Journal of Comparative Policy Analysis: Research and

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Against the COVID-19 Pandemic: Analyzing Role

Changes of Healthcare Street-Level Bureaucrats in
Mexico

Oliver Meza , Elizabeth Pérez-Chiqués , Sergio A. Campos & Samanta Varela

Castro

To cite this article: Oliver Meza , Elizabeth Pérez-Chiqués , Sergio A. Campos & Samanta Varela
Castro (2020): Against the COVID-19 Pandemic: Analyzing Role Changes of Healthcare Street-
Level Bureaucrats in Mexico, Journal of Comparative Policy Analysis: Research and Practice, DOI:
10.1080/13876988.2020.1846993

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Journal of Comparative Policy Analysis, 2020
https://doi.org/10.1080/13876988.2020.1846993

Against the COVID-19 Pandemic:

Analyzing Role Changes of Healthcare
Street-Level Bureaucrats in Mexico
OLIVER MEZA *, ELIZABETH PÉREZ-CHIQUÉS *,
SERGIO A. CAMPOS **, & SAMANTA VARELA CASTRO **
*Public Administration Division, Center for Research and Economics Teaching, Aguascalientes, Mexico,
**Public Policy, Center for Research and Economics Teaching, México City, Mexico
(Received 29 June 2020; accepted 1 November 2020)
ABSTRACT Healthcare workers are street-level bureaucrats (H-SLBs) who are expected to
perform according to specific roles. The COVID-19 pandemic has strained healthcare systems
to unprecedented levels. The acute scarcity of medical resources has left H-SLBs exposed to a
higher risk of personal harm and has them making an increased number of decisions in the
apportionment of scarce life-saving treatment. The article studies the case of H-SLBs in Mexico
to understand the impact of the crisis on their roles. The pandemic provides an opportunity to
observe role changes during crisis. Their roles, derived from two policy guidelines, and from the
de facto roles that H-SLBs shared in the storytelling interviews, are coded, analyzed, and
compared. Findings suggest two main roles, client-processing and resource-rationing, guide
the set of sub-roles H-SLBs perform to cope with the challenges brought by the COVID-19
pandemic.
Note: In the interests of space, street-level theory and the pandemic context underpinning the
articles for this Special Issue are discussed in detail in the Introduction to the Issue.
Keywords: SLB roles; COVID-19; policy comparison; healthcare workers; Mexico

Oliver Meza is research professor in the public administration division at CIDE-Center for Research and
Teachings in Economics. He holds a PhD in Public Policy and his main research examines the behavior and
decision-making processof public officials in local governments. Currently he is studying topics around
corruption in local governments embarking in a new line of research dealing with street-level bureaucrats.
Dr. Meza recently received the “2020 Annual Research Award” sponsored by the Mexican Academy of
Sciences.
Elizabeth Pérez Chiqués is a research professor in the public administration division at the Center for
Research and Teachings in Economics (CIDE) and a fellow at the Rockefeller Institute of Government in
New York. Her research centers on government corruption, public personnel management, and policy imple­
mentation.
Sergio A. Campos is a PhD candidate on public policy at the Center for Research and Teachings in Economics
(CIDE). He has been visiting research fellow at The Hebrew University of Jerusalem. His research centerson
how citizens use their agency during frontline interactions.
Samanta Varela Castro is a PhD candidate on public policy at the Center for Research and Teachings in
Economics (CIDE). She is currently working in studying healthcare street-level bureaucrats addressing the
covid-19 crisis.
Correspondence Address: Oliver Meza, Public Administration Division, Center for Research and Economics
Teaching, Circuito Tecnopolo Norte #117, Col. Tecnopolo Pocitos II, 20313 Aguascalientes, Ags.
E-mail: oliver.meza@cide.edu

© 2020 The Editor, Journal of Comparative Policy Analysis: Research and Practice
2 O. Meza et al.

