International Journal of Civil Engineering and Technology (IJCIET)
Volume 10, Issue 04, April 2019, pp. 2224-2233, Article ID: IJCIET_10_04_231
Available online at http://www.iaeme.com/ijciet/issues.asp?JType=IJCIET&VType=10&IType=04
ISSN Print: 0976-6308 and ISSN Online: 0976-6316
© IAEME Publication
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DISCRETION OF STREET-LEVEL
BUREAUCRATS IN PUBLIC SERVICES: A CASE
STUDY ON PUBLIC HEALTH IN MAKASSAR
Hasniati Hamzah
Departement of Public Administration, Faculty of Social and Political Science,
Hasanuddin University, Makassar, Indonesia.
Fitriani, Vinsenco R. Serano, Albertus and Y. Maturan
Departement of Public Administration, Faculty of Social and Political Science, Musamus
University, Merauke, Indonesia.
Muhammad Yunus
Departement of Public Administration, Faculty of Social and Political Science,
Hasanuddin University, Makassar, Indonesia.
ABSTRACT.
Street-level bureaucrats (SLBs) have a great opportunity in taking discretion in
public services. This is because in the provision of services is often confronted with the
scarcity of resources that are owned, so that requires them to make policies (discretion)
to get around the scarcity of these resources. Discretionary authority possessed by
SLBs can be a "disaster" if not used professionally and carefully, especially if it is done
in the field of health services that can have a negative impact on the community served.
This study aims to reveal various forms of discretion taken by SLBs in health services
in Public Health Center (PHC) in Makassar City, what is the background of taking
discretionary actions, as well as the impact of the discretion taken. This study uses a
qualitative approach with in-depth interview data collection techniques. The number of
informants interviewed was 24 people consisting of the head of the PHC, doctors,
nurses, midwives, pharmacists, as well as window clerks. Data processing and analysis
using the NVivo 12 Plus application. The results showed that the level of discretionary
use was different for each SLBs. Courage to take discretion is strongly influenced by
the experience and independence of SLBs, as well as considering the impact on patients.
In general, the discretion taken solely aims to facilitate service and is based on the
desire to save the lives of patients served.
Keywords: Discretion, Health Services, Street-level Bureaucrat, Public Health Center
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Cite this Article: Hasniati Hamzah, Fitriani, Vinsenco R. Serano, Albertus, Y.
Maturan and Muhammad Yunus, Discretion of Street-Level Bureaucrats in Public
Services: A Case Study On Public Health In Makassar. International Journal of Civil
Engineering and Technology, 10(04), 2019, pp. 2224-2233
http://www.iaeme.com/IJCIET/issues.asp?JType=IJCIET&VType=10&IType=04
1. INTRODUCTION
The main task of government is to provide public services. Bureaucrats who provide services
and interact directly with the community by Lipsky (2010) are referred to as street-level
bureaucrats (in this paper abbreviated as SLBs). While the bureaucracy institution where he
works is called the street-level bureaucracy. Because the task is in direct contact with the
community, the SLBs are seen as "moral agents," because he has greater discretionary authority
in carrying out his daily duties. In terms of theory, the community expects SLBs to be role
models and follow applicable laws and regulations.
The amount of power and authority possessed by SLBs is not identical to the high level of
bureaucratic discretion (Wibawa, 2009). Therefore, for public services, discretionary authority
is sometimes required to respond quickly to community demands, while what is demanded by
the public has not been regulated in certain laws or policies. In reality the law cannot possibly
cover all public and government problems in real terms according to the needs of the people
served, so SLBs need to take discrete actions to solve problems that occur in the field.
Therefore, professional discretion is needed (Cheraghi-Sohi & Calnan, 2013; Evans, 2011).
There has much debate about the extent to which professional discretion has been challenged
by recent organisational changes such as through the new forms of governance associated with
the introduction of the principles of the New Public Management (NPM) into health systems
and other public sector services (Cheraghi-Sohi & Calnan, 2013).
What was stated by Cheraghi-Sohi & Calnan (2013), and Evans (2011) became interesting
to study, especially in relation to public policies and services in Indonesia. In many cases, some
public officials have to deal with the Corruption Eradication Commission (KPK) as a result of
the discretionary authority taken. This is because SLBs have to deal with service provision and
translate short rules into comprehensive and specific language (Sowa & Selden, 2003).
