1 Introduction

As the primary interface between the public and the government, street-level bureaucrats carry a special responsibility, shaping in a large part how ordinary citizens perceive and experience their governance (Lipsky, 1980, 2010; Maynard-Moody & Musheno, 2003). Though charged with demanding obligations, street-level bureaucrats are often overburdened yet under-resourced (Brodkin, 2011), resulting in burnout, stress, and diminished productivity (Dudau & Brunetto, 2020; Shim et al., 2017). The complexity of regulations and administrative procedures adds another layer of difficulty for frontline workers, exacerbating cognitive and compliance burdens as well as intensifying the strain of an already stressful position (Peeters & Campos, 2021; Stanica et al., 2022). In resource-constrained settings, street-level bureaucrats confront heightened barriers in delivering services due to limited resources, escalating demands, and competing priorities (Alcadipani et al., 2020; Barnes & Henly, 2018; Gaede, 2016). It is, however, also the juncture at which the notion of discretion is most salient, as street-level bureaucrats resort to their judgment, interpretation of regulations, and understanding of context to manage sensitive situations and arrive at informed decisions.

Being the frontline public-facing representatives, street-level bureaucrats have duties that go far beyond the rudimentary policy implementation and service provision to include the meaningful work of building community relationships and resolving difficult issues (Levitats, 2023; Vike, 2018). This manifold role zeros in on the discretionary power vested in street-level bureaucrats, which enables them to exercise judgment (Maynard-Moody & Musheno, 2003) and take appropriate actions in situations where formal guidelines may be inadequate or impractical (Evans, 2015; Tummers & Bekkers, 2014). With the discretion afforded to street-level bureaucrats also comes extensive research examining how they address challenging situations and craft-coping mechanisms (see Tummers et al., 2015a, 2015b). Yet, as it may seem, street-level bureaucrats do more than just employ cognitive and behavioral coping reactions, as overwhelming workloads also compel them to improvise new practices (Cox et al., 2021) that diverge from formal guidelines and often have little connection to policy implementation itself (Masood & Nisar, 2022).

Whereas discretion revolves around the interpretation of formal policies and resources, policy repair involves improvised adaptations and informal resources that entrust frontline workers to dynamically reshape policy delivery from the bottom-up. Though discretion may be inevitable (Brodkin, 2012; Lipsky, 1980), it alone can prove insufficient for responding to contexts of intense pressure and scarcity, situations that may require exceeding the boundaries of formal policy (Eiró & Lotta, 2023; Lotta et al., 2022). In such cases where discretion falls short, repair becomes essential as street-level bureaucrats adapt through practices, for instance, combining resources in new ways (Masood & Nisar, 2022) or relying on unwritten knowledge despite limitations (Lavee, 2021, 2022). With the demand for adaptation becoming ever more acute, resource constraints can erode formal policies, further compelling frontline workers to forage through their personal resources (Lavee, 2021) and improvise practices in order to reconcile rigid dictates with ground-level needs (Ramani et al., 2021; Walker & Gilson, 2004). When the limits of formal discretion are exhausted, subtle practices of policy repair alongside improvised deployment of informal resources manifest as conduits enabling frontline workers to reshape service delivery on their own terms.

Our research is motivated by the need to address a gap in understanding the undocumented experiences that street-level bureaucrats devise to manage scarce resources and stressful conditions. While existing research overlooks these informal, improvisational practices (Cox et al, 2021; Lotta et al., 2022), they nonetheless remain the bedrock for policy implementation and service delivery on the frontlines (Lavee, 2021; Masood & Nisar, 2022). That said, current scholarship still lacks a nuanced examination of the overlooked practices of policy repair inherent in everyday street-level bureaucracy. Here, we contend that gaining textured insights into the on-the-ground challenges that street-level bureaucrats face when implementing policy in resource-constrained settings and high-pressure environments is warranted. Thus, our work seeks to expose how informal resources impact improvised decision-making and lead to ad hoc, makeshift practices that keep operations running in critical contexts where resources are severely limited due to an unexpected crisis. We argue that these underexplored dimensions fundamentally shape bureaucratic function, yet remain poorly comprehended. Through examining the everyday struggles and impromptu adaptations of frontline bureaucrats, we aim to enrich the understanding of the unscripted realities of policy implementation and repair when resources are scarce.

In this paper, we explore the particularities of how street-level bureaucrats navigate policy repair, exercise discretion in public service delivery, and make use of informal resources within these processes. We examine frontline healthcare workers deployed as part of Indonesia’s COVID-19 emergency response, observing how they turn discretion to their advantage when handling informal resources to repair policies and deliver services. Centered on their experiences during resource-constrained crisis situations, we focus our investigation on the following research question: How do Indonesia’s COVID-19 frontline healthcare workers, functioning as street-level bureaucrats, take on informal resources and practices to repair and adapt policies within the constraints of crises and limited resources for enhanced service delivery? These healthcare workers, working at the forefront of Indonesia’s publicly funded COVID-19 response, must govern an unpredictable landscape of formal emergency protocols and frontline realities, compelling them to improvise with informal resources and exercise discretion in care delivery. Hence, looking closer at how formal structures and informal factors intersect enshrines new light on the day-to-day realities for street-level bureaucrats as they balance rigid protocols against adaptations and discretion to deliver flawed programs.

In what follows, we begin with a theoretical review of discretion, informal resources, and policy repair. Next, we present the research methods. The findings are then organized into narratives exploring frontline healthcare workers’ experiences with discretion and informal resources in navigating policy repair. We conclude by discussing implications for both policy repair literature and street-level bureaucracy theory, as well as areas for further research.

2 Theorizing discretion, informality, and frontline repair craftsmanship

Street-level bureaucracy embodies the epitome that public service delivery often transpires at the frontlines of government, where public servants—including police officers, social workers, and healthcare workers—practice considerable discretion in decoding and implementing policies (Brodkin, 2011; Lipsky, 1980). Such discretion denotes the judgment frontline workers have in deciding how policies apply on a case-by-case basis—a flexibility that can gently deviate from formal policy obligations (Gofen, 2014; Maynard-Moody & Musheno, 2003).

While street-level bureaucrats undertake spontaneous, real-time measures addressing immediate service delivery gaps, spaces promoting collective reflection critically guide discretionary decision-making in a more systematic manner by surfacing contextual insights from multiple lenses to inform policy interpretations. Whether through formalized team meetings and case conferences or informal check-ins and ad hoc discussions, deliberating from different perspectives informs discretionary decision-making (Møller, 2021a, 2021b).

