Table 4.

Street-level bureaucrat influences over UPFS implementation

	Behaviour	Rationale underpinning behaviour
Hospital A	Clerks rarely informed patients about the possibility of exemptions	Do not delay patient processing by activating difficult exemption processes
	Clerks occasionally broke the rules to exempt patients without proof of unemployment	Charging obviously unemployed patients from whom you will not recover money artificially inflates the outstanding amount shown in the financial system
	Clerks were sometimes rude to patients (as described by patients)	Long queues and frustration at patients not bringing the correct information that would make clerks’ job easier
	Medical staff turned back patients who sought care without first reporting to the clerks	Supporting policy implementation
Hospital B	Clerks sometimes used their discretion to classify patients without supporting documents, e.g. exempting patients clearly old enough to be pensioners or classifying patients familiar to the clerks	Applying some common knowledge and sense to the process
	Clerks sometimes classified patients declaring an income into a higher category than warranted by the declaration	Encouraging patients to bring supporting documents and ensuring they don’t cheat the system

Source: observations and in-depth interviews in each hospital; researcher judgements based on experience in each hospital