Law No. 30/2014 concerning State Administration explicitly regulates discretion.
Discretion is defined in Article 1 paragraph (9) of Law No. 30/2014, as decisions and/or actions
established and/or carried out by government officials to address concrete problems faced in
the administration of government in terms of legislation that provides options, does not
regulate, incomplete or unclear and/or there is a stagnation of government. Thus, a discretion
can only be issued if the purpose of publishing the discretion is: (i) launching the administration
of government; (ii) fill the legal vacuum; (iii) provide legal certainty; and (iv) addressing the
stagnation of government in certain circumstances for the benefit and public interest.
However, fulfilling the purpose of discretion as described above is not enough. Law No.
30/2014 requires that discretion can only be used if its use meets the following conditions:
1. In accordance with the objectives of the discretion stated in Law No. 30/2014;
2. Does not conflict with the provisions of the legislation;
3. In accordance with the general principles of Good Governance;
4. Based on objective reasons;
5. Does not create a conflict of interest; and
6. Done in good faith.
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In addition to fulfilling the material requirements above, a discretion is also obliged to
fulfill the formal requirements stipulated in Law No. 30/2014 wherein basically government
officials who use discretion must obtain supervisory approval by first describing the intent,
purpose, substance and impact of administration and finance. In the case of faster public service
interests, discretion is needed in situations of uncertainty along with the increasingly rapid
dynamics of the development of public demands and ambiguous agency goals agency and
inadequate resources (Lipksy, 2010). In these conditions, a SLBs is possible to pursue
discretive policies as long as they remain in the corridor of their duties and responsibilities to
answer the demands of the people served (Lipsky, 2010), but need to pay attention to the role
of professionalism and the relationship between front line managers and workes and the nature
of discretion (Evans, 2011).
The problem is when SLBs are given a more discretionary space, then can they exercise
discretionary authority responsibly, is the discretion taken by the SLBs their authority, does
the discretion not contradict the provisions of the legislation, and is it really aiming for the
public (public) interests served, and how far the discretionary authority can significantly
increase the professionalism and quality of public services ?, what is the reason why the
discretion is taken, and whether the discretion is in accordance with the Good Governance
Principles ? Some of these questions will be answered in this study.
This article attempts to describe the opportunities for discretion that can be done by SLBs
when facing problems in health services, whether the problems are related to the resources they
have or the problems associated with the insistence of patients in meeting their needs to get the
services they expect. And when SLBs take discretion, whether the discretion does not conflict
with higher regulations, and whether it can fulfill the general principles of good governance,
especially related to the professionalism of SLBs. The last is to analyze why discretion is
carried out and how the impact will be on the quality of public services.
One of the tasks and responsibilities of the government is to provide services to the
community. Those who are assigned to provide direct services to the community are called
street-level bureaucrats, SLBs (Lipsky, 2010). In carrying out service duties, SLBs often take
discretion for the purpose of providing fast service, so that by Lipsky (2010) states that SLBs
are discretion policy makers.
The essence of the concept of discretion is freedom in making a decision. The freedom to
make decisions regarding the services provided by SLBs is certainly limited by several factors.
Some of the earliest discussions regarding the nature of discretion, originated within the legal
arena (Cheraghi-Sohi, 2013).
In the development of public administration theory, discretion or often referred to as
administrative discretion is the ability of administrators to choose between alternatives courses
of action (Evans, 2011) and decide how a government policy must be implemented in certain
situations (Lipsky 2010, Mangkoedihardjo, 2014). In line with that, Rabin (2003) and Cann
(2007) suggested that administrative discretion, referring to the implementation of flexible
assessments and decision-making that are made public administrators (in this article called
street-level bureaucracy, SLB) has the authority to apply discretion in their daily activities, but
in the course of time, these bodies often abuse this authority.
The need for discretion is still needed for the public interest, but it will be very dangerous
when SLBs use it arbitrarily which can lead to the destruction of the basic principles of
administrative law (Vaishnav & Marwaha, 2015). Therefore discretion in public services is
carried out solely to fulfill the public interest (Barth, 1992) and should not be contrary to the
law and wider public interest (Scott, 1997) and for performance improvement (Ortega, 2009).