Though seemingly mundane and uncodified on the surface, such informal resource improvisation and subtle repair practices in fact form the very foundation enabling needs-based service delivery when rigid formal systems falter. Yet in embarking on these subtle acts of policy repair, frontline workers depend on informal resources to reconcile rigid policy dictates with the realities they encounter (Lavee, 2021; Masood & Nisar, 2022). However, when institutional environments become highly constrained, with scarce resources, lack of organizational support, public distrust, and job insecurity, opportunities for productive deliberation diminish. Under such precarious conditions, frontline workers resort to coping mechanisms oriented around self-preservation over public service delivery, avoiding interactions with clients and managers, showing only minimal compliance, and developing cynical attitudes about their roles (Lotta et al., 2023).

As Møller (2021a, 2021b) discusses, these formalized and informal deliberative organizational routines enable collective reflection to guide policy interpretation and implementation when conditions allow. And yet, Lotta et al.’s (2023) probing examination showed how restrictive and hostile institutional settings can, conversely, elicit detrimental coping mechanisms from street-level bureaucrats reacting to excessively challenging conditions and systems. Still, though constrained environments impede formal deliberation and fuel unproductive coping mechanisms, many frontline workers nevertheless draw on informal discretionary judgment to continue serving public needs as best they can despite lack of systemic supports.

Informal resources constitute ad hoc adaptations grounded in improvisation, emerging from contextual needs and leaning on the experiential knowledge of frontline bureaucrats when formal resources are lacking (Lavee, 2022; Ramani et al, 2021). In contrast to formal resources, which adhere to codified rules and procedures, informal resources are makeshift and ephemeral, depending on the discretionary judgments of bureaucrats who improvise temporary measures when systemic supports fall short (Lavee, 2021). Traditionally, the concept of discretion has centered on formal resources, including agency rules and procedures, reflecting a bureaucratic view of frontline workers as passive implementers expected to mechanically follow top-down policies dictated by leadership. However, this overlooks how frontline workers shape policy delivery based on real-world circumstances, adapting informal resources and alternative methods enabled by their grounded discretion (Eiró & Lotta, 2023).

Especially in contexts of scarcity lacking formal institutional supports, examination of frontline worker discretion must consider informal resources and improvisations (Lavee, 2021). When formal budgets, human capital, and infrastructure are deficient, frontline workers are compelled to count on informal adjustments and grassroots innovations, delivering services through such means. Probing their use of informal social networks, relationships, and substitutes for formal resources, a bureaucratic conception of discretion solely in terms of formal resources risks obscuring the instrumental role that informal resources play in sustaining frontline service delivery when formal systems falter (Blundo, 2006). Rather than discretion alone, the analysis of how frontline workers match rigid policies with the realities in resource-poor settings is clarified by examining their reliance on informal resources and practices of policy repair (Baviskar & Winter, 2017; Honig, 2018).

Policy repair involves improvised actions that go beyond coping strategies to modify formal policies and address emerging needs (Masood & Nisar, 2022). When resources are scarce, frontline workers embark on creative remedial measures, devising interim solutions outside formal sanction yet vital for basic service delivery. More specifically, repair manifests through practices that include substituting materials, streamlining processes through new procedures, or expanding capacity by taking on extra duties (see Masood & Nisar, 2022). In contrast to the use of formal discretion, repair relies on informal adaptations and unspoken strategies, engaging in concealed craftsmanship to harmonize rigid mandates with real-world circumstances.

Although scholarship has made strides in advancing our understanding of street-level discretion, there are still notable gaps regarding how bureaucrats adapt informal practices and resources for policy repair in resource-constrained public sector environments (Lotta et al., 2023; Møller, 2021a, 2021b). The predominant academic focus remains confined to scrutinizing how bureaucrats make use of formal organizational resources to shape policy implementation (Peeters & Campos, 2022; Tummers et al., 2015a, 2015b), while disregarding the importance of improvisation and reliance on informal solutions in low-resource bureaucratic settings where formal resources are lacking. Echoing the gaps on improvisation, the literature on street-level discretion also often overlooks how frontline actors engage in subtle practices of policy repair, informally employing improvised organic solutions to address practical needs in under-resourced bureaucracies, a reality often obscured by a focus on formal resources (Peake & Forsyth, 2022). Hence, we contribute by clarifying how bureaucrats apply informality and adapt policies when improvisation becomes absolute due to scarce formal resources, exposing the discounted realities of street-level discretion in low-resource environments and imparting fresh knowledge into how bureaucrats counter austerity through informal discretion.

3 Research methods

3.1 Study design and setting

Drawing on a phenomenological methodology centered on exploring individual lived experiences, we employed a qualitative design to facilitate an investigation of the contextual intersections shaping individuals’ meanings and interpretations grounded in their particular life-worlds (Merleau-Ponty, 1996). Adopting this approach was well-suited for exploring street-level bureaucrats’ lived experiences during the COVID-19 pandemic, as it equipped us to examine participants’ individualized encounters from multiple angles in a way that put aside our own preconceptions (Creswell & Poth, 2016; Heidegger, 2010). This conditioned a more objective and impartial understanding of the participants’ perspectives that remained uninfluenced by our own pandemic realities, encouraging a concentrated analysis of the subjective phenomena as they naturally occurred in the contextual environment.

Our research focuses on Indonesia’s emergency healthcare workforce response, a policy implemented by the government to mobilize healthcare workers nationwide to treat COVID-19 patients in dedicated hospitals, as part of a broader containment and mitigation strategy. We focused on one of Indonesia’s largest COVID-19-designated hospitals in Jakarta, a makeshift facility reconstructed in early March 2020 with oversight by both government and non-government entities. The hospital, which is one of the world’s largest designated hospitals with a capacity to accommodate over 22,000 patients, spans ten buildings and approximately 7000 apartments within a 10-hectare site, and it has over 3000 frontline healthcare workers enlisted in at least 25 different departments. Given the massive scale and multifaceted coordination involved in orchestrating this response, we used a case study research strategy to investigate policy implementation and frontline experiences within this hospital, with the intentions to offer an insightful understanding into the nuances of Indonesia’s critical pandemic response in one major country setting.

