Working through the fog of a pandemic: Street-level policy entrepreneurship in times of crises.

Imposing significant challenges for both street-level implementation and policy (re)design, crises alter the environment for street-level policy entrepreneurship (SLPE), wherein street-level bureaucrats engage in policy formulation processes to secure future policy outcomes. Nevertheless, like street-level implementation in general, SLPE is studied during ordinary times but rarely during crises. Focusing on community-health workers in Brazil during the Covid-19 crisis uncovered a defensive motivation for SLPE, which aimed to legitimize community healthcare as an integral part of pandemic treatment, reforming the government's hitherto neglectful approach to community health services. Moreover, the continuing crisis created an unusually prolonged window of opportunity for securing community healthcare provision. By utilizing collective efforts and drawing on powerful politicians' mobilization, SLPE during crisis shares similarities with, yet differs from, SLPE during ordinary times, while further closing the interstices between local, professional, and political perspectives in the formulation of policy decisions.

INTRODUCTION

Times of crisis, like the Covid‐19 pandemic, impose significant challenges both to street‐level implementation, which serves as a central frontier of disease treatment, as well as for formal policy design, because governments must respond fast to unexpected, continuously changing circumstances (Farazmand, 2001; Gofen & Lotta, 2021; Henderson, 2014; Meza et al., 2021; Savi, 2014). Indeed, complex information management and decision‐making are inherent to government response to emergencies (Henderson, 2014), which depend on a constant, continued, bidirectional information flow between decision‐makers and implementers (Collins & Augsberger, 2020; Davidovitz et al., 2021; Malandrino & Sager, 2021), and especially with street‐level bureaucrats (SLBs), whose implementation actions construct formal policy decisions on the ground (Brodkin, 2012, 2013; Lipsky, 2010). Downward flow of clear, comprehensive information from the government to its workforce is crucial (French, 2011). Simultaneously, imposed policy (re)design cycles to address the crisis also require an upwards information flow that will provide feedback about how formal policy decisions meet and affect the ground (Gassner et al., 2020), which SLBs not only experience first‐hand but on which they often have a monopoly (Brodkin, 2012; Hoggett, 2006). The significance of bidirectional flow of information between policy design and street‐level implementation shifts attention to the involvement of SLBs in policy formulation processes in general, and to SLBs' efforts to influence policy outcomes in particular, namely, street‐level policy entrepreneurship (herein, SLPE, e.g., Arnold, 2015; Cohen, 2016; Lavee & Cohen, 2019). Like policy entrepreneurs in general, who aim to mobilize public attention in order to promote innovative policy solutions (Mintrom, 2000), SLBs who act as policy entrepreneurs seek to secure a specific policy outcome, which may be driven by varied motivations (Arnold, 2020; Frisch‐Aviram et al., 2018).

Despite the relevance of SLPE to crisis conditions, like street‐level research in general, SLPE is mostly explored in routine times and underexplored during crisis (Gofen & Lotta, 2021; Henderson, 2014). Moreover, exploring SLPE during crisis may contribute to the understudied conditions that enhance or hamper SLPE.

To explore SLPE during crisis, this study draws on policy entrepreneurship exercised by community‐health workers (CHWs) in Brazil during the Covid‐19 pandemic for three reasons. First, Brazil became an epicenter of the first wave of Covid‐19 infections, thus requiring ongoing policymaking cycles in order to address the continuing crisis and its public health, economic, and social implications (The Lancet, 2020). Second, Brazil has one of the largest public health workforces in the world (WHO, 2020), including more than 286,000 CHWs, who provide community healthcare services, inside citizens' domiciles across the country (Ministério da Saúde, 2020), thus representing a classic SLBs' category (Lotta & Marques, 2020). Third, the federative governance structure of Brazil generates a power balance between federative bodies and a center‐periphery dynamic of struggles between local and national agendas (Falleti et al., 2010). Drawing on local and national interplays between actors, agendas, and ideas, this structure enables a creative municipalities' reaction (Tendler, 1997), and local implementation reflects an experimental context (Lotta et al., 2021; Matland, 1995), in which many actors, in different sites, attempt to influence local and national policy agendas.

Two general insights emerged. First, the crisis created a prolonged window of opportunity for CHWs to promote community healthcare as a key policy solution for the pandemic. Second, SLPE during the crisis shared similarities with SLPE in routine times, yet also differed in some key respects. Prominent similarities are defensive motivation, and mobilizing insiders and outsiders as a key strategy (e.g., Arnold, 2020). Prominent differences are the mobilization of politically powerful supporters and drawing mostly on collective efforts.

To convey the relevancy of crisis to SLPE, the following literature review discusses SLBs as a distinct category of policy entrepreneurs while focusing on why SLPE during crisis matters. After specifying the research approach, findings elaborate on SLPE during crisis while emphasizing similarities and differences from SLPE during ordinary times, as presented in the literature. The concluding section summarizes contributions for both theory and practice.

WHY SLPE MATTERS FOR TIMES OF CRISIS

Policy change is often ascribed to policy entrepreneurs (Kingdon, 1984), who are commonly portrayed as actors investing extensive efforts into setting the policy agenda and mobilizing public attention in order to secure a future policy outcome, while not having themselves the necessary resources to effect policy change (Cohen, 2016; Mintrom, 2000; Mintrom & Norman, 2009; Zahariadis, 2003). Committed to a specific policy change, policy entrepreneurs advocate innovative policy solutions that disrupt the status quo (Mintrom, 2000) and are commonly characterized as having a distinct set of attributes, skills, and multidimensional strategies (for a systematic review see Petridou & Mintrom, 2020). Policy entrepreneurs are portrayed as skilled in identifying and utilizing a window of opportunity (Cohen, 2012), during which problems, solutions, and political streams converge (Kingdon, 1984; Zahariadis, 2008). Although it is often short‐term, unstable, and may not exist simultaneously at different government levels (Petchey et al., 2008), a window of opportunity is considered the most important condition for policy entrepreneurship (Cohen, 2016).

