Civil servant and professional – understanding the challenges of being a public service doctor in a plural health care setting in rural South Africa

Abstract

Using insider-ethnography the study is an exploration of the experiences of public sector doctors in a rural hospital in KwaZulu-Natal. In the context of a complex policy environment as well as a stressed public sector struggling to meet its constitutional obligations, the daily work of public sector doctors is at the civil service professional intersection. Engagement at this intersection is strongly influenced by the local context of the individuals and communities served. Interactions are also shaped by the local plural health care system where public sector doctors, private general practitioners and traditional healers form complex networks that are largely informal and dependent on personal relationships. The study uses Lipsky’s street-level bureaucracy as a theoretical framework to understand and explore the challenges of being a professional, a bureaucrat and a public official in the public health care sector. In interpreting the rules of their various roles they make many complex decisions that require considerable discretion. In this, their daily work as civil servant doctors remains largely regulated and managed locally by the doctors themselves. The convergence of the roles of professional and civil servant provides public sector doctors leverage to synergistically use discretion individually and collectively within their daily work. While discretion is abused at times, in the setting of a larger system struggling to deliver services, many of public sector doctors voluntarily align their activities and practices with the ideals of providing a high quality care to the population served. In this discretionary practice is vital for the service to function. While bureaucratic and professional standards of practices create distance and detachment from the people they serve, in their interaction with colleagues and the public care and caring is evident. Critically, caring is contingent on the space that discretion provides doctors to engage. These findings have considerable implications for how the work of public sector doctors is conceptualized, planned and managed.