Our choice of the Indonesian context is justified by the particularly devastating impact of the COVID-19 pandemic there, which saw higher caseloads and mortality rates compared to many neighboring countries (see Olivia et al., 2020), where it leads us to an exploration of policy implementation and adaptation of informal resources to address unprecedented challenges. Furthermore, our focus on Indonesia’s COVID-19 response qualifies us to attain a better grasp of the dynamics of policy repair and adaptation within a real-world, large-scale crisis setting. The magnitude and obscurity of this response, including the construction of one of the world’s largest designated hospitals, present a rare environment to study how street-level bureaucrats appropriately use informal resources and practices in the face of resource constraints and evolving circumstances.

While grounded in a single country, Indonesia’s experiences often mirror those of developing democracies in the Global South, marked by resource constraints and bureaucratic complexities (Eiró & Lotta, 2023), with which it produces lessons applicable to a broader spectrum of countries facing analogous challenges. Although focusing on a single country limits generalizability, our in-depth analysis of Indonesia gives a rich understanding of the nuances and complexities of policy implementation and frontline realities during a critical pandemic response, advancing a granular exploration of how street-level bureaucrats navigate challenges with informal practices.

3.2 Participant recruitment and sampling

After obtaining ethical clearance from the Lead Researcher’s university and ethical approval from the hospital, which served as the focus of the study setting, recruitment of study participants commenced. A Google questionnaire form was disseminated across WhatsApp working groups made up of frontline healthcare workers at the hospital in order to solicit sign-ups, and workers registering interest through the form were then contacted directly to arrange interviews. The inclusion criteria required direct frontline involvement in COVID-19 patient care over the past year to provide firsthand perspectives on discretion needed to apply rigid protocols under shifting pandemic realities. Exclusion criteria were established to disqualify administrative personnel who lacked recent, hands-on patient care experience, ensuring that the selected participants possessed the necessary frontline engagement and direct patient interaction required for the research focus.

Employing purposive sampling methodology, we interviewed a cohort of 15 frontline healthcare engaged in the direct care of COVID-19 patients, with the sample including individuals with varied expertise across a range of medical occupations: 6 medical personnel (3 general practitioners and 3 pulmonologists), 5 nurses, 2 nutritionists, and 2 clinical psychologists (see Table 1). This limited yet heterogeneous sample provided detailed accounts of frontline workers’ lived experiences across medical hierarchies, clarifying the contextual complexities of healthcare policy delivery within the pressing realities of the pandemic setting. The intimate perspectives of these frontline healthcare workers, derived from their direct engagement in COVID-19 patient care, consolidated the meaning of diverse experiences in understanding the necessity for discretion and adaptability when applying formal emergency protocols amidst the ever-evolving frontline conditions.

Table 1 Description of sociodemographic characteristics
Full size table

Data collection was concluded after 15 interviews, as data saturation was reached after 13 interviews, with the final 2 interviews providing largely confirmatory data without revealing new substantive themes, affirming adequate depth of understanding had been reached (Saunders et al., 2018). While a larger sample could have broadened the scope, our focused phenomenological approach prioritized capturing granular details and situational nuances. Rather than seeking statistical generalizability, we pursued a phenomenological lens focused on capturing the contextual details and subjective perspectives unique to frontline healthcare workers’ lived experiences during the COVID-19 pandemic (Giorgi, 2009). With the use of purposeful sampling aimed at procuring vivid, information-rich narratives from these workers about the realities they faced in hospitals rather than representativeness (Patton, 2007), we sought to understand the challenges and perspectives of those working directly with patients during the pandemic.

It also merits mention that the emergency hospital setting, defined by intense demands and constant pressures inherent to such environments, presented participant recruitment challenges. Frontline healthcare workers struggled to find time for interviews amidst overloaded schedules and physically and emotionally draining working conditions in the high-stress COVID-19 wards during a pandemic, making recruiting willing participants extremely difficult. Though the sample size is modest, the sampling strategy remains theoretically appropriate, as phenomenological research prioritizes in-depth understanding over breadth by eliciting rich, detailed data from a deliberately selected group of individuals with relevant experiences (van Manen, 2023).

Bringing together multiple healthcare roles, such as pulmonologists, general practitioners, nurses, nutritionists, and clinical psychologists, also reinforced the methodological rigor and validity of the study in several ways. In some aspects, it mitigated assumptions, strengthened analysis through the integration of their specialized skill sets and knowledge bases, and countered singular viewpoints by including different frontline perspectives. Specifically, the diversity of participants revealed sophisticated insights into the complexities of policy implementation and service delivery that a homogeneous sample or narrower group of participants may have overlooked.

3.3 Data collection

Once signed written consent was voluntarily obtained from each participating frontline healthcare workers, the Lead Researcher conducted in-depth, semi-structured interviews lasting 45–90 min in-person. The interviews probed a spectrum of topics that included reflecting on broader experiences serving at the emergency hospital compared to previous work, to more specific areas such as managing challenging client interactions and colleague relationships (see Appendix 1). In the efforts to further augment the trustworthiness of the accumulated qualitative evidence, the Lead Researcher also invested a period of 10 months from June 2021 to March 2022, using firsthand observation, sustained engagement over time, and direct proximity as strategic techniques. During the months of June 2021 to August 2021, she conducted participant interviews while also partaking in the daily routines and activities of frontline healthcare workers. Through this extensive 10-month engagement, coupled with her continuous on-site presence, interactions, and observations within the emergency hospital (see Appendix 2), the Lead Researcher was able to gain intimate familiarity with the research site and participants. This engendered a richer, more contextualized understanding of the subjects’ outlooks and captured the essence of their lived experiences with greater acuity than transient interactions would have allowed. Such longitudinal participation, in fact, afforded additional perspective into the dynamic, diverse, and demanding realities confronted by healthcare workers in their roles, spelling out the delicate intricacies that may have been missed through cursory or transactional encounters.

3.4 Data analysis and validity procedures

We analyzed the data through an inductive approach that involved verbatim interview transcription followed by systematic coding using an iterative approach with open and axial coding (Saldaña, 2021) to identify themes, refine codes, and examine relationships (see Appendix 3). We then conducted phenomenological analysis to delve into the essence of participants’ lived experiences while bracketing preconceptions (Moustakas, 1994). We also employed several strategies to validate the qualitative data, including probing during interviews for deeper insights, such as asking participants to elaborate on unclear statements. Triangulating data from multiple sources also verified findings; for instance, comparing observations noted in field notes to participants’ interview responses corroborated emerging themes. We also shared synthesized data with participants to check interpretive accuracy and enable critical reflection after each interview to assess effectiveness.