Introduction
Street-level bureaucrats are known to deploy several roles while on duty (Maynard-Moody
and Musheno 2000, 2003, 2012; Jewell and Glaser 2006; Lipsky 2010; Gofen 2014;
Baviskar and Winter 2017, Frøyland 2018; LeRoux et al. 2019); these are either assigned
to them by formal policy guidance or enacted during policy implementation. The complexity
in the relationship between formal policy and SLB work is well established in the literature
(Meyers et al. 1998; Lipsky 2010; Sager et al. 2014; Vink et al. 2015; Vohnsen 2015), but less
is known about the connection between policy guidance and SLBs roles, especially less in a
context of uncertainty and crisis. This article explores the roleplay of healthcare SLBs (H-
SLBs) in Mexico during the COVID-19 pandemic.
The literature on SLBs has identified multiple SLB roles (Frøyland 2018; Nothdurfter
and Hermans 2018), however, the conceptualization of “role” remains relatively vague
(see Jewell and Glaser 2006), and just recently some works are using a more precise
definition of the concept (Loyens and Maesschalck 2010; Dubois 2016). These authors
draw from a tradition of social theory that understands role as socially constructed
(Goffman 1961; Mead 1972; Hughes 1993) and as a set of normative duties, demands,
and obligations that comes with a social position or status (Goffman 1961, p. 75; Hughes
1993, p. 134). Two aspects of role theory are of interest here: the way in which roles
institutionalize and routinize, creating a conflict between individual personality and
institutional role (Hughes 1993; Dubois 2016); and the distinction between role as
normative demands and role enactment as “the actual conduct of a particular individual
while on duty in his position” (Goffman 1961, p. 75).
Our study proposes a typology to make sense of the roles and role changes of H-SLBs
during crises. Drawing on the above definitions, we define roles of SLBs as patterns of
expected and actual behavior within their policy scope affected by an environment of
institutions (Jewell and Glaser 2006). Our analysis focuses on two roles in the SLB literature,
client-processing and resource-rationing (Lipsky 2010), that are considered essential to deal
with scarcity and uncertainty – conditions that are common to SLB work (Lipsky 2010) and
that become aggravated during crises (Perrow 1999; Skilton and Robinson 2009).
We analyze roles derived from two policy guidelines and compare with the de facto
roles that H-SLBs shared in storytelling interviews. Findings suggest that although
during normal circumstances the client-processing roles guide the resource-rationing
roles of H-SLBs, during crises, the public health frame imposes the role of resource-
rationing as the main guiding principle, as H-SLBs switch from a client-centered to a
population-centered approach (Institute of Medicine 2012; Mexico Healthcare Council
2020; Mexico Health Secretariat 2020). For H-SLBs accustomed to client-processing as
their main role, this change in dominating frames is not costless or frictionless. We
identify a variety of sub-roles that arise in response to the policy and environmental
changes brought by the pandemic; this adds nuance to the study of H-SLB roles and role
changes during crises and can serve to better understand the relationship between
different types of policies and SLB work.

The Roles of SLBs

Several roles have been assigned to SLBs concerning policies, these range from the
classic implementer or policymaker role (Meyers and Vorsanger 2003; Lipsky 2010;
 Against the Covid-19 Pandemic 3

