The use of street-level bureaucracy theory in health policy analysis in low- and middle-income countries: a meta-ethnographic synthesis

This article presents a synthesis of studies that explicitly use the theory of street-level bureaucracy to illuminate health policy implementation in low- and middle-income countries. Street-level bureaucrats are frontline workers in bureaucracies, e.g. nurses, who regularly interact directly with citizens in discharging their policy implementation duties and who have some discretion over which services are offered, how services are offered and the benefits and sanctions allocated to citizens. This synthesis seeks to achieve the dual objectives of, first, reflecting on how street-level bureaucracy theory has been used in the literature and, second, providing an example of the application of the synthesis methodology of meta-ethnography to the health policy analysis literature. The article begins by outlining meta-ethnography and providing more information on the papers on which the synthesis is based. This is followed by a detailed account of how the synthesis was achieved and by an articulation of the synthesis. It then concludes with thoughts and questions on the value and relevance of the synthesis, the experience of conducting the synthesis and the partial way in which street-level bureaucracy theory has been used in the literature examined.