To address validity threats and strengthen credibility through transparent examination of the evidence, we identified and analyzed negative and deviant cases to challenge potential analytic biases (Merriam & Tisdell, 2015). While qualitative research inherently contends with subjectivity, we exercised multiple validation strategies, including interrogating the data through ethical techniques aimed at reducing bias, such as assessing discrepancies, evaluating alternate perspectives, and scrutinizing assumptions. The systematic coding, phenomenological analysis of subjective experiences, and validation steps we undertook also lent integrity to the findings by ensuring authentic representation of participants’ experiences, despite inherent qualitative imperfections. At last, evaluating potential biases, deviations, and preconceptions further bolstered credibility by facilitating ethical analytical processes focused on reducing subjectivity through thoughtful interrogation of the data.

4 Findings

Indonesia declared a National Public Health Emergency in April 2020, giving the government authority to mobilize resources for large-scale emergency infrastructure projects across the country in response to the pandemic. One such critical undertaking was the emergency hospital in Jakarta examined here—a hastily constructed makeshift medical center to handle patient overflow as existing hospitals reached full capacity during a period of high transmission. As one of the world’s largest designated facilities, with ten specialized wards spanning multiple converted apartment towers, the massive scale of this hospital reflected Indonesia’s urgent efforts to respond to the crisis. Despite its imposing exterior, the healthcare workers who arrived found that this towering emblem of resilience was underequipped and disorganized on the inside. As public health infrastructure worked to meet the needs of over 275 million citizens, even dedicating resources to construct this large-capacity facility placed much strain on medical supply chains already facing constraints.

Frontline workers faced extreme shortages of fundamental medical supplies, including beds, oxygen tanks, diagnostic tests, and protective equipment required to handle the surge of critically ill patients. These substantial resource deficits rendered healthcare teams largely helpless, unable to provide basic interventions as the most fundamental treatment elements remained unavailable. Even obtaining standard supplies, such as IV tubing and syringes, was a constant strained struggle, as fulfilling basic patient care necessities was routinely obstructed by supply shortfalls. Repeated logistical disruptions also halted vital equipment and medication shipments for thousands, often nearly stopping critical operations entirely. These difficult working conditions left staff psychologically and physically vulnerable—within just one month of opening, a staggering number of frontline workers tested positive for COVID-19 themselves. The high workload and risk led to many frontline workers departing, creating a turnover problem; yet some persisted despite the lack of replacements to fill vacant roles, hazard pay to compensate the risk, mental health resources to cope with distress, or sufficient protective equipment to reduce transmission hazards.

While jeopardizing their own safety working intense shifts with sudden midnight calls in overcrowded wards often lacking adequate protective gear, healthcare teams watched patients succumb not only from a life-threatening illness, but also because missing staffing and supplies made treatment impossible regardless of medical expertise. Witnessing preventable deaths when simple interventions were out of reach took an extreme psychological toll, straining already collapsing morale and inflicting moral injury on top of physical exhaustion. Eventually, shortages peaked into disasters such as having a disproportionate ventilator-to-patient ratio for the influx of critically ill patients arriving daily. The decisions around rationing essentially non-existent care resources to stabilize rapid declines left staff traumatized and desperate for leadership support or backup personnel to relieve the extreme strain.

Faced with extreme resource deprivation and the collapse of formal support systems, frontline healthcare workers were forced to rely on informal coping strategies and discretionary efforts among peers to fill the gaps. Improvising solutions with insufficient resources available, these workers banded together in solidarity—at times even providing the most basic care resources from their personal supplies—to ease patients’ distress and suffering. What emerged, in the absence of leadership and amidst such crises, was a story of resilience through grassroots collaboration. With this context of institutional failure and peer-driven survival tactics in mind, we now present our findings on the specific dynamics of this informal response.

4.1 Negotiating the boundaries of discretion

Similar to other street-level bureaucrats confronting scarce resources and overwhelming workloads, the frontline workers at this emergency hospital also struggled with the perils of non-existent systems and inadequate infrastructure, leading to burnout risks from accumulating duties. At the time of their first arrival at the hospital, the bureaucrats reflected on encountering meager resources, a shortage of certified personnel, and a lack of well-organized structural systems, with some noting that any existing systems were insufficient for the task at hand.

During a morning meeting, the struggles of doctors, nurses, and administrators became much more obvious as they discussed shortages in PPE and brainstormed solutions such as requesting donations from local businesses. This dire situation was further brought into focus by a conversation with a military nutritionist after the meeting, who voiced frustration at the stark contrast between the structured environment of his military life and the chaotic demands at the under-resourced hospital.

While working at this emergency hospital, I have been facing the challenges of treating patients from many backgrounds. The problem is made worse by the shortage of certified nutritionists and other qualified professionals, and the involvement of some individuals who are not yet qualified as nutritionists in providing care. This is very different from my previous 20 years of experience working in hospitals with operational systems that allowed for professional work. It feels quite frustrating to lack control over the system and to be compelled to adapt to the current way of doing things without any established guidelines to follow. (Participant 2, Nutritionist)

On top of the inherent strains of operating with limited resources and a poorly organized system, some bureaucrats were further aggrieved by the periodic rotation of leadership, which added another layer of frustration to their work. The constant flux of leadership, with each new appointment bringing a new set of protocols, procedures, and standards that allowed for little to no flexibility or discretion in their duties, exacerbated the already existing sense of helplessness and emotional exhaustion among the bureaucrats. For example, a psychologist articulated the collective frustration stemming from the military’s rotating command structure, noting that “with the constant changing of leadership, our work routines keep getting interrupted and we can never build stability as a team, leaving a lot of us dissatisfied and less productive”.

Yet, despite their initial frustrations, most of the street-level bureaucrats gradually developed a sympathetic understanding of the limitations within their environment, enabling them to adapt to the constraints and challenges they faced by improvising, creating new informal tasks, and exercising their discretion. Through their adaptability, those bureaucrats not only improved care delivery within the emergency hospital system and met patients’ specific needs but also voluntarily took on new responsibilities that assisted in the mending of policies to benefit patients. For one nurse working a busy shift at this understaffed hospital, this involved exhibiting compassionate care by going above standard protocols and procedures expected of nurses. As such, she took extra steps to understand an aggressive patient’s outburst, stemming from grief over missing his mother’s funeral, which allowed her to calm the patient and tailor care to his situation in a way that exceeded normal procedures.