It is now well‐accepted that not only politicians and top‐government executives act as policy entrepreneurs, but also lower‐level bureaucrats, including SLBs (Arnold, 2015, 2020; Cohen, 2016; Frisch‐Aviram et al., 2018; Zahariadis, 2008). SLPE is often ascribed to the close and direct relationship of SLBs with the public, which allows to identify on‐the‐ground needs and windows of opportunity for taking action (Arnold, 2015, 2020) and contributes to public trust (Arnold, 2015; Lavee & Cohen, 2019). SLBs who exercise policy entrepreneurship share some similarities, yet are distinct from other policy entrepreneurs (Arnold, 2020). Similarities include utilizing entrepreneurial strategies, such as building multidimensional coalitions, sharing knowledge with allies, and gaining professional and political knowledge “for effectively influencing a matter concerning policy” (Lavee & Cohen, 2019, p. 9). Differences emphasize the high costs that entrepreneurial actions generate to SLBs due to their distance from decision‐makers (Arnold, 2015; Mintrom & Norman, 2009), as well as the greater effort constancy, which derives from counting on a less powerful network of supporters and acting based on a defensive motivation (Arnold, 2020). SLPE may have various motivations, including the pursuit of work efficacy (Arnold, 2015), ideology, or economic efficiency (Frisch‐Aviram et al., 2018), as well as protecting clients' well‐being (Lavee & Cohen, 2019). SLPE therefore echoes the well‐established notion of public service motivation (Perry et al., 2010) and “policy practice,” which entails SLBs' deliberate efforts to change policy in order to improve the lives of vulnerable policy‐client populations, mainly within the social work profession (e.g., Gal & Weiss‐Gal, 2020). Ascribing unselfish motivation for SLPE somewhat differs from the common self‐serving and self‐interested images of policy entrepreneurship, even when driven by ideological motivation, following its inherent feature of investing resources with expectation of a future return (Cohen, 2016).

Despite SLPE relevancy to times of crisis, like street‐level scholarship in general, SLPE studies focus on established routines, while contexts of intense crises and extraordinary times are understudied (Brodkin, 2021; Gofen & Lotta, 2021; Henderson, 2014). Relevancy of SLPE to times of crisis derives from changes imposed both on the routine environment within which SLBs work (Cox et al., 2021; Gofen & Lotta, 2021; Henderson, 2014; Meza et al., 2021), as well as on the conditions in which formal policy decisions are (re)designed (Comfort et al., 2001; Davidovitz et al., 2021; Goodsell, 2002). In general, times of crisis impose significant threats on people's lives while changing the rules of the game, and therefore test citizens' behavior as well as the functioning of political authorities and public agencies (Comfort et al., 2001; Goodsell, 2002). Specifically, lack of regularity and previous experience (Carter & May, 2020) impose new and significant challenges for street‐level implementation (Brodkin, 2021; Gofen & Lotta, 2021; Møller, 2020). In addition, the fast‐changing conditions disrupt the status quo and intensify urgency (Newswander, 2012; Tang et al., 2020), thus require shorter time cycles of policy design (Davidovitz et al., 2021). Moreover, continued policy (re)design, which occurs under extreme uncertainty and intensified public risk (Gofen & Lotta, 2021), necessitates an agile‐adaptive approach (Moon, 2002) that depends on on‐going, rapid updates regarding how formal policy design meets on‐the‐ground reality. Hence, during emergencies, bidirectional information flow between the government and its workforce is critical (French, 2011; Gofen & Lotta, 2021). Continuous downward flow of comprehensive emergency plan information is essential for emergency treatment (French, 2011), especially for SLBs, who depend on information provided by higher‐ups for understanding the changing conditions and for facilitating a course of action (Davidovitz et al., 2021; Weick, 2012). Moreover, legitimacy of emergency plans is often contingent on transparency and inclusion of key stakeholders, such as frontline health professionals, in the decision‐making process (French, 2011; Meza et al., 2021; Møller, 2020; Pérez‐Chiqués et al., 2021). Continual upwards feedback about the ways through which formal policy decisions meet the streets is expected to play a vital role within the imposed fast cycles of policy (re)design. Times of crisis therefore amplify the importance of SLBs' unique structural position as an essential buffer between decision‐makers and the public and as the ultimate source of vital upwards feedback (Gassner et al., 2020; Gofen & Lotta, 2021; Musheno et al., 2021). Similarly, crisis' times highlight the well‐known information monopoly of frontline organizations about the environment within which they are embedded (Smith, 1965), and the mediating politics role of street‐level organizations (Brodkin, 2012; Gassner & Gofen, 2018).

Crisis conditions are therefore expected to enhance the advantages of SLBs as policy entrepreneurs. Furthermore, in routine times, SLBs' unique structural position provides them with both advantages and disadvantages in acting as policy entrepreneurs (for a full discussion see Lavee & Cohen, 2019). However, it is expected that during crises the advantages will overshadow the disadvantages, including occupying a rather low position in the organizational hierarchy, lacking direct communication with decision‐makers, and missing formal authority or legitimization to influence policy formation (Lavee & Cohen, 2019).