Gofen 2014; Baviskar and Winter 2017), to other more specific roles, such as being
regulators or inspectors of policies (Carter 2017) and gatekeepers (Yngvesson 1988).
According to Prottas (1979), one of the main SLBs’ role is the massive processing of
people during public service. A more nuanced approach to Prottas’ people-processing role
is depicted in two roles present in Lipsky’s conceptualization of SLBs: client-processing
and resource-rationing (Maynard-Moody and Portillo 2010). SLBs are client-processing
given that they face citizens who become clients of a service (Alford and Speed 2006) –
determining citizen eligibility, verifying requirements, turning citizens into clients of a
service, and engaging with them through provision of services. Resource-rationing, on
the other hand, has to do with SLBs’ mandate to ration the supply of services, which, in the
public sector, are frequently insufficient to meet demand. Resource-rationing includes
decisions such as “who to assist and who merely to process through the system”
(Maynard-Moody and Portillo 2010, p. 4) given the available capacity.
Under regular circumstances, both roles are effectively interrelated. For instance, the
resource-rationing role may be part of the client-processing role, used as a coping strategy
of SLBs to process people by creaming the stream of people they attend (Lipsky 2010;
Hupe and Buffat 2014). However, under circumstances of crisis where the public service
gap (Hupe and Buffat 2014) unravels uncontrollably, resource-rationing emerges as a
critical and explicit role for SLBs. H-SLBs, specifically, are obliged to modify their
clinician practice, employing client-processing tasks leaning towards management of
resources – a change of role that comes with resistance (Hoyle 2014). The situation of a
pandemic offers a context to account for this nuanced difference with clear conceptual
analytical paths, although, as we demonstrate further in our empirical analysis, these two
roles still overlap according to our characterization of H-SLBs’ performance.
Considerations of how each role is performed are conditioned by the task at hand and
specific circumstances. Lipsky saw healthcare workers as SLBs in the traditional sense
(Lipsky 2010; Harrison 2015); however, H-SLBs are strongly affected by professional
identities (Harrits and Møller 2014). SLBs and H-SLBs mediate between two distinct
operations; “an effort to have policy implementation conform to general and abstract
rules, and an effort to apply rules to specific and concrete cases” (Bannink et al. 2015, p.
64). Crises are characterized by increased uncertainty, conditions that threaten core
values, requirements for immediate action, and scarcity of resources (Rosenthal et al.
1989; Boin et al. 2016; Nohrstedt et al. 2018). Crises are uncertain and disrupt supply
chains (Perrow 1999; Skilton and Robinson 2009) which makes SLBs’ knowledge of the
context essential for resource-rationing. In the context of the pandemic, we show how
SLBs’ classic roles enter into conflict, and new mediating and balancing sub-role
positions emerge for H-SLBs to cope with the critical situation.

Context and Research Design

In response to the COVID-19 pandemic, the Mexican government revised prior bioethical
codes, and set new guidelines to prevent the overwhelming of the health system. Because a
scarcity of resources was anticipated, the General Sanitary Council published the Bioethical
Guide for Distributing Limited Critical Medicine Resources in Emergency Situations (BGSR)
in April 2020. The document guides hospital ethical committees and H-SLB decisions and
4 O. Meza et al.

privileges the criterion of social justice. It suggests creating triage teams and prioritizing
patients that have a higher probability of benefiting from the use of scarce resources.
Additionally, the “Hospital Reconversion Guide” (HRG) provides a technical guide for
expanding capacity through the conversion of hospital areas or entire hospitals to treat
COVID-19 patients. It requires reorganizing and reassigning H-SLBs to small hierarch­
ical teams in charge of the reconverted spaces.

Methods and Data

To understand the impact of the pandemic on H-SLBs roles, during May–June 2020 we
conducted policy document analysis, interviews with experts, and storytelling sessions
with H-SLBs.

Policy Guide Analysis. We analyzed the BGSR 2020 and the HRG guides. Qualitative
coding focused on the roles and role changes the policies demanded from H-SLBs in
triage positions and clinical practices. Two authors independently coded the policy
documents, while a third author verified coding for reliability and finalized the analysis.

Interviews with Key Informants. We conducted four semi-structured interviews with

experts in the field of bioethics and medicine. Interviews lasted 45–60 minutes and
provided context to understand how policies developed. Interviewees helped coordinate
storytelling sessions with H-SLBs affected by the policies.