Irrespective of the myriad frustrations induced by scarce resources and disorganized systems, these frontline workers exhibit a notable degree of resilience in carrying out their duties, improvising and undertaking new informal tasks as needed. Their selflessness not only improves care provision within the deficient hospital system, but also impels them to fulfill individualized patient needs, at times surpassing formal responsibilities to assist in the repair of policies for the benefit of patients. The accounts of resilience and adaptability emergent from these bureaucrats’ lived experiences speak to how the parameters of discretion can be stretched, challenged, and negotiated amid crisis. Confronted with limited resources and chaotic structures, these bureaucrats manage to connect their frustration as a catalyst to exhibit flexibility, versatility, and improvisation, channeling adversity into innovative problem-solving that irradiates the strengths of the human spirit.

4.2 Managing ethical dilemmas in the face of rationing

The COVID-19 pandemic has provoked street-level bureaucrats, especially frontline healthcare workers, with unprecedented challenges, not the least of which is the testing task of rationing scarce healthcare resources among critically ill patients. Under these conditions, frontline bureaucrats pointed out the vast discretion required in patient prioritization, focusing on the critical role of integrity in ethically complex decisions which frequently demand navigating a precarious balance between personal relationships and professional duties. When discussing these challenges, experienced bureaucrats, such as one senior pulmonologist, particularly expressed frustration with the lack of a definitive COVID-19 treatment, encapsulating ongoing defeats and limitations in healthcare rationing during the pandemic, as he shared:

I have dedicated almost two decades of my career to this field, and as this hospital’s original pulmonologist, I have been here since the beginning. But it can still be a challenging experience to come to work every day and be responsible for deciding which patients to “select” from the many vulnerable options. Knowing that my decisions could mean life or death is a huge responsibility to carry, and it is even tougher when I have to predict the possible outcomes of each decision. It has come to the point where the emotional toll of my work has become so draining that it dulls my heart to the news of patients’ deaths, yet I must still find the strength to continue with a tough heart in order to think clearly and focus on saving the patients that I can save. (Participant 13, Pulmonologist)

Indeed, making life-or-death rationing decisions takes a heavy psychological toll on frontline healthcare workers, potentially giving rise to burnout, compassion fatigue, and mental health struggles as they bear the weight of this responsibility alone. In response, frontline workers facing distressing experiences with rationing called for formal protocols that ethically and equitably consider medical necessity. Especially within the Emergency Department, where healthcare workers faced the difficult choices on limited critical care access, such as ICU beds and ventilators, the hospital responded by convening specialists to develop coordinated rationing frameworks. Through regular late-night meetings, pulmonologists, internists, and cardiologists collaborated to facilitate challenging rationing decisions and streamline care across their respective specialties, fostering a natural integration of expertise and coordination.

Another round of observational data continued to highlight the integral importance of multimodal communication protocols, including the use of tools, such as Cisco Webex and WhatsApp groups. These technology platforms had an essential impact in ameliorating ethical dilemmas surrounding resource rationing, which often relies on split-second decision-making. Coordinating patient hand-offs through video tools and messaging platforms further revealed not only the fragile margin of error but also the lifesaving potential when transfers of data and responsibility successfully unfold, with this technology-assisted coordination highlighting the continuity of care hanging in the balance. Beyond information exchange, regular interdisciplinary reporting sessions enriched the collaborative evaluation central to sound clinical judgments under complexity. Yet connections fostered at patient care reviews did more than augment individual discretion through exposure to varying vantage points. Providing space for candid group reflections and questioning also strengthened the social fabric interweaving professional capabilities while restoring the sense that harrowing rationing dilemmas need not lie in isolated hands alone.

The moving personal interpretations of these frontline healthcare workers indeed call attention to the challenges of rationing scarce resources and making ethically fraught decisions in the throes of a crisis. Amidst emotionally draining moral quandaries, healthcare workers reflect perseverance, advocating for clear communication and adhering to their commitment to providing quality care despite the constraints imposed by limited resources. Their experiences expose the demands of wrestling with complex ethical dilemmas, scarcity, and potentially life-altering choices, even as they carry out their duty despite its weight. As it is, these bureaucrats materialize as a testament to the dedication and compassion that defines the healthcare profession, when they confront the ethical labyrinth and emotionally taxing obstacles posed by resource scarcity and crisis decision-making.

4.3 Institutional autonomy and the experiences of alienation

The tension between institutional structures and individual agency manifests when institutional policies and practices impose limitations and restrictions on individuals’ ability to exercise their discretion, leading to a sense of powerlessness, frustration, and even alienation. A general practitioner with prior experience as a community health worker in a Jakarta neighborhood’s community health center encapsulated how institutional policies and practices can greatly affect individuals’ capacity to perform their duties effectively and autonomously. The decision of the Indonesian government to redirect personnel from contact tracing efforts to prioritize COVID-19 vaccination created a sense of powerlessness and frustration for the healthcare worker, as it limited his ability to exercise agency in fulfilling his duties. Elaborating further, he recounted:

The government terminated our contracts as personnel responsible for COVID-19 tracing and instructed us to focus exclusively on vaccination efforts. Consequently, during this period, there were no cases in my area. However, it becomes clear that without tracing, the number of cases in my Puskesmas [community health center] decreased significantly. It makes me feel frustrated because I was unable to use my knowledge to help others in carrying out my duties. I also feel guilty about the increase in cases that occurred afterward, as I believe that the lack of contact tracing contributed to it. Currently, the government has reintroduced tracing measures, particularly after Lebaran [Eid Al-Fitr], such as implementing restrictions on community activities and installing insulating posts, causing the number of cases to start going up again. (Participant 4, General Practitioner, ICU)

Also drawing on the experience working at a community health center, another general practitioner suggested that the recent surge in COVID-19 cases following the Eid Al-Fitr was not surprising, as a comparable increase in cases had occurred in the past when the government reintroduced tracing efforts. As she saw it, the sudden increase in tracing efforts was directly responsible for the current surge in cases and the resulting strain on emergency hospitals, which contradicted the government’s earlier commendation for its COVID-19 management. She then maintained that the decrease in officially reported cases earlier during this period did not necessarily reflect a genuine reduction in infections, but could have partly stemmed from less aggressive tracing temporarily removing cases from the statistics.