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Thus, in using discretionary authority, SLBs must not be arbitrary and what they do must be
reasonable in order to fulfill the principles of good governance.
The theory used in this study is a framework developed by Lipsky (2010). Although
Lipsky's (2010) theory was developed in the American context, Lipsky believes that this
theoretical framework can be applied to all public services, including health services in the
PHC in this study. Lipsky (2010) defines street-level bureaucracy as a bureaucracy that
interacts directly with the people served such as PHC, Civil Registry Offices, and District
Offices in providing services to the community. While the working bureaucracy is referred to
as the street-level bureaucrats. Street-level bureaucrats are the main actors in implementing
public policies and services. It is the most important variable in the success of policy
implementation. These bureaucrats are storefronts of a bureaucracy that can influence people's
perceptions and views of the policies implemented. Where this is highly dependent on
discretion and interpretation of street-level bureaucrats in implementing a policy
Street-level bureaucrats implementing public policies have a certain degree of autonomy –
or discretion – in their work (Tummers & Bekker, 2014). Discretion and interpretation of
policies are carried out to answer the challenges and demands of various backgrounds of the
people served, ranging from people who have no education at all to the educated community.
Conditions like this require special treatment in policy implementation, whereas a policy is
usually general in general. That is where discretion and interpretation of a policy becomes a
necessity for SLBs.
The PHC, is a health service facility that organizes public health efforts and first-rate
individual health efforts, prioritizing promotive and preventive efforts, to achieve the highest
degree of public health in its working area. PHC are frontline bureaucracies because they
interact directly with the community (patients) in providing services. The bureaucrats who
work in the PHC are referred to as frontline bureaucrats, namely the Head of the PHC, Doctors,
nurses, fields, pharmacists, and window clerks. They deal directly with patients in carrying out
their daily tasks. In the situation of limited resources such as medical equipment, medicines, a
wider range of services, the SLBs at this PHC have the authority to make decisions or discretion
so that the services provided can be faster and satisfy the patients served.
2. METHODS
This research was conducted at the PHC Makassar. PHC is street-level bureaucracy due to
direct interaction with the community in providing health services. A total of 24 SLBs were
interviewed in 4 PHC in Makassar City in the period June - September 2018. Four people were
line managers (Head of PHC), and the rest were SLBs namely doctors, midwives, nurses,
pharmacists, and window clerks. The criteria used to determine the informants are those who
have worked for at least one year, so that they have experience in making discretion in the
services they provide (Alexander et al., 2018; Elisabeth et al., 2018; Philipus Betaubun and
Nasra Pratama Putra, 2019; Supriyadi et al., 2019).
The research approach is descriptive-qualitative which aims to provide an overview of the
discretionary phenomena taken by SLBs in providing services to the public (community) in
order to explore various forms of discretion taken by SLBs in dealing with cases that the same,
why is the form of discretion taken, and the impact on professionalism and quality of public
services.
Data collection techniques are: (1) observations relating to objects that can look like the
behavior of SLBs in providing services; (2) in-depth interviews to explore forms of discretion
and why discretion was taken by SLBs and their impact on professionalism and quality of
public services; (3) documentary techniques to complete data from interviews and
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observations, the researcher will also collect a number of data and information from available
documents related to health services in Makassar City.
Data management and analysis techniques are using the Nvivo 12 Plus application
developed by Tom Richard since 1981 (Gibss, 2004). The purpose and use of the NVivo 12
Plus application is so that data processing can be more efficient and effective so that the results
can be accounted for. The stages in data management begins with importing research data into
the NVivo 12 Plus application. The next stage is coding (open coding, axial coding, and
analytical / selective coding). Open coding is done by making nodes in accordance with the
research theme to be answered, namely the forms of discretion used by SLBs, the reason for
discretion, and the impact on the people served. Axial coding is done by retrieving information
from internal data files and then inserting them into themes or sub-themes that match the nodes.
The last process carried out was to do selective coding by identifying and describing the forms
of discretion used by the head of the PHC, doctors, nurses, pharmacists, and counters in health
services, the reasons for using the discretion, as well as the impact on patients and also for the
professionalism of SLB.
