Coping with Denialism: How Street-Level Bureaucrats Adapted and Responded to COVID-19 in Tanzania

Abstract

Context: This article aims to highlight challenges and adaptations made by local health officials in Tanzania in working to contain and manage COVID-19.

Methods: The study takes an inductive approach, drawing on the reported experiences of 40 officials at different levels of government across four purposefully selected regions in July 2020. Interviewees were asked about the guidance they received to contain COVID-19, the source of that guidance, their challenges and successes in implementing the guidance, and if and how they adapted the guidance to their particular setting.

Findings: The interviews depict considerable challenges, including a lack of supplies and resources for implementing infection control, surveillance, and mitigation practices and dealing with fear and stigma. At the same time, they also provide evidence of innovation and adaptation among street-level bureaucrats. Respondents overwhelmingly praised the president, whose limited national response is seen as helpful for reducing fear and stigma.

Conclusions: Other scholars have highlighted the potential dangers of street-level discretion if local officials “make policy” in ways that contradict their agencies' stated goals. In contrast, our study suggests benefits of autonomy at the street level—particularly in contexts where the central state was relatively weak and/or acting against the public interest.

The COVID-19 pandemic is unprecedented in its global reach; nearly every country in the world has faced major threats to population health, disruptions to daily life, and economic recession. The consequences of the pandemic are far from uniform, however, and arguably reflect differences in how governments have responded. To date, scholars have focused on the responses of different countries' executives, highlighting the importance of regime type, federalism, electoral institutions, interpersonal and institutional trust, and bureaucratic corruption, among other factors, to explain variation in government responses (Bosancianu et al. 2020; Frey, Chen, and Presidente 2020; Greer, King, and Massard da Fonseca 2021; Kavanagh and Singh 2020). However, a focus on national-level responses may limit our understanding of policy implementation, which is often conducted by local officials.

An important group of local officials, particularly in low-income countries, are street-level bureaucrats (SLBs)—the “public service workers who interact directly with citizens in the course of their jobs” (Lipsky 1980: 3). Critically, SLBs are understood not simply to be “policytakers” (Gofen 2014: 473); rather, they frequently make policy themselves. Per Michael Lipsky's (1980: xii) influential conceptualization, “the decisions of street-level bureaucrats, the routines they establish, and the devices they invent to cope with uncertainties and work pressures effectively become the public policies they carry out” (original italics). However, to date, little attention has been paid to the responses of street-level bureaucrats with respect to COVID-19.

Studying local responses is especially important in low-income settings, which are frequently characterized by considerable distance between the policies made in capital cities and actual implementation on the ground (Brinkerhoff 1996). As a result, “policymaking” by SLBs is even more likely to influence outcomes. In particular, scholars have highlighted critical implementation gaps in the health sector, reflecting insufficient infrastructure, equipment, and supplies; a lack of trained personnel; and generally poorly functioning health systems (Kruk et al. 2018; Ridde 2008, 2009; Sanders and Haines 2006). To date, however, studies looking at the street-level implementation of health policies in low- and middle-income settings are few and far between.¹ For example, a recent meta-analysis of street-level bureaucracy theory in health policy analysis in African countries could identify only four relevant articles (Erasmus 2014). The nascent literature on street-level responses to COVID-19 has focused primarily on middle- and high-income settings (Alcadipani et al. 2020; Gofen and Lotta 2021).

We help fill this gap by documenting the experiences of local officials in Tanzania working to contain the spread of COVID-19. Our interviews span a range of levels of government across four regions, which vary in socioeconomic status, geography, and regime support. Interviewees were asked about the guidance they received to contain COVID-19, the source of that guidance, their challenges and successes in implementing the guidance, and if and how they are adapting the guidance to their particular setting.

Notably, our interviews all took place in July 2020, after the president of Tanzania had declared the country free of COVID-19 and the government had dialed back or reversed containment and monitoring efforts such as school closures and widespread testing. Figure 1 shows how Tanzania compares to the rest of Africa in terms of the average stringency of government responses across the continent during July 2020 using data from the Oxford COVID-19 Government Response tracker (Hale et al. 2020).² We see that Tanzania had considerably fewer restrictions in place to contain the spread of disease than most other countries in Africa.