Sharing a similar stance, a general practitioner in a leadership position within the hospital department expressed opposition to the Indonesian government’s directive to limit the number of people to be traced for COVID-19 due to concerns expressed by local leaders regarding the designation of their areas as red zones (indicating a significant concentration of cases). He proposed a different view, suggesting that a higher number of cases could lead to an increased understanding of the threat and facilitate the implementation of targeted interventions within the community. He further voiced discouragement and dissatisfaction with the stances of the elites, raising questions about whether their priorities solely revolved around reducing the number of cases rather than completely eradicating the infection.

As the conversation progressed, the frontline bureaucrat shared his frustration and feelings of powerlessness regarding the current policies enforced by the elites. Despite holding a high-ranking position, he acknowledged being a government worker and field implementer obligated to follow directives, meaning that even if the regulations required a decrease in the number of tracings, there was no choice but to comply. He further stated, “If the number of cases continues to rise, who will take responsibility? We, the workers, are unable to do so, we lack the power to do so”. These remarks are indeed indicative of how institutional autonomy and government directives can constrain individual agency and discretion, which in turn can lead to a sense of alienation among frontline workers who feel powerless to take ownership and responsibility for their work.

The systemic constraints revealed in these stories expose the complex institutional dynamics that can limit frontline workers’ discretionary practice—even with extensive experience and expertise, restrictive policies can promote feelings of powerlessness among implementers as bureaucrats, hindering their capacity to exercise agency to help vulnerable communities. While hierarchical configurations instill compliance, frontline perspectives depict contradictions and unintended repercussions unfolding on the ground, with which it points to disconnect between top-level decrees and the situational knowledge imperative for ethical, optimal care.

4.4 Building collegial relationships for emotional support

In high-stakes environments marked by austerity reminiscent of those negotiated by street-level bureaucrats tasked to interpret policy face-to-face with citizens, frontline healthcare workers discussed the deep impact of bonding together to cope with rationing necessary care. Seeking communal support to endure the ethical distress of denying treatment, healthcare workers described how peer connections can empower resilience by lessening isolation in hardship. The frontline bureaucrats further explained how camaraderie emerges organically in clinics stretched thin by scarcity, cultivating a sanctuary to process moral quandaries without judgment among those who understand the sacrifice firsthand. Through reinforcing human bonds eroded by rationing life and death decisions, grassroots alliances of providers on the ground work to maintain empathy and prioritize patients despite barriers. This alleviates the burnout from shouldering rationing policies alone, fostering greater dialog and solidarity within devoted circles united by deeper purpose even when resources seem unable to meet compassionate needs.

As one example, amidst road closures obstructing essential provisions for thousands during a pandemic wave, one nutritionist facing this crisis rallied colleagues to jointly problem-solve. Meeting in the breakroom, the nutritionist detailed the flooding damage hindering food deliveries as peers closely listened and offered ideas. Through open and compassionate dialog, this makeshift group cohered around devising an alternative supply route. Their rerouting of deliveries enabled needed provisions to reach patients and staff during dire scarcity, navigating impediments confronting solo responders. As this case shows, banding together in fellowship can spark fresh solutions when lone capacity hits walls—redeeming the sacrifices of rationing by fueling shared purpose against the odds. With empathy nurtured in spaces permitting vulnerability, isolation recedes for the capacity of camaraderie to lift the human spirit despite grim odds, renewing the kinship.

In another case, a leading pulmonologist in hospital administration faced intense stress when leveraged by a demanding patient seeking special treatment, mirroring the nutritionist’s emotional toll from high-stakes pressures. Yet despite his prominent authority, hierarchical power offered no immunity to hardship at the frontlines of rationing scarce resources. In resonating with the nutritionist’s journey to communal coping, a significant transformation followed as he embraced peer support networks. Rapidly emerging positivity signified collegial solidarity’s capacity to help navigate wrenching decisions with empathy intact across roles, redeeming isolation by forging spaces for vulnerability beyond status.

Expanded observational data sets revealed more instances highlighting collegial relationships and peer support groups as critical in providing emotional support and resilience among healthcare workers. As one account showed, one general practitioner was observed organizing informal gatherings with colleagues to create opportunities for sharing experiences and discussing the challenges inherent in their professional roles, in conducts that mutually offered needed emotional assistance. She detailed how the stress of extended work hours and emotionally draining patient cases could accumulate, leading to fatigue, cynicism, and diminished empathy. However, convening with peers who understand these daily hardships allowed for renewal through shared catharsis and camaraderie, allowing for a platform for expressing frustrations to colleagues who could validate their feelings through similar experiences.

Reiterating these insights, a nurse drew attention to the need of nurturing a dependable, compassionate support system within her social network, detailing how this network proved instrumental in imparting much-needed guidance and support during trying times. While maintaining a service-oriented mindset, the healthcare worker described her determination to persevere and deliver optimal care despite the considerable stresses and demanding responsibilities inherent in her role. From a place of deep-rooted connection, she relied on encouragement from reliable confidants, admitting the central role these relationships played in filling her with strength. In challenging situations requiring resilience, sharing her emotions with others frequently brought her comfort, symbolizing the meaning of these connections during difficult times.

As these stories have shown, compassionate colleague relationships act as a central basis of support for frontline workers facing tremendous pressures with limited resources. Their narratives reveal how human connection nurtures resilience in myriad impactful ways, such as sharing struggles, jointly innovating solutions, or leading with vulnerability. There are also mutual displays of understanding that offer comfort when confronting complicated situations with no clear solutions, enabling camaraderie to foster strength amidst times of hardship. Through depicting how shared humanity enables them to cope, adapt, and uphold care despite everything, these street-level bureaucrats reveal an empowering reality: no one need to stand alone, even in the most difficult roles, when united by bonds of collegiality. In fact, their experiences relate that when institutional support falls short, it is the informal network of care made up through a culture of compassion that sustains those serving on the frontlines.

4.5 Interpersonal dynamics of collegiality and collaboration

Within the boundaries of resource-constrained settings, governing street-level bureaucratic discretion often metamorphoses into a precarious undertaking involving weighing competing client rights while managing scarce resources. As frontline bureaucrats discussed experiences, enhancing individual and organizational collegiality emerged as crucial for ensuring expertise-based and efficient task distribution. Some bureaucrats particularly noted that effectively managing limited resources and client needs entailed more than just sound individual judgment and discretion—it also demanded collaborative decision-making. Undoubtedly, there was a shared understanding that the complex balancing of client needs and scarce means, paired with the emotional toll of ethically difficult choices, would require structural changes to promote more collective wisdom.

