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They build on Etzioni's definition of power as ‘an actor's ability to induce or influence another actor to carry out his directives or any norms he supports’ (1961: 4). From the enforcement perspective, implementers are bureaucratic subordinates managed by a form of coercion, as reflected in accountability rules and internalized formal authority. Such coercion is accepted by implementers as part of their broader acceptance of public ideals and responsibilities. The performance management perspective sees implementers as agents contracted by principals and managed by material power, in the form of incentives or sanctions. Finally, in the co-production image, implementers have relative autonomy and work within a joint framework. They have power because their professionalism and expert judgement is trusted; but that power is constrained by the series of relationships they have with others to whom they are accountable. Implementation is essentially about co-producing shared results. A different approach to understanding power is presented by those who understand policy as ‘meaning making’ (Open University, no date).
This body of work suggests that the language of policy and the meanings that people give to that language themselves become policy and influence individuals’ responses to policy interventions. Policy language is constructed not only by politicians and senior government officials, but also by implementers, the managers, professionals and public service staff who interpret policy for themselves as well as clients and the wider community. However, Fischer (2003, p. … Discourse, in this view, does more than reflect a social or political ‘reality’; it actually constitutes much of the reality that has to be explained … Instead of understanding power only in negative terms - such as power to control or manipulate others - the approach … also emphasizes that discursive power can determine the very field of action, including the tracks on which political action travels. Theory does not, however, give a particularly clear sense of the concrete ways in which power is exercised—for this, we turn to empirical examples.
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The exercise of control or resistance can be direct and visible: as when a subordinate, in a characteristically top-down way, is ordered to perform an implementation task and complies, or when employees go on strike to resist a management decision. However, organized resistance might be fairly rare in the organizational contexts of health policy implementation and even some forms of top-down control are less obvious. Resistance can include, for example, front-line providers who develop their own working routines, such as when nurses take tea breaks and for how long, to give them greater control over their clients and tasks. It can also be seen in a small act such as the non-completion by a dissatisfied health worker of parts of the records needed to collect fees from patients for certain procedures. Although not reversing the policy of fee collection, such an act might require other colleagues to work harder to find and capture the information, as well as reducing the amount of fees collected, thereby affecting both the process of policy implementation and the extent to which the intended goals are achieved.
Less obvious exercises of power often have a discursive flavour, as when negative labels or identities are assigned to others. Indeed, this is a common practice: Those seeking to discipline subordinates and colleagues frequently seek to dismiss their resistance by imputing negative motives. So, for example, derogatory labels or identities such as ‘trouble-maker’, ‘whinger’, ‘chip on their shoulder’, ‘jealous’ and ‘looney feminist’ frequently have significant symbolic and disciplinary impact on those considering resistance. The ways in which policies are framed by and for implementers can be another often overlooked exercise of power that influences outcomes, as seen in two South African examples. Higher level managers have framed the hospital fee policy, which includes provision for exemptions, as essentially being about revenue generation, leading to an under-emphasis on the provision of exemptions (Nkosi et al.2007). Yet another example of the exercise of discursive power is the use of humour to resist and criticize what is difficult to challenge openly. Griffiths (1998) discusses how humour has been used by a UK team of community mental health workers to resist the instructions of powerful colleagues and to undermine professional hierarchies.