While some interviewees expressed frustration at Tanzania's limited response, many praised it—in particular lauding statements by the president, which were seen as an effective means of reducing fear and stigma and avoiding further negative consequences. As one of our interviewees put it, this allowed local health officials to see COVID-19 as a “normal” disease and thus draw on repertoires and experience developed in responding to prior outbreaks such as Ebola and HIV/AIDS. Perhaps because of their prior experience in managing other diseases—and the hands-off approach of the federal government toward COVID-19—our interviewees described developing independent policies and activities that were likely helpful in mitigating spread of COVID-19.

Other scholars have highlighted the potential dangers of street-level discretion if local officials “make policy” in ways that contradict their agencies' stated goals (Lipsky 1980). For example, Ermin Erasmus's (2014) meta-study of SLBs in the health sector in Africa presents evidence of divergence from official policy objectives and intentions, leading to mostly negative outcomes. In contrast, our study suggests benefits of autonomy at the street level—particularly in contexts in which the central state is relatively weak and/or acting against the public interest.

At the same time, our study highlights the limits of autonomy in authoritarian settings. Tanzania is understood to be a “hegemonic party regime,” since the same political party has been in power since independence in 1961, despite the legalization of multiparty politics in 1992. However, opposition politicians have made some inroads at the local level, where COVID-19 containment and other public health policies are implemented. We therefore compare responses in ruling-party strongholds versus localities under opposition control.

This article proceeds as follows. The next section describes the Tanzanian context, including the trajectory of the COVID-19 outbreak and government response, as well as the decentralized nature of health care. We then describe our data and methods. Findings are presented in the following three sections—we first present evidence of challenges in adhering to international best practices and central government guidelines to contain COVID-19. We then describe how local officials adapted to these challenges. Finally, we examine the nature of responses in the context of hegemonic party rule. We conclude by discussing our study's implications for the broader conversation on health politics and policy in relation to COVID-19.

Background and Context

Tanzania's gross national income (GNI) per capita (Atlas method) was $1,080 (current US$) in 2019, ranking 32nd among the 54 African countries (World Bank 2021). Current health expenditure per capita is $36.82 (current US$), which is lower than that of neighboring countries Kenya, Uganda, and Rwanda (UNICEF 2020). In 2020 the Tanzanian health sector allocation accounted for 6.7% of the total national budget and 1.5% of gross domestic product—significantly lower than the Abuja Declaration target allocation for health of at least 15% of national budgets (UNICEF 2020). Life expectancy at birth is 66 years, and 320 children younger than 5 years of age die every day as a result of preventable causes (UNICEF 2020).

As noted above, political scientists tend to classify the country as a hegemonic party regime. While the lack of a strong opposition party suggests democratic deficits, the country has been recognized as a beacon of stability in a sometimes volatile region, with executives transferring power peacefully and respecting the results of elections that have generally been deemed free and fair by international observers (Freedom House 2020).

Decentralized Governance under Hegemonic Party Rule

The tenor of Tanzanian politics changed in late 2015, when President John Pombe Magufuli took office with reformist zeal; his forceful actions to stamp out government corruption and waste earned him the nickname “The Bulldozer” (BBC News 2019). However, his critics at home and abroad quickly began to express concerns that he was applying the same force to trample human rights. The last five years have seen limits placed on freedom of expression and freedom of assembly as well as reduced space for opposition parties to operate (Paget 2017). Such actions have affected Tanzania's standing in the international community, leading some donors to withdraw funds (Reuters 2018). However, Magufuli remained quite popular at home. In the latest (2017) round of the nationally representative Afrobarometer survey, more than half of all respondents indicated that they strongly approve of the president's performance, and another 34% stated their approval (Afrobarometer 2017). Magufuli won a landslide reelection victory in late October 2020, though he was able to serve only a few months of his second term. Magufuli died in March 2021 because of “heart complications,” which many believe were exacerbated by COVID-19. He was succeeded by his vice president, Samia Suluhu Hassan, who is seen by close observers as unlikely to reverse the country's authoritarian turn (Cheeseman, Matfess, and Amani 2021).