SLPE relevance to crisis is also reflected in recent findings that uncover three conditions under which SLBs tend to exercise policy entrepreneurship (Lavee & Cohen, 2019): when circumstances are perceived as an acute crisis, and SLBs are “sensing threats … [thus understanding] that without their immediate intervention, their clients might face severe damage to their rights, needs, well‐being, and even personal safety” (p. 12); when the general atmosphere calls for innovation and activism; and when SLBs see themselves as “untrained or lack[ing] the required knowledge to respond to issues raised in a new context” (p. 13).

The above review suggests that the unique and well‐documented structural position of SLBs makes them key players in (re)designing policy solutions for emergencies following the complex decision‐making and information management inherent to government response to crises (Henderson, 2014). Nevertheless, whereas SLPE during routine times has gained recent scholarly attention (Arnold, 2020; Lavee & Cohen, 2019), SLPE during crises is understudied. Exploring SLPE during crises also accords with recent emphasis on policy entrepreneurship as a context‐specific activity, which implies that taking into account contextual factors is crucial for a better understanding of the strategies, actions, and influences of policy entrepreneurs (Petridou & Mintrom, 2020).

METHODOLOGY

This study is part of a broader research agenda about street‐level implementation during the pandemic. During the first steps of data collection, it was realized that CHWs are practicing SLPE, which, as mentioned above, eventually developed into a formal change of policy. Because street‐level implementation in general, and SLPE in particular, are rarely explored in a crisis context, this study adopts an exploratory qualitative approach and uses a grounded theory of social inquiry (Charmaz, 2000; Corbin & Strauss, 1990). Putting SLBs at the forefront of pandemic treatment and imposing a few substantive challenges to street‐level implementation, Covid‐19 provides an opportunity to explore SLPE during an ongoing crisis. Specifically, the pandemic demands additional and extensive work from some SLBs' groups, mostly frontline health workers, social workers, and police officers (Alcadipani et al., 2020; Gofen & Lotta, 2021). The pandemic compels frontline workers to exercise discretion in contexts of high unpredictability, with higher demands yet fewer resources, and where their practices and rules have been disrupted (Gofen & Lotta, 2021). Furthermore, physical distancing policies that have been introduced all around the world challenge one of the core features of street‐level implementation, that is, direct, face‐to‐face interaction with clients (Alcadipani et al., 2020).

Case selection

Analysis draws on CHWs in Brazil during the Covid‐19 pandemic for four interrelated reasons. First, Brazil is ranked as the world's worst country in pandemic response (Lowy Institute, 2021) and therefore provides an illustrative case study to explore the ongoing policymaking cycles required to address the continuing crisis and its implications.

Second, Brazil has one of the largest public health workforces in the world (WHO, 2020), which comprises more than 286,000 CHWs providing across the country community healthcare services inside citizens' domiciles (Ministério da Saúde, 2020). Moreover, CHWs in Brazil represent a classic SLB, that is, directly interacting with citizens on a daily basis to provide health services while holding significant discretionary power. Like many well‐documented SLBs, CHWs in Brazil have a strong professional identity as well as privileged access to information about the community they serve, especially among the residents of the neighborhoods in which they work (Lotta & Marques, 2020). CHWs in Brazil are nationally recognized as a strong workforce capable of influencing citizens and implementing preventive health policies (Nunes, 2020), which is mostly ascribed to living within the community they serve (Lotta & Marques, 2020).

Third, by focusing on emergency health services and hospital care during the first months of the pandemic, the government response in Brazil disregarded community healthcare as a policy instrument to fight the pandemic. Hence, health problems, including infection and treatment of those who did not require hospitalization, were overlooked. Moreover, the denialism of the president and the health ministry, as the regulator of community‐health services, led to major uncertainties and confusion regarding CHWs' role in addressing the pandemic. To shift from the hitherto dismissive attitude to community healthcare policies, CHWs started practicing SLPE, promoting community‐health policies as a relevant, contributive, effective policy instrument that should be integrated into government treatment of the pandemic.

Lastly, the healthcare crisis in Brazil was not only heightened by the pandemic, but also intensified by a multifaceted political struggle in the country, which relates to the federative structure and its dynamic of balancing power between national, state, and local governments (Falleti et al., 2010), especially regarding the political conflicts, also playing out in many other countries, over whether government response should prioritize public health outcomes or economic interests (Comfort et al., 2020). Specifically, the central government constantly prioritized the maintenance of economic activity and the president, as a denialist of the pandemic, decided that the central government should not develop health policies to fight the disease (Lotta et al., 2020a). Indeed, by August 2020 the Ministry of Health spent only 30% of emergency funds on the pandemic. Furthermore, many of the country's governors and mayors prioritized public health and introduced physical distancing and social isolation policies (Ortega & Orsini, 2020). This political conflict created a challenge for states and municipalities, which have autonomy in setting policy priorities but depend on the central government for funding and regulation. Disagreements between different federative levels inhibited coordination efforts and sent contradictory messages on how to behave, which led to public confusion.

Data collection

To provide comprehensive and diversified information, data draw on multiple sources (O'Brien et al., 2014) and include almost 600 different types of online communications, following the limitation on face‐to‐face contacts during the pandemic. One data source was a public Facebook group with membership of more than 20,750 CHWs working all over Brazil. Researchers asked for permission to collect data in the group. Data draws on posts created by CHWs in this group during the period of March–May 2020, which included 112 discussions related to the pandemic, involving 600 CHWs. In addition, 76 CHWs answered a message we posted that asked for testimonials on their work during the pandemic and promising not to publicize their names out of the Facebook group. Although not randomly selected, this respondents' sample included people from a broad spectrum corresponding to all five regions in Brazil. Respondents used their Facebook identity and their posts were visible to other community members. Additional online sources included materials collected from the official website of the CHWs' confederation and unions, including 22 live transmissions and videos, two documents sent to deputies demanding attention to CHWs' requirements, and two official documents from the Ministry of Health redefining CHWs' role during the pandemic.

