bureaucrats are “public service workers who interact directly with citizens in the course of their jobs, and who have substantial discretion in the execution of their work. ” Typical street-level bureaucrats are teachers, police officers, social workers, judges, public lawyers, health workers, and many other public employees who grant access to government programs and provide services within them. According to Lipsky, street-level bureaucrats actually create policy through the multitude of decisions they make in interacting with the clients.

They posses discretion that cannot be completely controlled because there are never enough resources to provide close, frequent, and direct supervision of them, and also because they are physically separated from their superiors. There are no precise performance criteria in existence that specify exactly how an engineer, public health nurse, social worker, or teacher should do their job. In sum, argues Lipsky, policies are formed in implementation by program operators developing routines and shortcuts for coping with their everyday jobs

Obviously, the street-level bureaucracy’s comprehension of the program influences their work and thus program output and outcome. The capabilities of the street level bureaucrats will also impinge on program results. A seemingly universal problem is that front-end personnel feel that their resources are too scarce. A lack of educated personnel and technical equipment impedes the discovery of regulatory violations and their prosecution in court, and decreases the quality and quantity of the services provided.

For some inspections, the magnitude of the legislative charge makes it virtually impossible to have enough inspectors to keep an eye on violators. Occupational safety and health standards apply to more than 20,000 workplaces, yet the U. S. Board of Occupational Safety and Health (OSHA) can only inspect a tiny fraction of them every year. Time constraints generally limit the ability of inspectors to discover many of the infractions of norms and regulations. They are too hurried to a thorough job. Hemenway has pointed out that OSHA inspectors spend only about one-third of their available time in the field.

The rest is used to prepare for travelling and reporting the site visits. Regional inspectors for American Nuclear Regulatory Commission spend only about 25 percent of a typical working week at the power plant. In adjustment to the resource problem, program operators adopt various coping strategies. To avoid case load caseload, they limit information about their services, ask clients and inspectors to wait, make themselves unavailable to contacts or make ample use of referrals of client to other authorities (Vedung, 2000).

Interest groups on public health policy. The pace of politics and interest group competition had picked up by the early 1980s. A plethora of health related interest groups had opened offices in the capital, along K Street, N. W. More and more of the lunches consumed at the Rotunda, the Monocle, and other long-time power-lunch eateries huddled at the foot of Capital Hill were being bought by professional lobbyist whose clients wore white coats to work, or worked closely with those who did.

President Jimmy carter’s demand for spending controls on hospitals had aroused the powerful Chicago-based AHA, which stepped up its lobbying and built up its campaign contribution base. Business lobbyist, too, had health care on their menus. Cost had caught the eye of business executives as the fringe benefit line in their annual reports began to show a higher rate of growth that wages, sales, or profits. Though the AMA and a few other organizations had PACs in the 1970s, PACs became a noticeable feature of the political landscape only in the 1980s, thanks in part to reforms of the 1970s.

In an attempt to shrink the influence of a few well-heeled givers, those who wanted more citizen financed campaign had pressured congress to cab contributions from individuals and interest groups and to set up a public financing mechanism for major party candidates for president The authorization of PACs in the 1974 law led to an extraordinary increase in their number and influence. Health care associations took notice.

Clearly there are many whose interests were not being represented by the AMA, the AHA, or the insurance companies. With their own PACs, optometrists, chiropractors, dentist, nurses, nursing homes, group practice associations, family doctors, pharmacist, drug companies, occupational therapists, and others could mount lobbying efforts or make campaign contributions to ensure that when the body politic wrote national health insurance legislation, it did not neglect the part of the human body in which they had a particular interest.