Although the ruling Chama Cha Mapinduzi (CCM) party has maintained a firm grip on the executive branch of government, opposition parties have gained power at the local government level since the first multiparty elections in 1995. Specifically, they have taken control of more districts—the second-tier administrative unit in Tanzania—which are governed by councils composed of members elected from each district's 20–40 wards.³ While opposition parties won control of just 3 (out of 134) districts in 2005 and 8 districts in 2010, they managed to take 31 districts in 2015 (McLellan 2020).⁴

Districts are also service delivery hubs. Following health sector reforms in the 1990s, primary health services were decentralized to districts, with the regional secretariats designated to supervise them and provide technical assistance, including policy interpretation (Mpambije 2016; URT 1998).⁵ In 2019 local authorities were responsible for delivering 45% of the total health budget (UNICEF 2020). However, they face challenges with budget execution, given disbursement delays, bureaucratic processes that impede full expenditure or fund reallocation, and supply interruptions (UNICEF 2020). At the national level, the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) is responsible for the overall direction of the health sector through development of policy and guidelines, strategic planning, resource mobilization, and monitoring and evaluation as well as managing the secondary- and tertiary-level hospitals. The President's Office - Regional Administration and Local Government (PO-RALG) shares regulatory and accountability functions with MoHCDGEC, particularly for primary health services (Kigume and Maluka 2019).

In general, district councils rely heavily on the central government for funding, and centrally appointed personnel serve alongside elected officials with overlapping mandates in some cases (Hulst, Mafuru, and Mpenzi 2015; Mollel 2010). As a result, local service delivery often suffers, particularly among opposition-led councils. Indeed, recent studies suggest that opposition-led districts have been disadvantaged when it comes to receiving central government grants (Weinstein 2011) and that opposition voters are sometimes punished in the allocation of public goods and services (Carlitz 2017).

Tanzania's Experience with COVID-19

Tanzania confirmed its first case of COVID-19 on March 16, 2020. On March 17 the Tanzanian government banned all forms of public gatherings, including sports activities, and closed all schools (Citizen Reporter2020). On March 23 the government mandated that international travelers undergo 14 days of quarantine in specific hotels (Taylor 2020). For a brief period, Tanzania limited travel from other countries, but such restrictions had been lifted by mid-May (Hale et al. 2020).

In the months after the first case was reported, the president and MoHCDGEC advised Tanzanians to use traditional remedies to treat COVID-19 symptoms, including ingestion of local herbs and steam inhalation (Kamazima and Kakoko 2020). The government also advised prayer as a remedy—houses of worship remained open, and, on April 16, 2020, the president asked citizens to spend the following three days “to pray to God who can do all to help us evade this disease” (25).

Compared with other African countries, Tanzania provided data on COVID-19 cases less frequently (Reuters 2020) and would soon halt all reporting. Tanzania released its final COVID-19 surveillance report on May 8, 2020, reporting 509 cases and 21 deaths. Addressing parishioners on May 17, Magufuli reported a drastic decrease in COVID-19 cases and called for another three days of national prayer to give thanks for this “miracle” (Kamazima and Kakoko 2020). On May 22 President Magufuli declared Tanzania COVID-19-free. Up until his death, Magufuli had not backed down from this stance, and, as vaccines became available on the continent, his government explicitly refused them (Makoni 2021).

The obfuscation characterizing COVID-19 monitoring in Tanzania is in keeping with broader efforts to suppress or distort information that paints the ruling party in a bad light (Carlitz and McLellan 2020). While such tendencies intensified under Magufuli's rule, Tanzania performed poorly on international rankings of government transparency and freedom of expression prior to his taking office.⁶ Moreover, Magufuli did not act unilaterally in downplaying the seriousness of the pandemic. For instance, in February 2021, the permanent secretary of the Ministry of Health Mabula Mchembe took to the ministry's official Twitter account to proclaim that “it is not true that hospitals are full of corona patients,” blaming “some people with bad intentions on social media” (author's translation; Wizara ya Afya Tanzania 2021). The following month, the country's former chief medical officer downplayed concerns of self-censorship among local scientists (Buguzi 2021). In April 2021 Tanzania's new president gave her first official public address, announcing plans to create an expert coronavirus task force to advise her government on the pandemic (Ombuor and Bearak 2021). However, as of this writing, further details have not been released.

During the period we studied (July 2020), the country's (albeit limited) response to COVID-19 reflected the nature of decentralized governance described above. Guidelines and other standard operating procedures were developed by MoHCDGEC in collaboration with PO-RALG. The guidelines also took into consideration statements of the president and prime minister on the direction of the country in response to COVID-19. Officials at the regional levels were to help district officials interpret the COVID-19 containment guidelines and appropriately translate them into responsive actions.