Data also draw on testimonials from six CHWs from the city of Sao Paulo, whom we knew from previous research, who replied to our request to answer general questions, such as their perception of the pandemic and its treatment, and how it affects their work.

Lastly, three in‐depth interviews with union representatives, including one local representative in São Paulo and two interviews with a national leader, who serves as president of the national association of CHWs (Conacs). Interviews took place in March, April, and July 2020, lasted around 60 min, and were recorded and transcribed.

Analytical procedure

Interview transcriptions (N = 3), as well as WhatsApp and Facebook testimonials (N = 81), documents (N = 2), website posts, and debates documented on Facebook (N = 600) were conceptually coded through constant comparisons, using NVivo software. Following grounded theory (Charmaz, 2000; Corbin & Strauss, 1990), first, open coding identified which aspects of street‐level implementation exercised by CHWs were influenced by the pandemic and in what way. Open coding allowed distinguishing evidence that refers to SLPE, that is, to all aspects of CHWs' engagement in policy formulation processes that aim at securing future policy outcomes. For examples, statements that described attempts to approach a politician were labeled “Politicians' Mobilization,” statements that described engagement on social media were labeled “Social Media Activities” and statements that suggested policy options were labeled “Policy Solutions.” Next, seeking similarities, differences, contrasts, and relationships between categories derived in open coding guided an axial coding process (Corbin & Strauss, 1990).

Four distinct dimensions of SLPE emerged as influenced by the crisis. First, the crisis served as a window of opportunity. Second, motivations for SLPE. Third, entrepreneurial strategies, including mobilization of powerful politicians facilitated by the conditions imposed during the continued, wide‐ranging crisis. Fourth, the exercise of SLPE emerged as a collective effort.

Acknowledging the challenge to strengthen internal validity and generalizations in qualitative inquiries, besides drawing on multiple data sources for triangulation, attention was paid to how the setting relates to the established literature (Yin, 2013). In addition, using instant message applications and online meetings, the authors discussed findings and rival explanations for the phenomena observed.

SLPE DURING CRISIS

In general, SLPE during crisis emerged as having both similarities and differences with SLPE during ordinary times, as presented in the literature. Specifically, our analysis identified four distinct features of SLPE in a crisis context. First, the crisis provided a prolonged window of opportunity for policy entrepreneurship. Second, SLPE during crisis reflected a defensive motivation of securing the continuity of healthcare services. Third, SLPE involved extensive, continued efforts to mobilize insiders and outsiders, including powerful politicians. Fourth, SLPE during crisis emphasizes a collective rather than an individual effort. In the following sections, each feature is specified and compared to current portrayals of SLPE during regular times, as presented in the literature.

The crisis as a prolonged window of opportunity for SLPE

Analysis indicates that crisis conditions alongside implications of consequent government response opened a problem stream, which was coupled with public confusion about how to behave during the pandemic following the inconsistent policy directives and political disputes between the government levels. The policy solution introduced by CHWs promoted the use of community‐health services and its workforce as a key policy instrument to fight the pandemic. Specifically, in July the congress legislated a new law which explicitly recognized CHWs as professionals who exert a key role in the pandemic response, and community healthcare was highlighted as a priority for health policy (Lei 14.023, 2020). This legislation included CHWs with the officials to whom governments should supply protective equipment, as professionals whose activities involve direct contact with citizens during the pandemic. Moreover, following this law and an additional decision of the Supreme Court, local and state governments were granted autonomy to develop their own solutions for fighting Covid‐19. On multiple occasions, CHWs succeeded in influencing policy design at state and local levels, so that newly introduced policy decisions utilize community healthcare as a main policy instrument in fighting the pandemic. One such example was mentioned on Facebook: “My city created a commission to confront Covid‐19 formed by nurses, health and epidemiological surveillance and with the help of the CHWs to accompany the families by WhatsApp and collect and transmit the patient's instructions.”

Problem

A policy window was opened by the problem stream, in which multiple public health issues captured most, if not all, public and political attention. Both the severity of the pandemic and the government response imposed significant limitations on community‐health services' delivery.

Specifically, conditions imposed by the pandemic jeopardized the core element of public services provision in general, and community‐health services in particular, that is, CHWs' face‐to‐face interactions with policy‐clients. Lack of personal protective equipment put CHWs and their clients at risk. Neglecting community‐health services brought additional problems, including infection and treatment of those who did not require hospitalization. Additional unmet health needs arose from neglecting other public health issues, including the interruption of vital community‐health services, as argued by one of the CHWs on Facebook: “CHW's work is essential not only to fight Covid, but also for dengue, tuberculosis, H1N1, active search for pregnant women, baby vaccines and many other things.”