Reinforcing this sentiment, some healthcare workers, especially pulmonologists and general practitioners, expressed appreciation for a specific evening reporting activity and the connections it cultivated among colleagues. Their experiences revealed this structured reporting practice facilitated both medical case reviews and consultations with colleagues on patient concerns—such as soliciting internists’ perspectives on a kidney disorder or a cardiologist’s insights on a cardiac issue—while also engendering heightened team cohesion and shared comprehension of care delivery. Those engaged in these reflective exchanges highlighted the merits of this practice, including its impacts on relationship-building across disciplines, sharing experiential insights, and promoting thoughtful clinical decision-making throughout treatment courses.

During one of the hospital’s departmental meetings, a similar situation transpired where it was examined that doctors and nurses assembled as the head nurse led a discussion to review recently updated COVID-19 protocols. The participants were seen parsing details surrounding new ICU transfer procedures, deliberating potential ramifications for care coordination duties, and plotting upcoming training sessions to guarantee new protocol implementation across the department. This meeting clarified how group discussion of formal policies enabled coordinated, informed decisions on adapting procedures to maintain effective care delivery. That is, it embodied how such forums fortified interpersonal ties, fostered cross-disciplinary accord, and encouraged frontline-driven refinements to workflows through prudent discretion.

Even more notable was how fostering relationally strong interpersonal bonds among the bureaucrats not only raised their collective professionalism but also grew an embedded culture of peer accountability within the organizational fabric. As the collegial ties linking the healthcare workers were strengthened through their interactions, a heightened sense of duty toward their fellow colleagues also naturally emerged, compelling them toward discretionary actions characterized by transparency and accountability in solidarity with one another. Also pivotal in enabling more discretion and peer accountability to take root among the nursing community were the strong interpersonal ties cultivated by senior nurses in leadership roles, who acted as mentors and parental figures to fellow nurses. At its focal point, developing stronger bonds with colleagues appeared to motivate the healthcare workers to make decisions with greater care and thoughtfulness, prioritizing the best interests of their peers and the broader healthcare community.

These details interpret how practices of collaboration and collegial bonds can inspire discretionary decision-making despite constraints. It depicts how teamwork, founded upon open communication and knowledge sharing, catalyzes creative problem-solving even with limited resources available. What is more, interdisciplinary engagement enables consultative analysis and promotes collective wisdom to inform practical judgements. In providing insight into how cultures of solidarity and mutual care promote resilience and progress, these descriptions show that even in demanding public service roles, a shared sense of humanity remains the ethical foundation.

5 Discussion

As implementers of policy at the grassroots level, street-level bureaucrats have a frontline perspective for identifying where systems are falling short and opportunities for improvement. With their proximity to real-world complexities and their position within bureaucracies, they are strategically situated to advocate for constructive changes that are attentive to practical needs while navigating institutional pathways for reform. Still, the scope of many systemic gaps implies that impactful policy repair cannot rest solely on individual frontline efforts but rather compels collective action across administrative silos. To be sure, there remains the sense that such repair may hinge less on individual efforts and more on collective endeavors, relationships, and shared experiences among frontline bureaucrats addressing institutional deficiencies.

The lived experience of frontline healthcare workers negotiating the parameters of discretion paints the picture of the acumens of street-level bureaucrats contending with constraints (Lipsky, 2010; Tummers et al., 2015a, 2015b). Examining discretion amidst such administrative landscape exposes its pronounced strain as a source of distress and stress, particularly regarding resource allocation conundrums and trade-offs (see, for example, Alcadipani et al., 2020; Olvera & Avellaneda, 2023). As Gofen and Lotta (2021) spotlight, street-level bureaucrats meeting challenging situations head-on often create inventive solutions yet also expose their emotional burdens in the process. As they confront the emotionally-charged realities, bureaucrats piece together empathy, resilience, and emotional assets to take on new roles and institute guidelines for moderating both psychological tolls and discretion dilemmas (Macon, 2012). This emotional capital, ingrained in their roles, denotes not just inner resources to cope with the strains of discretion, but also informs how discretion gets exercised when confronting morally ambiguous situations (Tu et al., 2023).

The harsh reality of street-level bureaucrats especially surfaces through the massive trials of rationing scarce resources in times of crisis, where frontline workers wrestle with tough decisions bearing life-or-death consequences daily (Lavee, 2021). The emotionally draining moral topography provoked when making ethically complicated decisions brings the discretion exercised on the frontlines into focus (Zacka, 2017). This discretion vests frontline workers to adapt policies based on locally acquired, experiential knowledge, and “street smarts” developed from hands-on experience with contemporary situations, rather than relying solely on one-size-fits-all top-down directives (Møller, 2022). While shouldering this weighty responsibility can be emotionally and mentally taxing, sharing these distressing experiences can attend to stimulate advocacy for formal protocols and improved coordination by revealing areas where additional guidance and support are needed. Therefore, while individual discretion leads to responsiveness to pressing needs, shared and collective experiences are more likely to prove how policy improvements also emerge from on-site realities rather than centralized policies alone (Møller, 2021a, 2021b).

As discretion and emotional regulation are woven into the fabric of the street-level bureaucrat experience, meaningful connections emerge between the notion of institutional autonomy and the phenomenon of alienation among frontline workers (Tummers, 2012), surfacing implications for collaborative governance and collegiality (Møller, 2021a, 2021b). Alienation can propagate a sense of disconnection and powerlessness among street-level bureaucrats, hindering their engagement in policy implementation (Tummers, 2012; Tummers et al., 2015a, 2015b). Yet developing compassionate, supportive affiliations and bonds with colleagues can serve as an antidote to such estrangement, offering renewal through shared understanding and reinforcing resilience where institutional backing falls short. This points to how street-level bureaucrats constitute integral components of broader collaborative networks aligned to achieve common goals, rather than isolated actors. At the same time, it emphasizes how street-level bureaucracies stand to gain from developing not solely policy crafting capabilities, but also institutional culture and peer support networks which empower personnel, attend to their well-being, and catalyze collective growth.