Storytelling Sessions. Adapting Maynard-Moody and Musheno’s (2003) story-eliciting

strategy, we collected stories using web-based storytelling sessions with 11 healthcare
professionals – physicians, medical residents, and nurses – working with COVID-19
patients in hospital settings (see online Appendix A for interviewee characteristics).
Through storytelling, we wanted to gain insight and identify commonalities in the
experience of H-SLBs in the Mexican context. Storytelling and narrative analysis are
considered powerful tools to both explore the minutiae of experience and to identify
patterns and themes (Maynard-Moody and Musheno 2003, p. 26). Prior to the sessions,
we asked interviewees to think of stories that illustrated what their work was like before
and during the COVID-19 pandemic. Interviewees narrated their stories and answered
clarifying and follow-up questions (see online Appendix B for script); sessions lasted
30–45 minutes. With interviewee consent, sessions were recorded and transcribed ver­
batim for analysis. Data was anonymized.

Coding Strategy. We coded policy documents and interview transcripts for H-SLBs roles.
We organized the analysis using Maynard-Moody and Portillo’s (2010) conceptualization
of the client-processing and resource-rationing roles as a starting point and general
framework for the identification and specification of sub-roles. Verbatims that reflected
a primary concern for client categorization were classified as highly associated with
client-processing. Verbatims that reflected a primary concern for rationing the supply of
services were categorized as highly associated with resource-rationing (see online
Appendix C and D). Given the overlap, we considered both concurrently, and constructed
 Against the Covid-19 Pandemic 5

sub-roles that reflected this thinking (e.g. high on client-rationing, low on and resource-
rationing), revealing a variety of sub-roles.

Results
H-SLBs Roles According to the Policy Guides
Analysis of policy documents yielded information on the two classic roles played by H-
SLBs in the context of the COVID-19 pandemic in Mexico (see online Appendix C
and D).
Resource-rationing, or roles that center on determinations regarding the rationing of
the supply of services (Maynard-Moody and Portillo 2010), was clearly present. The
hospital reconversion guidelines (HRG) designated certain hospitals to care for COVID-
19 related illnesses; other non-respiratory emergencies, patients with chronic conditions,
and other acute problems had to find accommodation elsewhere. The HRG mentions
“physical medicine and rehabilitation scheduled appointments are suspended, and tasks
of health staff are reassigned” (HRG:1). Similarly, the bioethical guidelines (BGSR)
stated that “the objective in public health during an emergency of this nature is twofold:
to treat the largest number of patients and to save as many lives as possible” (BGSR:1);
H-SLBs’ decision-making should align their resource-rationing role with this objective.
Policy guides also direct H-SLBs to maintain their client-processing role, or roles that
center on eligibility determination and provision of services (Maynard-Moody and
Portillo 2010); these, for instance, include “diagnosis, treatment, rehabilitation of patients
based on scientific evidence” (HRG:3), but should cater to the challenges of the pan­
demic. The BGSR required H-SLBs to make calculations based on specific public health
criteria within the triage process to decide whether a person is admitted to emergency
services, and therefore converted into a client or not (BGSR:2). Also, the HRG dictated
specifications for the client-processing role that impacted H-SLBs’ clinical practice,
“separate flow of patients with acute respiratory infections and establishment of cohorts
of suspected or confirmed COVID-19 patients” (HRG:2).
Analysis clarified certain consideration between client-processing and resources-
rationing based on the policy guides. While disease prevention and individualized
treatment are the objectives in everyday medical practices, these change in public health
practices: “the objective is that the population’s health be the best possible according to
the amount of available resources [and] during a health emergency, such as COVID-19,
most of the everyday medical practice is subsumed into public health practice”
(BGSR:6).
Analysis revealed sub-roles associated with the two main roles but also other stand-
alone roles. Within resource-rationing, three sub-roles were identified. The first asks H-
SLBs to perform as participants-in-deliberation aiming to resolve resource-allocation
demands immediately: “on the allocation of resources [. . .] medical and nursing health
personnel who directly care for patients [. . .] should participate in the deliberations on
each case” (BGSR:3). The second, patient-evaluator, called on H-SLBs to periodically
reassess the triage score of patients to evaluate the continuation or not of the provision of
treatment supplied to critical patients (BGSR:10). A third sub-role, resource-creator,
demanded that SLBs expand their clinical capacities: “staff preparation should broadly
consider training and recruitment to reduce staff shortages” (HRG:4). It also requires
6 O. Meza et al.