Additionally, the gap between on‐the‐ground needs and delivery of community‐health services further intensified because CHWs were either provided with no directives or given contradicting instructions about their work. One representative example is a new formal orientation published in March by the Health Ministry, which in its first part required CHWs to stop visiting patients during the pandemic, while in its second part required them to take care of sick patients and visit them at home (Ministério da Saúde, 2020). Later government policies that included no mention of CHWs reflected a dismissive attitude to community healthcare in fighting the pandemic, as summarized by a CHW in a post on Facebook: “It is a pity that governments do not value and take advantage of the prevention work that CHWs can do.” In a similar manner, CHWs expressed great frustration at not knowing what to do, as described in one of the replies to our posts: “We are feeling alone. We don't know what to do and nobody is protecting us as we keep doing our job at this moment.” Furthermore, although by July the unions counted more than 70 deaths of CHWs due to Covid‐19, there was no official orientation or training, as summarized by a CHW saying that CWHs are “learning from the television [how to prevent getting infected and spreading the disease].” Central government stagnation forced CHWs to re‐design their daily work by themselves, as explained by the president of their association: “The government still has to establish the CHW's routine and their tasks. We are lost; we don't know what we should do, who should we talk to.”

Disregard of medical knowledge and evidence during the design of policy solutions emerged as an additional problem. One illustrative example is a decision of the Brazilian president that demanded the Army to produce hydroxychloroquine as a treatment for Covid‐19 (Junqueira, 2020), despite warnings from health authorities, including the World Health Organization, that hydroxychloroquine is not an effective treatment for the virus.

Due to their direct interaction with the public, this situation emerged to deepen CHWs understanding about the gaps between intentions and outcomes in public health, as exemplified in a post in their Facebook group: “While we are fighting the pandemic with all seriousness, Jair Bolsonaro goes through the debate with nonsense topics. (…) The use of chloroquine as a salvation, for example, should not waste our energy and confuse patients. It is a false debate. It's more fake news from the president.” Similarly, an additional post explicitly described this government's response as a sabotage of CHWs' on‐the‐ground efforts to fight the pandemic: “It is frustrating for CHWs to work trying to reduce cases of Covid‐19 and governments undo our guidelines with the promise of a cure with ’drugs’ without scientific proof and without guaranteeing people the conditions to avoid leaving home.”

In sum, the problem stream encompasses more than the public health issues imposed by the pandemic. Rather, CHWs consistently presented the government response to the pandemic as inconsistent, inadequate, and insufficient to meet public needs and to stop the spread of the pandemic.

Politics

Three key actors—public opinion, the federal government, and local governments—became involved in a political struggle that concerned not only the management of the pandemic in general, but also CHWs' role within the crisis. Public opinion and political climate were reflected in CHWs' repeated references to the decreased efficacy of their direct‐delivery actions, which was ascribed mainly to the increased public noncompliance with the physical distancing required to avoid health risks imposed by the pandemic, compounded by inconsistent instructions from the government at different levels. Analysis indicates that the general political dispute in the background reflected a disagreement about whether to prioritize public health or economic interests, which, in turn, encouraged public noncompliance and thus intensified CHWs' work burden. Notably, the president has been denying the crisis while prioritizing economic interests over public health considerations as reflected in a general statement to the public on March 24, 2020, in which Bolsonaro referred to Covid‐19 as a “small flu” that will “pass soon” and “our life must go on” (President Bolsonaro, March 24, 2020). In contrast, many governors and health authorities stated the opposite, reinforcing the pandemic seriousness. Some governors and mayors, supported by scientists, also opposed the president's decision to recommend hydroxychloroquine and started a campaign against the president. More generally, in contrast to the central government, mayors and governors often prioritized public health, introducing various policies that promoted health while inhibiting economic activity in the country (Ortega & Orsini, 2020).

Inconsistency in government instructions created confusion and generated insecurity among citizens, which was intensified by the inconsistent message from the government as expressed by the health minister during the early stages of the pandemic, who said in an interview to the largest television network in Brazil: “This [lack of clarity] leads the Brazilians to a dubiety. He [a citizen] doesn't know if he listens to the Health Minister, if he listens to the President, whom he will listen to.” He was soon after dismissed by the president. CHWs consistently mentioned experiencing this confusion, for example, when citizens demanded from them medications even when not having a doctor's recommendation (Lotta et al., 2020a, 2020b).

Directly interacting with the public and representing public health interests, CHWs were pushed into a difficult position following this economic versus health dispute, as noted by a union representative who described CHWs as put “in the middle of this war.” Besides dividing society, the on‐going political dispute fueled public noncompliance with policy directives, which CHWs were encountering first‐hand. Alongside an increased exposure to health risk, CHWs were further challenged by new friction during direct‐delivery interactions while being increasingly burdened by the need to convince people to comply with social distancing. Explicitly ascribing the burden to the president, a CHW working in a big city argued that “the president is making our work much more difficult, creating a big mess.”

In sum, the political stream reflects a general confusion in the public which was ascribed not only to the uncertainty imposed by the crisis but also was amplified by the dispute between the different government levels as to how to treat the pandemic.

Policy solution

In general, during the first months of 2020, community healthcare was the policy solution promoted by SLPE to fight the pandemic, while the health policies designed and implemented by the Brazilian government focused on the most severe patients, mainly by shifting resources to preparing hospitals with intensive care units, which included exceptional legislation that allowed acquisition of ventilators and additional supplies without the regular regulation process. Consequently, while it had been provided all around the country during ordinary times, community healthcare services, and CHWs as its frontline workforce, were marked as unimportant and irrelevant to the pandemic response (Lotta et al., 2020a). Indeed, CHWs were not given any formal authority or responsibility as health officials who take part in addressing the pandemic. In fact, the training, resources, and activities of CHWs in the new policies introduced to address the pandemic were overlooked. Moreover, the crisis and government policies introduced in response to the pandemic forced limitations on community‐health services, which, in turn, made it almost impossible to facilitate new forms of community healthcare delivery while imposing extreme challenges on CHWs' ability to carry out routine activities and to develop capacity for necessary work adjustments.