3. RESULTS
SLBs in carrying out their duties to serve patients in PHC are often faced with limited
resources. Therefore, the opportunity for discretion is very open to them. This study has
interviewed 24 informants who are included in the SLBs, namely the Head of Puskesmas,
Doctors, Nurses, Pharmacists, Midwives, and Counters, to explore the forms of discretion used
by them when faced with various dilemmas in service.
The questions we use to uncover the discretion used by the Head of the PHC regarding
their main tasks are what problems you often face in carrying out your duties as head of the
PHC, whether in overcoming these problems you use discretion, what constitutes their actions,
and how is the legality of the decisions taken and the impact on the community as users of
health services. The author will give specific examples of each answer to the questions we ask
the informants. This is intended to provide a clearer picture of the decisions they take in
carrying out their duties.
3.1. Discretion in Public Health Services
The implementation of health services at the PHC is carried out by SLBs consisting of the Head
of the PHC, Doctors, nurses, pharmacists, window clerks, and laboratory staff. The head of the
PHC as the highest leader in the PHC has the main task of leading, supervising, and
coordinating health services in a comprehensive manner to the community in their working
area. In carrying out these basic tasks, a head of the PHC often takes discretion to get around
the shortcomings and scarcity of resources.
Each PHC has standard operating procedures, so that a head of the PHC in carrying out its
duties always refers to the standard operating procedures. Based on the results of interviews
with the heads of PHC, it can be concluded that the activities of monitoring and coordinating
activities to doctors, nurses, pharmacists and clerk clocks can run in accordance with existing
service standards. But there are some things that in certain conditions are forced by a Head of
PHC to use discretion especially when getting pressure from the community of service users
and to provide faster services.
Carrying out my daily tasks, I often take discretion in overcoming various obstacles that I
face. Such as providing referrals to patients who are forced to be referred by giving diagnosed
disease information that is allowed to be referred. I was forced to lie by writing not in
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accordance with the patient's condition, because if I was honest the hospital would not accept
the patient. (SLBs1, PHC 1)
When it comes to discretionary policies, I have held discretion several times to provide
referral letters to patients who can still be treated or treated at the health center because the
illness can still be treated. However, because of the pressure from the patients concerned, we
were forced to provide referrals (SLBs 2, PHC 2)
There are also SLBs who refer patients to the hospital because of the limited equipment
they have, the following excerpts of the interview:
Some occasions I took a policy to refer patients because the limitations of the existing
equipment in the PHC were not adequate, although in the rules Health Care Security (BPJS)
was not allowed to be referred to the hospital because for such diseases it should be the
authority of the PHC to serve it (SLBs 3, PHC 3)
The discretion taken by doctors is generally related to drug administration. For medicines
available at the PHC, doctors often give prescriptions to be purchased at the pharmacy.
Whereas in the rules, the patient has the right to get medicine at the PHC according to the
illness he suffers, but because the doctor wants the patient to take a better quality medicine, the
doctor prescribes it to be purchased at the pharmacy. On the one hand, a pharmacy officer can
replace drugs prescribed by a doctor, with similar drugs as long as they have the same
properties as drugs written by doctors.
Discretion is carried out on the provision of drugs that are sometimes not available at the
PHC given prescriptions, so they do not replace drugs. Unless anti-biotic drugs are usually
replaced with other brands with the same composition (SLBs 4, PHC 1)
Another form of discretion that is mostly carried out by SLBs in PHC is to serve patients
even though the domicile of the patient is not included in the coverage that can be served
according to the provisions of Health Care Security (BPJS) regulations. In the Regulation
Number 1 of 2017 concerning Equity of Participants in First Level Health Facilities, patients
who can be served are those who have a domicile in accordance with the coverage area of the
PHC.
Take a policy to continue to provide services to patients who are not included in the service
area in accordance with BPJS rules with consideration for patient policies and safety (SLBs 23,
PHC 3)
In general, there are two discretions that are often taken by the window clerk, namely (1)
issuing a policy not to go to the counter for patients who need immediate treatment or action
such as accident victims, and not queuing for the elderly and disabled, (2) registration services
online patients have not been run because they are considered to be rambling. Although online patient services have been suggested by the Department of Health with consideration of
the high patient visits. Both types of discretion are basically aimed at the effectiveness and
efficiency of services provided to patients, and primarily aim to provide fast services for
patients who immediately need services.