SLBs to adapt their practice within the modified medical units, away from their usual
functions (HRG:5).

Within the Client-Processing Nuanced Roles, Three were Uncovered. The first is a sub-
role of H-SLBs to address the complexities of patient–family liaisons – a central aspect
of client treatment provision. For instance, providing a bridge to communicate and report
to family members outside the hospital premises using available technologies (BGRS:4).
The second sub-role calls on H-SLBs to become health-promoters, conveying all medical
units to filter access, “avoiding magnifying the spread of the disease among patients”,
providing alcohol gel in the entrance (HRG:7), adding to H-SLBs’ responsibilities
regarding categorization in client-processing. Third, a different version of a resource-
creation sub-role based on professional rules emerged under client-processing. For
example, policy guides encouraged health personnel to apply measures considered
pertinent and professionally appropriate (BGSR:5), as well as establishing that health
personnel should receive training in medical response algorithms regarding care of
critically ill patients (HRG:8), expanding clinical decision-making capabilities in treat­
ment provision.
Distinct to client-processing and the resource-rationing roles, two additional roles
emerged. First, the BGSR stresses the need for H-SLBs to be health-promoters, to
“exercise the moral influence in society and before the authorities to promote measures
to preserve ecological systems, clean water, food and the factors that protect human
health and biodiversity” (BGSR:9). Second, the policy guides asked H-SLBs to conduct
themselves as peer-supporters in case help is needed “to mitigate the moral anguish that
falls on treating doctors” (BGSR:11).

H-SLBs De Facto Roles

Analysis of de facto roles identified in the interviews offers a consistent but wider
spectrum of sub-roles compared to those mandated by policy guides. Table 1 provides
a graphical perspective of the sub-roles within a two-by-two matrix. Sub-roles are
classified depending on their relation to client-processing and resource-rationing roles.

Resource-Minded. Quadrant one groups the sub-roles that are highly associated with
resource-rationing and less associated with client-processing. This group is associated
with the public health concern of managing scarce resources to benefit the greater
number of people. H-SLBs are de facto assigned to be uni-taskers due to the unloading
of activities derived from hospital reconversion: “the entire hospital became COVID; we
no longer accept any other pathology” (5:01). Furthermore, H-SLBs need to balance
resource-rationing along risk-management sub-roles, given that they should consider
themselves as “valuable resources for people and for colleagues” (1.11). Additionally,
sub-roles such as patient–family liaison within resource-rationing place H-SLBs in
difficult situations: “The family member [. . .] is afraid, he does not know how to face
all this, but one does not have the time to sit down and talk when I have five [patients]
outside who are choking” (4:16). Finally, the patient-evaluator sub-role within resource-
rationing demands tough decisions: “You get an 85-year-old patient who is super ill vs. a
 Against the Covid-19 Pandemic 7

Table 1. Quadrant of sub-roles’ positions

High association with resource- Q (1) Q (2)

rationing Resource-minded Balance-in-stress
Uni-tasker Patient-evaluator
Patient–family liaison Risk-manager
Patient-evaluator
Low association with resource- Q (4) Q (3)
rationing Self-coping Client-minded
Uni-tasker Uni-tasker
Peer-support Risk-manager
Health-promoter Participants-in-deliberation
Resource-creation
Patient–family liaison
Patient-evaluator
Low association with client- High association with client-
processing processing

22-year-old girl who also comes in very poor shape, you leave the bed for the 22-year-
old” (5:28).