The policy solution promoted by CHWs aimed to shift from the dismissive government approach to community healthcare to utilizing and taking advantage of community‐health infrastructure, workforce, and resources in addressing the pandemic. Getting engaged in policy design processes, CHWs presented a policy solution which emphasized that, instead of investing only in hospitals and emergency care or in nonapproved medicines, government policies should draw on the community healthcare system, which provided across the country. Utilizing community healthcare policies to fight the pandemic, and drawing on CHWs' daily work as a key policy instrument, was framed as responding to three emerging issues in both the problem and politics streams: first, helping to stop infections and treating patients with no need for hospitalization as well as treating additional life‐risking health problems; second, allowing clarity and effectiveness in community‐health services; and third, relaxing and assuring citizens, which was required not only by the stress imposed by the pandemic itself, but also following the disagreement between different federative levels, which sent contradictory messages to citizens on how to behave.

In sum, CHWs' SLPE introduced a fundamental shift in the public health approach, that is, from relying only on emergency health services for severe patients' treatment, to a more integrative approach, which includes community healthcare and providing community‐health services for patients with milder symptoms at home, and efforts to prevent virus' spread in local communities.

Comparing the crisis as a window of opportunity with policy windows' portrayals in the literature highlights two differences. First, policy windows are often fleeting (e.g., Zahariadis, 2008) and SLPE is “often persevering through the long slog of policy implementation… rather than engaging in intense advocacy around a fleeting policy window” (Arnold, 2020, p. 12). In contrast, the crisis emerged as providing a prolonged window of opportunity and SLPE as continued intense advocacy effort. Second, responding to the pandemic, the policy window opened in the problem stream, and therefore was expected to follow a consequential process during which policy solutions are designed to address “real” problems, which is commonly distinguished from policy windows opening in the political stream that reflect a “solution chases problems” pattern (Zahariadis, 2008). Our analysis, however, demonstrates that community healthcare was promoted not only as a policy solution for the emerging problems, but also in response to threats to CHW credibility and necessity, and also as a way to secure the continuity of community healthcare, that is, CHWs' work, in regular times. SLPE during crisis therefore presents a mix of the two patterns, which somewhat contrasts with the current dichotomy between a rational versus nonrational pattern (Zahariadis, 2008).

SLPE during crisis: Defensive motivation

As mentioned above, changes imposed by the pandemic and by the ensuing government response inhibited the ability and capability of CHWs to continue implementing community‐health policies to their communities. Hence, advocacy of community‐health policies as an instrument to fight the pandemic reflects a defensive motivation to secure the continuity of health service provision to the public. Moreover, SLPE aimed to influence policy design to guarantee that CHWs' professional role in health services got recognition as essential in fighting the pandemic, as mentioned by a CHW in a Facebook post arguing that “now we have to prove that we are useful.” Similarly, the president of their union emphasized the need for CHWs' proving their vital role, as discussed in one of the videos: “It is time for us to prove that our presence is fundamental and necessary [to fight the COVID‐19 crisis]. If we are not on this front [of the pandemic], we are proving to the government that we are not needed [for health policies]. And then our efforts [to become influential in health policies] will be weakened.”

A defensive approach to SLPE was also reflected in descriptions of CHWs being terrified due to the risk of being infected and/or infecting others, as explicitly argued by the president of their national association: “CHWs are terrified. Nobody wants to become a dead hero.” As time passed, and CHWs' exposure to risk further increased, and the need for protective equipment and for updated guidance intensified, as indicated by a national survey with 870 CHWs in June, which found that 87% of CHWs cited not feeling prepared to work during the pandemic (Lotta et al., 2020a, 2020b).

Reflecting a defensive approach, SLPE during crisis is similar to SLPE during ordinary times, which aims to “avoid losing, rather than gaining, important resources or favored policy dynamics” (Arnold, 2020, p. 9), and with the common notion that entrepreneurial bureaucrats respond to organizational legitimacy threats and in general act to protect the status quo (Baez & Abolafia, 2002; Breit et al., 2016). Defensive motivation is also reflected in CHWs' struggle for official acknowledgment of their relevancy, their potential contributions, and their key role in fighting the pandemic, thus echoing SLPE during routine times which “coheres with findings that entrepreneurial bureaucrats act to protect the status quo and combat threats to organizational legitimacy” (Arnold, 2020, p. 9). In sum, our analysis indicates that SLPE during the crisis was repeatedly ascribed to attempts to defend provision of community‐health services and secure CHWs' professional position.

SLPE during crisis: Mobilizing insiders, outsiders, and powerful politicians

In an attempt to promote the need for extensive policy revisions, and specifically for utilization of community‐health as a policy solution for addressing the pandemic, and to defend public health interests, CHWs started investing efforts to influence the policy agenda by a national articulation of the legitimacy and relevancy of community healthcare. Specifically, CHWs used multiple social media and other platforms to mobilize different actors, and to share arguments about the importance of community‐health and its potential contribution to fighting the pandemic. One prominent strategy to mobilize public opinion was the initiation of online weekly public meetings in different cities in various areas of the country. During these direct interactions with the general public, CHWs focused on collecting demands and producing an agenda of claims to later present to decision‐makers. In many ways, these meetings posited CHWs as the general public representatives who voice public needs and demands to decision‐makers. Notably, before the pandemic, they used to organize one big meeting per year.