3.2. Professionalism of SLBs in Using Discretion
Professionalism in using discretion becomes very important in health services. This is because
of the impact of discretion which can be fatal for patients. A doctor, nurse, or pharmacist must
prioritize patient safety in providing health services, even if the patient urges to get certain
medicines to cure the illness. Not infrequently in health services occurs a patient asks the doctor
to write a prescription according to his wishes, even though in terms of medical medicine is
very dangerous.
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I often handle patients who insist on sleeping pills every time they come for treatment, even
though the use of sleeping pills for a long time will have a negative impact on the patient's
health because it will cause dependence. In cases like this, I only provide vitamins (SLBs 6,
PHC 3)
A number of informants interviewed stated that in using discretion, which is the top priority
is to provide good service to patients, and pay attention to patient recovery. Like the example
of a nurse who handles a patient's ulcer wound.
Sometimes it does not follow SOPs or theories such as treating ulcers / abscesses based on
existing experience and using cold heat treatment using hair drayer and ice cubes, depending
on the wound. So even though doctors recommend taking drugs such as supratur, because they
contain high vaseline so that ulcers that have ulcers can get worse (according to experience),
sometimes only using Rifanol, and sometimes not using gauze to treat the patient's wounds,
due to injury considerations very severe patients (SLBs 12, PHC 1)
In certain cases it was also found that a nurse dared to advise the doctor not to give referrals
to patients because they felt that the patient could still be treated at the PHC. In another case
example, a midwife at the PHC 4 showed her professionalism in handling a mother who would
give birth. Even though the medical equipment and facilities are classified as modest, but he is
able to help deliver well and satisfy the patient.
In the condition of the patient who had to give birth, I tried to help her delivery. At that
time, the doctor was not in place, but because of the emergency patient's condition, I tried to
provide first aid according to my abilities, such as giving an IV, then I consulted the doctor by
telephone, because doctors were not always in the PHC (SLBs 16 , PHC 4).
I replace the tools used to treat patients with other devices that are considered to have the
same function as patient safety considerations. For example, replace gauze with gloves to cover
bleeding temporarily. This action was taken because it was considered not to endanger the
patient (SLBs 23, PHC 3).
From the two examples above, it appears that SLBs take professional discretion based on
their experience in handling patients. In addition, the experience of the two SLBs in taking
discretion reflects that each SLBs have the authority to take discretion, as long as SLBs are
confident in their abilities. Faith and sincere intentions to help others will help them deal with
every problem faced.
3.3. Consideration in Using Discretion
A number of SLBs interviewed revealed that the main consideration in using discretion was to
provide a more responsive and fast service, in order to save the lives of patients being served.
The provision of referrals that should not be given by the Head of the PHC to urgent patients,
neglect of the queuing system to patients in an emergency condition, the provision of services
to patients who are not service areas, is an example of the desire of SLBs to provide fast and
satisfying services to patients. Even though in reality, the Head of the PHC must write a
diagnosis that is not in accordance with the patient's condition, but because he wants to show
empathy to the patient.
3.4. Impact of Discretion
The discretion carried out by the head of the PHC, doctors, nurses, pharmacists, booth clerk as
a whole aims to provide fast and satisfying service to the community. This can be seen from
the discretion used by paramedics to provide services that are needed by the community.
Among them is to provide convenience for access to advanced health services. The head of the
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PHC makes referrals to the community when it is really needed by the community to get better
quality health services such as better medical equipment that the PHC cannot provide.
Thus, the general discretion used by SLBs in PHC has a positive impact on the community
(patients). These positive impacts can be identified as follows: (1) ease of access to services,
as perceived by people who are not domiciled outside the working area of the PHC, (2) the
speed of obtaining services, as perceived by patients who do not need to queue for service due
to conditions which requires prompt handling, (3) improvement of service facilities, as
perceived by the community requesting referrals to hospitals because of limited facilities
owned by the PHC, (4) increasing satisfaction of the people served.
4. DISCUSSION
It was found that, in connection with the implementation of the BPJS Regulation No. 1 of 2017
concerning Equity of Participants in First-Level Health Facilities, the PHC had the authority to
interpret the rules they considered appropriate. The head of the PHC as a line level manager at
the first level health service, generally takes positive discretion regarding health services,
namely providing health services to patients who are not actually in the service area, for
example someone from another district in South Sulawesi, what happened to Makassar visited
relatives and suddenly experienced pain. because of the condition of the patient who needs
quick help, even though in terms of the patient's rules cannot be served, the Head of the PHC
instructs the doctor to serve the person concerned. In the case as above, discretion for SLBs is
important to do considering its link to efforts to improve the effectiveness of public services.