Balance-in-Stress. Quadrant two groups sub-roles considered to be highly associated

with both client-processing and resource-rationing roles; clinical practices changed to
address the challenge of resource scarcity. The aim is “trying to save as many people as
possible” (1:16). This affected H-SLBs’ patient-evaluator sub-roles as hospital admis­
sion criteria changed: “80% [oxygen saturation in blood] is still enough to go find
another hospital” (5:08). “Decisions are made based on the risk of respiratory arrest
and death [. . .] we cannot take other things that we as physicians would like to take into
consideration to decide what to do with the patient” (4:09). H-SLBs sub-role as patient-
evaluator involved ethical and bioethical considerations, which are not easy to resolve:
“There is no prognostic scale for the disease, how to evaluate, how we are going to
respond with scarce resources, and all the expenses in this patient . . . should we treat
them?” (8:08). Ethical considerations in the patient-evaluator sub-role require SLBs to
balance their own emotions: “Sir, if you think we are going to kill you, why are you
coming? [. . .] why waste my time and waste the bed?” (5:07). Furthermore, evaluating
patients during a pandemic becomes critical because it requires a certain level of
specialization: “It is necessary that there is an infectologist doing triage” (10:13), and
also due to other contextual circumstances, such as number of nearby hospitals. H-SLBs
also engaged in risk-management sub-roles. For example, some clinical practices chan­
ged to avoid risk, illness or death: “We have to balance the risk-benefits [when generat­
ing aerosols] if we do heroic procedures, we will lose the opportunity to attend to another
100 patients” (1:08).

Client-Minded. Quadrant three, the largest and qualitatively richest group, groups sub-
roles considered highly associated with client-processing and less associated with
resource-rationing. Hospital reconversion made H-SLBs adopt a role of uni-taskers:
“before the COVID, our demand was for various diseases” (1:02). The risk-manager
8 O. Meza et al.

sub-role is relevant to client-processing, too, because H-SLBs changed their clinical

protocols: “It is contraindicated to make exhaustive explorations of the respiratory
function for patients with Covid-19” (4:06). Balancing risk-manager within the client-
processing role becomes a critical task for H-SLBs during triage processes: “[H-SLBs]
need to have a lot of judgment to decide if the patient stays or leaves. Saying “leaves” is
very high risk for the patient; they may not be able to solve his or her problem at another
health institution in the state” (6:04).
H-SLB sub-role of participants-in-deliberation and resource-creation were intimately
related within the client-processing role. The analysis identified a pattern across inter­
viewees, who expressed the need to face uncertainty in a collaborative way, requiring
high levels of deliberation. Official policy guides were disregarded: “A bioethical guide
came out, but to be honest, the workload is so great that we have never held a session
where this bioethical debate is taken into account [. . .] all these decisions were by
consensus” (1:12). Deliberation took many forms, as a H-SLB stated, sometimes “we
read summaries and keep up to date and try to give the best care to patients and try not to
be so futile” (9:07); other times “different specialists, the infectologists, the pulmonol­
ogists, held weekly meetings to determine [why and how patients are dying] they made
[informal] flow charts until they saw a change in mortality, only then the official flow
chart was modified” (5:22). Deliberation was not always easy: “Medical decisions are
sometimes contrasting because they [other medical specialties] are not prepared for
taking care of a patient with a life-threatening respiratory infection” (4:03).
Patient-family liaison is a sub-role deeply affected by the pandemic within the client-
processing role: “we had to modify the contact with the family of patients changing it to
a minute service from one that was once an hour” (4:04). Time becomes a valuable
resource affecting H-SLBs’ work; sometimes lack of time is perceived as lack of
empathy, “because if you get five who were dying, you have to save them, relatives
are overwhelmed, but you cannot give reports” (10:12). This sub-role is challenging
because the interaction can get emotional: “I am afraid to get to the hospital because our
entrance is where the family of the deceased patients is” (7:04); “if the patient or family
member is hostile to you, one is also hostile [to them]” (5:24). H-SLBs needed to act as
the bridge between family and patients, but, given that face-to-face contacts were
counter-indicated, after the hospital reconversion all reports were given by phone (8:15).
Finally, the sub-role of patient-evaluator changed considerably. Before the pandemic,
patients were more involved in their treatments; they “were the ones who decided not to
intubate, not to hospitalize” (8:09). Patients’ agency changed, and H-SLBs had to make
most clinical decisions, often with little communication with patients’ family, and under
emotional strain. As an interviewee said: “One also shuts down because after several
[bad] experiences, one gets fed up with complaints, right?” (5:08). In the case of non-
COVID diseases, H-SLBs had to frequently see patients by phone (6:02) because they
could not see them in the hospital.