The interconnections among frontline healthcare workers within street-level bureaucracy (Lipsky, 2010) can deeply shape their beliefs and meaning-making (Siciliano et al., 2017) while also serving as a conduit for exchanging insights grounded in practical wisdom (Maynard-Moody & Musheno, 2003). Yet these relationships transcend transactional value; they fuel a culture of collaboration, engendering an environment where practices are shared, knowledge flows freely, and collective learning flourishes (Møller, 2021a, 2021b; Nisar & Maroulis, 2017; Oberfield, 2014). It could be posited, therefore, that such meaningful collaboration and collegiality amplify the capacity of street-level bureaucrats to accelerate policy repair and optimize resource allocation for superior care provision. These communal practices promote collective accountability and responsibility, empowering street-level bureaucrats to render thoughtful decisions that improve resource allocation for enhanced care delivery. Building on this shared empowerment, policy repair manifests not merely from individual discretion, but through the consolidated efforts of bureaucrats capitalizing on collaborative channels to address common circumstances.

As depicted in Fig. 1, meaningful repair is shown to emanate not merely from the individual discretion of frontline workers, but more fundamentally through the iterative process of informal collaborations, communal knowledge sharing, and bonding through shared lived experiences on the frontlines. This points to policy repair as a phenomenon that emanates from the aggregated interconnections, joint sensemaking, compassion, and solidarity nurtured through peer interactions. Where policy repair evolves through collective improvisation between those on the frontlines and bureaucratic overseers, opportunities for impactful change emerge. Rather than discretion operating in a closed system of hierarchical permissions, significant policy improvements manifest when creativity flows openly across all administrative levels. While discretion permits deviation from formal policies, impactful repair also entails dynamic reworking and tailoring those policies through creative frontline initiatives to meet contextual needs and situational demands.

Fig. 1
figure 1

Key relationships in policy repair

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Indeed, by fostering a collaborative ethos across bureaucracies empowered by compassion and solidarity, the constraints of top-down thinking can be transcended, with means that allow for expansions beyond limiting dimensionalities that nurture optimal conditions through which the scope of effective repair dramatically expands. This indicates the potential for institutional policies that, instead of merely enforcing rigid guidelines, focuses on providing adaptable support and resources for customizable solutions tailored to contextual insights that generate a shared sense of responsibility and accountability for better public service outcomes. When navigating systemic inadequacies under constrained resources, new approaches organically emerge by virtue of the consolidated acumen of multiple bureaucrats working in coordination rather than isolation. More than mere individual discretion, policy repair maps this complex web of symbiotic relationships and influences that empower bureaucrats to collectively rework rigid policies into solutions attuned to contextual needs.

Here, the focus becomes the sustenance of bidirectional learning to accumulate practical wisdom at frontiers of implementation, transcending atomistic perspectives of knowledge overly isolated within silos. This wisdom, accrued communally through solidarity in service rather than individualistically in a vacuum, forms a collective reservoir, which when tapped unlocks creativity to ripple throughout bureaucracy by facilitating cooperation realigning priorities, instead of merely procedural protocols, to people. After all, it is within the intersection of compassionate cultures enabling collective care that these unheard yet impactful voices unite across bureaucracies to drive collaborative policy repair rather than just isolated dysfunctional actions.

6 Conclusion

Exploring the frontline bureaucratic experiences of healthcare workers in Indonesia’s COVID-19 emergency response, we clarify how informal relationships and collective action shape impactful bureaucratic policy repair in times of crises. Our findings suggest that impactful policy repair does not arise solely from individual discretion, but rather through the shared improvisation, collective learning, and symbiotic knowledge exchange between frontline bureaucrats negotiating common constraints. This questions compliance-centered paradigms and compels greater recognition of the collective improvisation underlying repair, bringing into focus the new pathways for strengthening global public sector responsiveness. We, as a result, contribute fresh perspectives to public administration scholarship on the challenges of governance and policy implementation by elucidating this frontline collaborative agency, representing a meaningful step toward untangling the nuances of bureaucratic practices.

Considering the foundational role of frontline collaboration, localized knowledge creation, and collective resilience in facilitating adaptable policy refinement, our research bears practical implications for strengthening bureaucratic efficiency and fortifying public sector governance, especially in times of crisis and uncertainty. This signals the need for investing in spaces that foster compassionate connections, peer learning, and collaborative innovation across bureaucratic levels. It also implies the relevance of designing mechanisms and allocating resources to promote solidarity among bureaucrats across hierarchies, in ways that amplify voices from the grassroots. In such contexts, it becomes obvious that policymakers should acknowledge that impactful solutions frequently arise organically from individuals grappling with complex realities, compelling a reevaluation of bureaucratic paradigms that have conventionally fixated on individual discretion or compliance. With this perspective, resilient governance encourages empowering collective wisdom and grassroots innovation to respond to emerging challenges, hinting at a roadmap to advance bureaucratic camaraderie and localized creativity while preparing for future uncertainties.

While we have opened meaningful clues, there are still significant knowledge gaps in our understanding of policy repair processes and the development of resilient governance capacities across various bureaucratic contexts, warranting further research. A promising direction for future research involves conducting additional comparative case studies across different cultural and institutional contexts, as they would not only contribute to assessing the applicability of frontline improvisation in facilitating impactful policy responses but also offer a broader perspective on the nuances of these processes. To complement these case studies, employing quantitative analysis to explore bureaucratic attitudes can disclose deeper understanding, as it enables a more ample grasp of disparities in discretion, compliance, and policy repair, along with their influence on governance in diverse cultural and institutional settings. Further to this, conducting longitudinal studies to track frontline healthcare workers’ relationships and improvisations over time within specific contexts can elucidate their evolution of practical wisdom, particularly in response to escalating resource constraints and ethical dilemmas during extended crisis situations. Equally important, in-depth ethnographic research grounded in embedded participation has the potential to offer granular insights into the grassroots emergence of creative solutions to moral distress through developing an intuitive comprehension of institutional dynamics as they arise.

Reflecting on our contributions to understanding the collective improvisation at the core of impactful bureaucratic policy repair, the landscape of transformative governance beckons further exploration. Within these uncharted territories, the emphasis is on fostering interconnected, collaborative frontline networks and nurturing resilient, human-centered systems with the capacity for adaptive responses to emerging crises. It is within these unexplored avenues that one can uncover the true potential of transformative governance, empowering frontline bureaucrats as catalysts for positive change and fostering a more responsive and resilient approach to governance in an ever-changing world.