Methods

Our study was conducted in July 2020 in four purposefully selected regions:⁷ Dodoma, Dar es Salaam, Morogoro, and Arusha. Table 1 shows how these regions vary with regard to population, health status, public health, and health care infrastructure. We selected localities that captured a range of socioeconomic characteristics, demographics, and patterns of mobility to draw more general conclusions.

We purposively selected three types of local officials to interview: 1) regional level officers, such as members of Regional Health and Regional Referral Hospital Management Teams who were involved in the implementation of response to COVID 19; 2) district-level officers, including social welfare and medical officers; and 3) local officials at ward, village (rural), and mtaa (“street,” i.e., urban equivalent of village) levels who were involved in the implementation of response to COVID-19. We interviewed a total of 40 officials. Our sample included 7 regional-level leaders, 17 district-level leaders, and 16 ward- or village-level officers. Eighteen respondents were from CCM-led districts and 13 were from opposition districts. All interviewees are government employees, which may have limited the degree to which they felt free to express their true feelings about the president or other high-level officials.⁸ We take this perspective into account when discussing our findings below.

We were interested in understanding how local officials responded to the COVID-19 crisis, the challenges they faced, and to what extent the central government influenced their response. Thus we asked each respondent about the guidelines they received to respond to COVID-19, what activities they implemented, challenges to implementation, adaptations they made, and lessons learned. Our protocol was approved by the President's Office - Regional Administration and Local Government, following a request through Mzumbe University.

Interviews were conducted in person by three Tanzanian researchers, including one of the authors (Mollel) and two trained research assistants who have a minimum of a bachelor's degree and have worked with Henry Mollel in previous capacities. Interviewers maintained a six-foot distance and wore a mask. Verbal informed consent was obtained without recording participants' names. Interviews were conducted in Swahili and were translated into English for analysis. Interviews lasted between 20 and 30 minutes.

Data Analysis

We analyzed the data using a thematic analysis approach (Miles and Huberman 1994). We generated codes deductively from our interview guide, based on prior research about decentralization in Tanzania. Codes were grouped into six overarching categories (example codes for each category are provided in parentheses): (1) perceptions of central guidance (positive; negative); (2) perceptions of ability to take up COVID-19 health guidelines from central authorities (perception that it was a challenge; guidelines should be adapted to local context); (3) social protection policies (responsive to social protection policies issued by central authorities); (4) challenges (lack of supplies and resources; not taking COVID seriously); (5) adaptations (adaptations they made to the central guidelines; reduce community resistance); and (6) stigma (COVID-19 stigma; response to stigma). During our data analysis, we inductively added two codes that emerged as themes: decentralization and working with partners such as nongovernmental organizations (NGOs).

A research assistant coded all the translated interviews using Dedoose version 6.2.2. The principal investigator reviewed the coded transcripts for consistency in applying the codes. During our analysis, we compared and contrasted quotes based on respondents' region, affiliation with the ruling party, and the government level at which they operated.

Challenges Experienced in Pandemic Response

To put their adaptations in context, we describe the guidelines issued by the MoHCDGEC and the challenges enacting those guidelines as reported by our respondents. We organize the challenges into five domains, according to the World Health Organization's (WHO 2018) recommended measures for managing epidemics: (1) surveillance (e.g., testing); (2) containment (e.g., contact tracing, quarantine); (3) protecting the health workforce (e.g., providing personal protective equipment (PPE) to frontline responders); (4) mitigation (e.g., social distancing, mask wearing, handwashing); and (5) communication (e.g., public health messages, trust in messages). We also explore how the level of government influenced respondents' experiences of challenges adhering to central guidelines.

Surveillance

In March 2020 the MoHCDGEC issued a series of standard operating procedures (SOPs) that included surveillance for COVID-19. The guidelines stated that all patients with acute respiratory illness should be screened for COVID-19 and that health care facilities, especially emergency centers and outpatient clinics, should identify an appropriate area and person to do the screening (MoHCDGEC 2020). Health facilities were advised to use a national screening checklist, which included symptoms, travel history, and contact with probable or confirmed cases. Travelers, especially those from countries with COVID-19 outbreaks, were to be quarantined for 14 days and tested. However, it is important to note that on May 3, 2020, President Magufuli suspended the head of the national laboratory, just before stopping all COVID-19 surveillance (Reuters 2020).