Therefore SLBs must be given a more loose discretionary space as long as they are intended
for good for the people being served (Wibawa, 2009). With a more loose discretionary space,
SLBs can carry out their duties and functions independently and professionally (Cheraghi-Sohi
& Calnan, 2013; Evans, 2011), especially in public services where they are dealing directly
with people with a high level of plurality.
Another finding in this study is that line level managers (PHC heads) have flexibility in
taking discretion, such as taking the wisdom to provide a referral letter for actual hospital
admission that these patients can still be treated at PHC. This finding is in line with Wangrow,
et all (2015) that at the manager level there is flexibility for discretion or the latitude of action
available to managers (Evans, 2011). The way to get around the rules is to provide a diagnosis
of the disease that can be referred to. This referral letter is due to pressure from patients who
want to get services with more complete facilities at the hospital. In the regulations, a patient
who can be referred to a hospital is if the disease suffered by the patient cannot be treated at
the PHC. But because of the demand and pressure from patients who do not want to understand
the regulation, the Head of the PHC is forced to provide a reference. This finding is interesting,
because discretion is usually done because of pressure from above (top-down (Loveland, 1991)
or because of limited resources (Lipsky 2010, Alden, 2015), but in this health service at PHC,
discretion is taken not only solely because of the limited resources available, but also because
of the pressure (bottom-up) that comes from patients who want to get better service.
In other cases, often the Head of the PHC takes discretion to refer patients to the hospital
because of the limited resources they have, such as the limitations of medical equipment
owned. This is in line with Lipsky's (1980) view that uneven distribution of resources results
in uneven, which forces SLBs to take a policy of insurance for their shortcomings. Coping
behavior carried out by SLBs has also been written by Lipsky (1980) approximately forty years
ago. The behavior of the prevention carried out by the Head of the PHC is to write a diagnosis
according to the illness that can be referred to, in order to provide an opportunity for patients
to get more adequate health services, especially in terms of equipment.
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From the cases of discretion taken by SLBs in the PHC, it shows that the discretion taken
is all aimed at the safety and interests of the patient. The assumption that develops, discretion
is dangerous so it must be limited or not even necessary. But Wibawa (2009) argues differently,
that SLBs need to be given more discretionary space along with paying for their performance,
which can increase public service efforts without increasing corruption (Kwon, 2014). Wibawa
(2009) further argued that bureaucratic discretion would need to be protected so that anyone
who would use the bureaucracy for their own interests or the group would get strict sanctions.
Bureaucratic officials in carrying out their duties and responsibilities need to be protected when
taking discretionary decisions in order to overcome more urgent problems. The line of authority
between political and bureaucratic officials needs to be emphasized so that no one intervenes
and dominates among them which in turn harms the public interest
The sluggish bureaucracy that has always been complained about so far in public services,
especially in administrative services, is rarely found in health services in PHC. It might be
because the context of the service provided is different from the administrative service. Health
care is more about humanitarian issues. SLBs who work in the PHC get a feeling of satisfaction
(intrinsic satisfaction) when they can help patients who are served. Motivation of public
services (Perry & Wise, 1996) from SLBs can be demonstrated by a commitment to the desire
to serve the public interest (Downs, 1967).
5. CONCLUSION
Discretion can be defined as the ability of SLBs to choose between alternatives and decide how
a government policy must be implemented in certain situations. Discretion in public health is
taken not only solely because of the limited resources available, but also because of the pressure
(bottom-up) that comes from patients who want to get better service. The discretion taken by
SLBs in health services shows that discretion are basically aimed at the effectiveness and
efficiency of services provided to patients, and primarily aim to provide fast services for
patients who immediately need services. The results showed that the level of discretionary use
was different for each SLBs. Courage to take discretion is strongly influenced by the experience
and independence of SLBs, as well as considering the impact on patients. In general, the
discretion taken solely aims to facilitate service and is based on the desire to save the lives of
patients served.
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