To gain public attention that will press both the Congress and the Ministry of Health, CHWs not only proactively created coalitions but also joined existing networks, such as the coalitions in defense of public health. Coalition building aimed at a wide range of partners, including both insider and outsider networks (Arnold, 2020). Specifically, CHWs invested efforts to bring media actors, health specialists, officials of the judicial system, as well as high‐level politicians into the coalition. Mobilizing the main media channels was exercised both locally and nationally, as CHWs at the local level were responsible for activating their contacts in the local media, while other CHWs made contact with national channels. As an example, they communicated the significance of community healthcare for the pandemic and in general through writing opinion articles, giving interviews for newspapers, magazines, and radios, and by participation in shows with high visibility, such as a news series on the largest TV channel in Brazil, which was celebrated by the CHWs' group on Facebook with a post entitled “Our cause is in evidence in national media.”

To form a large and established coalition with a professional stance, CHWs mobilized other health professionals and scholars who have a similar agenda, as exemplified in organizing the first public meeting with unions of nurses. This process was also conducted locally and nationally, as CHWs engaged professionals and scholars in their states and, at the same time, there was an effort to engage national representatives and unions of these actors. Investing efforts in visibility in order to gain the support of the professional health community is exemplified in the new activities that CHWs undertook, including, as the president of their association described: “We started to be part of the national movement for the health system with some important people from the academy, health professionals. We created a network with representation from all over Brazil and discussed weekly important topics for public health and CHW.”

Efforts to mobilize the judicial system were identified as a response to the Ministry of Health ignoring the union's requests for protective equipment during March and April. Either through unions or in small groups, CHWs appealed to the judicial system and prosecuted the central government, arguing that providing them with protective equipment should be mandatory (see as an example CNTS, 2020).

In contrast to common portrayals of SLPE as unlikely to mobilize politically powerful actors (Arnold, 2020), CHWs' initiatives gained the attention of powerful politicians, which may be ascribed to the lengthy and the wide extent of the crisis in allowing CHWS to transform local political mobilization into national. Using the support of the media, the health policy community, and the judicial system, CHWs were able to mobilize high‐level politicians. Knowing that government responses had to be quick, and that the epicenter of policy decisions was the central government, required the mobilization of high‐level politicians in order to ensure that community healthcare would be integrated into the pandemic response. One evidence of this achievement was the weekly meetings with legislators to acquaint them with prioritized policy solutions. After a pressure, using the media, Facebook messages, and massive emails, politicians agreed to take part in the public debate about community healthcare and included the CHWs demands about prioritizing healthcare policy into their legislative agenda. Several deputies from different parties unified and created a group inside the Congress to defend CHWs' agendas, which later, during the institutional process in the legislature, presented prioritized policy changes supported with evidence. Intensifying SLPE efforts with powerful politicians is explicitly mentioned by the president of their association, who said: “The strategies we used have changed. Before, we had contact with the face‐to‐face deputies, national meetings, and use of social networks. But now we are much more intense in that. We are sending daily emails to pressure the deputies, we are recording videos with them lending their image to our agenda. These are our new strategies.”

SLPE during crisis: Collective efforts

Policy entrepreneurship is commonly portrayed as the effort of an individual, whereas policy entrepreneurship exercised by a team or a group is underexplored (Tang et al., 2020; Zeigermann, 2020). Recent emerging interest in collective policy entrepreneurship emphasizes its value to low‐level bureaucrats, who “have difficulty promoting policy changes on their own and need solidarity, cooperation, and effective interaction, to achieve common goals” (Tang et al., 2020, p. 66).

SLPE exercised as collective effort during the crisis emerged mostly as imposed rather than as a choice, as evidenced in the understanding that influencing policy design and succeeding in promoting a policy change requires acting collectively and not as individuals, as reflected in one of the posts on Facebook: “Unfortunately, during the last years, we were very disunited and dispersed. Each CHW was looking out for his or her own interests. But, facing so many omissions and contradictions by the central government, we had to do something together. And we started using the technologies, creating WhatsApp and Facebook groups with other CHWs, and also with the community. And in this way, we were able to establish some communication and start requiring collectively some changes.”

SLPE as a collective effort was reflected in strategies mobilized locally and nationally at the same time. Another example is that every public statement, video, and post of the CHWs' meetings ended with the words “Together we are stronger.” Collectiveness was also reflected in the constant portrayal of SLPE as a “national movement” to defend not only CHWs themselves, but also policy, as commented online by a CHW, who argued that “The national movement is doing an excellent job during the crisis defending us and the policy.” Moreover, CHWs in general, and not only the union leadership, received credit, as articulated by a CHW online: “I want to make a public statement to thank the colleagues leading the national movements that are representing our cause very well in the national scene during the crisis.”

The collective strategy was made possible with the intensive use of technologies. SLPE activities were coordinated, for example, in online debates, during which testimonials of local leaders suggested this transformation from local and individual causes to a national and collective effort.

Collectiveness emerged as facilitating public attention, as mentioned by a CHWs that, “In these lives we collectively discuss our difficulties and try to propose changes. And with that, we are well regarded by society and the press. We are also holding meetings on a virtual platform with each region and we have achieved a connection and strengthened as a professional category.”

