Street-level bureaucrats and the (in)effectiveness of malaria control in Punjab

ABSTRACT This research sheds light on various environmental factors that lead to different decisions regarding the implementation of health policy by street-level bureaucrats (SLBs) in similar districts. The paper explores the factors behind different incidence of malaria in two districts of South Punjab-Pakistan that possessed similar characteristics, focusing on the actions of frontline workers and policymakers. Based on semi-structured interviews with frontend workers, observation of health units from the two districts and review of policy documents on epidemic control programs, we find that SLBs practice lesser discretion when they perceive the policy issue as grave and as policymakers increase surveillance of SLBs, their discretion decreases. We also find that when SLBs have higher room for discretion, they choose convenient behaviors that provide them quicker results.