Self-Coping. Finally, Quadrant four groups the sub-roles that have little or nothing to do
with both classic roles, offering a distinct set of sub-roles adopted by H-SLB to cope with
the pandemic. In this sense, the uni-tasker sub-role translates to giving up activities they
generally performed, such as “teaching and research” (4:17). Classes were canceled
(10:1) and medical students had to abandon their training because of the risks, sparking
 Against the Covid-19 Pandemic 9

worry because “COVID is not going anywhere, they will have to learn to live with it”
(6:17).
Another sub-role was related to peer support, however, on a different aspect: “[we] take
care of each other so as not to get infected (9:5), [also] we try to zoom, send each other
support videos” (9:12). Self-coping includes health-promotion roles such as when physicians
decided to clean their own instruments before working (7:05), or other decisions made by H-
SLBs to facilitate their everyday work, such as interdisciplinary meetings to establish
management guidelines to improve response to the emergency (6:12).

Discussion and Conclusion

In the context of the pandemic, we show how mediating and balancing sub-role positions
emerge to help H-SLBs cope with the critical situation. Prior to the pandemic, client-
processing – making crucial decisions regarding the health and life of current or prospective
patients – was considered H-SLBs’ principal role. During periods of crisis, H-SLBs had to
modify the focus of their clinician practice to shift away from a client-based approach to a
public health approach to deal with scarce resources. We observe nuances in the intersection
between client-processing and resource-rationing roles but we admit that clear lines seem
nonexistent to us, and that some categorical decisions were made with the aim of unveiling
the richness of the work in which H-SLBs are involved. Worth noting is that this article
studied H-SLBs in real time during a hospital crisis with all the challenges that involves.
Future iterations on the topic could offer a different perspective, once the crisis has subsided;
however, some insights, which we only touch the surface of, merit further discussion.
Firstly, H-SLBs were more responsive to policy guidelines that change their working
environment than policy guidelines that attempt to direct their decisions. This provides
nuances in a common assumption regarding the relation between policy and SLB work
(Meyers et al. 1998).
Secondly, when facing high levels of uncertainty, professional capacity strongly
guided H-SLBs’ decision-making and decision-taking. This primes the idea of continu­
ing, if not reinforcing, the continuous professionalization of SLBs as an effective
mechanism for coping in relevant ways under high uncertainty. Interviews pinned the
way the H-SLBs left their comfort zone to engage between them to understand the
disease, and to explore and experiment with bottom-up innovations.
Thirdly, the scope of the roles of H-SLBs during the crisis is wide and malleable, but
highly necessary. In the case of the pandemic, many countries made unprecedented
efforts to access ventilators, beds, medicines and vaccines, but very few resources
went to support H-SLBs’ widening span of work; missing a critical piece in the response
system. Moving forward, an integral plan is needed to support the SLBs workforce, their
futures, and families.

Acknowledgments
Authors are grateful to all interviewees, specially to Adrian Soto, Asuncion Alvarez, Carmen Castillo and
Fernando Rivas for their immense and generous support with preliminary medicine and in-sector consultations.
10 O. Meza et al.

Supplemental Data and Research Materials

Supplemental data for this article can be accessed at here.

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