CONCLUSIONS

Despite changes imposed to the environment of street‐level implementation by crisis conditions, street‐level scholarship (Henderson, 2014; Savi, 2014) and SLPE studies tend to focus on ordinary times (Gofen & Lotta, 2021). Shifting attention to SLPE during a crisis uncovered that, while sharing similarities with SLPE during ordinary times, it also differs. First, like common portrayals of policy entrepreneurship as making effective use of windows of opportunity (e.g., Zahariadis, 2008), SLPE during crisis emerged to take advantage of the window of opportunity created by the crisis, in which multiple health problems coupled with a political atmosphere of public confusion allowed CHWs to legitimize community healthcare as a policy solution in the pandemic response. Nevertheless, in contrast to the common notion that policy entrepreneurs must be skilled in identifying and quickly acting on fleeting policy window (Kingdon, 1984), the crisis provoked a prolonged window of opportunity. Moreover, the well‐documented dichotomy between “problems searching for solutions” and “solutions looking for problems,” which represent rational versus nonrational patterns (Zahariadis, 2008), SLPE during the crisis emerged as a mixed pattern in which securing community healthcare was promoted to address the pandemic yet also utilized to guarantee and further establish the professional status of CHWs.

Second, in contrast to the common portrayal of SLPE during routine times as an optional, voluntary undertaking (e.g., Arnold, 2015; Cohen, 2012, 2016; Frisch‐Aviram et al., 2018; Lavee & Cohen, 2019), SLPE during a crisis emerged to follow an immediate need and was exercised to secure the continuity of providing the public with existing services, as well as to respond to newly emerging needs. Responding to de‐legitimization threats imposed by both the crisis and the consequent government response, SLPE during crisis reflects a defensive motivation aiming to guarantee the continuity of the policy and secure the status quo (Arnold, 2020). Shifting attention to defensive SLPE further emphasizes the understanding that, while having substantial power to influence the lives of citizen‐clients, SLBs are often vulnerable as well (Gofen et al., 2019; Hupe & Hill, 2015), especially when employed through nongovernmental organizations (Lipsky, 2010).

Third, similar to SLPE during routine times, SLPE during the pandemic was also based on joining existing coalitions as well as mobilizing insider and outsider networks (Arnold, 2020), including other health professionals, the media, and the judicial system. Nonetheless, in contrast to current conventional thinking about SLPE as involving mainly less powerful actors, our findings indicate that the crisis conditions required and enabled CHWs to mobilize powerful politicians, who got engaged due to the visibility gained by CHWs within the networking process.

Fourth, policy entrepreneurship exercised as a collective effort is understudied (Meijerink & Huitema, 2010; Tang et al., 2020; Zeigermann, 2020) as the predominant focus of current scholarship is the individual policy entrepreneur, mainly high‐level politicians (Baker & Steuernagel, 2009; Tang et al., 2020; Zahariadis, 2008, 2016), although multiple policy entrepreneurship features imply collectivity. Specifically, policy entrepreneurs often engage in collaborative action and utilize group‐oriented strategies (Béland & Cox, 2016; Mintrom et al., 2020; Mintrom & Norman, 2009; Petridou & Mintrom, 2020). Moreover, the chances of policy entrepreneurship succeeding increase “the more collective the needs or problems that can be addressed by the policy entrepreneur's solutions” (Cohen, 2016, p. 193). Similarly, SLPE studies often refer to the individual entrepreneur (Arnold, 2015; Cohen, 2012), and even the engagement of a group of SLBs in policy entrepreneurship is approached as an assemblage of individual activities rather than as a collective and coordinated undertaking (e.g., Frisch‐Aviram et al., 2018; Lavee & Cohen, 2019).

Uncovering that SLPE during a crisis is exercised as a collective, orchestrated effort, this study joins a handful of recent studies, in various policy sectors, that explicitly refer to collective policy entrepreneurship while emphasizing the key role of critical mass and building collective agency in spurring policy innovation (Anderton & Setzer, 2018; Galanti, 2018; Giambartolomei et al., 2021; Mallett & Cherniak, 2018; Safuta, 2021). Specifically, SLPE during crisis accords with emerging portrayals of collective policy entrepreneurship as allowing utilizations of different capacities and skills (Meijerink & Huitema, 2010), as taking “advantage of the opening up of possibilities for forming a new policy in times of change” (Sundet et al., 2020, p. 714), as well as the dissemination of new policy ideas by framing issues through means that include “manipulation of decision‐making forums where citizens are present” (Galanti, 2018, p. 51).

Notably, SLPE during a crisis utilizes well‐documented policy entrepreneurship strategies, which require time to be carried out and to influence the policy agenda (Mintrom, 2019). Nevertheless, securing policy outcomes in fast‐changing and high‐uncertainty conditions requires policy entrepreneurs not only to accelerate and intensify efforts, but also to orchestrate their entrepreneurial activities, which further emphasizes the well‐documented understanding that networked individuals engaged in collective entrepreneurial action play a critical role in policy innovation (e.g., Arnold et al., 2017; Christopoulos & Ingold, 2015) and that “the policy entrepreneurs had to collectively work with and through others” (Roberts & King, 1991, p. 147). Furthermore, SLPE during crisis supports the newly emerging understanding about collective entrepreneurship as especially helpful for lower‐level officials (Tang et al., 2020), like SLBs, whose resources are limited and whose work conditions expose them to constant pressure (Gofen et al., 2019; Keiser, 2010).

Finally, it is now well‐accepted that SLBs exercise three main roles, which are to deliver policies, to mediate policies, and to mediate politics (Brodkin, 2013). Extensive research focuses on the construction of policies on the ground during direct‐delivery interactions (Brodkin, 2013; Gofen, 2014; Lipsky, 2010). Hence, whereas the delivery and mediation of policies are well‐documented, mediating politics is understudied (Lotta & Marques, 2020). SLPE, though, manifests SLBs as mediating politics, especially when it involves representing and voicing policy‐clients' needs and requirements to higher‐ups (Brodkin, 2013).

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.