Regional and district officers were primarily responsible for coordinating testing but reported insufficient laboratory capacity. They complained that the national laboratory experienced substantial delays in processing coronavirus tests. District health officers said that the laboratory took one to two weeks to deliver results. One respondent mentioned that sometimes the laboratory results seemed inaccurate in that “a patient tested negative while he/she had critical signs.” Respondents across levels also reported difficulties testing and quarantining travelers because of a lack of resources for maintaining contact with travelers.

Containment

When the case definition for COVID-19 was met, the SOP required that the patient should immediately be isolated in a separate, well-ventilated room and given a mask (MoHCDGEC 2020). Staff entering the room were required to keep at least one meter's distance from the patient and to wear a fit-checked PT2 respiratory (or N95) mask, disposable gown, gloves, and eye protection. Visitors were to have limited contact with the isolated patient. Moreover, psychosocial support was to be provided to isolated patients and their families, including reducing social stigma, assessing patients for psychological conditions, networking with other service providers to ensure psychosocial support, and developing a plan of mental health treatment if necessary (MoHCDGEC 2020).

The majority of respondents mentioned challenges adhering to the containment guidelines. Respondents across levels mentioned insufficient facilities for isolation. Some respondents cited a lack of self-contained rooms in isolation centers, forcing quarantined patients to use public toilets. Providing sufficient food to patients in quarantine was also cited as a challenge.

District health officers, compared to respondents at the other two levels, had more responsibilities for containment, including isolation and contact tracing. They described the shortage of properly trained personnel and the lack of proper isolation centers. They mentioned insufficient transportation funds and vehicles to conduct contract tracing and visit isolated patients. They lamented that they could not provide adequate psychosocial support to potentially exposed individuals.

Ward officers enlisted by district officers to help with contact tracing and keeping patients in isolation also reported challenges. One ward executive officer explained that “some patients did not disclose all the important information [necessary to contact trace] to health workers, and sometimes they even escaped the isolation centers if there was not sufficient security.” Some communities did not want isolation centers in their areas, fearing they would bring COVID-19 to them.

Fear and stigma presented further difficulties. One district health official expressed frustration about people “hiding information about patients and . . . locking them in due to fear of stigmatization and isolation by community members.” They explained that hiding patients made it difficult to trace their whereabouts and their contacts.

Health Worker Protections

In terms of protecting health care workers, the MoHCDGEC guidelines required wearing PPE to check on isolated patients. Based on guidance from the WHO, the SOP included instructions on how to properly don PPE and decontaminate isolation rooms. Moreover, the SOP described how to provide a safe and dignified burial, including using PPE to transport the deceased person to a body bag and burial site (MoHCDGEC 2020).

More than three quarters of all respondents mentioned being hindered by a lack of supplies, particularly PPE, for the protection of health workers. As one district official noted, “Most of the issues specified in the guidance were not practical on the ground during implementation. For example, dealing with confirmed positive cases required wearing of full [PPE], which were not available to all health workers treating COVID-19 patients.” Some respondents mentioned that community members stigmatized health care workers for their work with coronavirus patients, assuming that health care workers were the ones responsible for bringing COVID-19 into communities.

Mitigation

Mitigation measures in the MoHCDGEC guidance included frequent hand hygiene with soap and water or alcohol, social distancing, and mask wearing for sick persons. Within communities, individuals were instructed to “maintain distance of at least 1 meter from any individual with respiratory symptoms (e.g., coughing, sneezing); perform hand hygiene frequently; and cover nose and mouth with flexed elbow or paper tissue when coughing or sneezing” (MoHCDGEC 2020: 68). Physical distancing was mentioned in the context of health care, isolation, and burials. In contrast, the Africa Centre for Disease Control and Prevention recommended that all communities engage in physical distancing of one meter between people as soon as community transmission was evident (Africa CDC 2020).

Respondents experienced several challenges implementing mitigation measures. Enforcing physical distancing was difficult for respondents, in part because of cultural expectations around hugging and shaking hands among other ingrained customs. Respondents also reported that some COVID-19 patients perceived social distancing as stigmatization.

A number of respondents mentioned citizens in their jurisdictions being unable to afford or unwilling to wear masks. District health officers, in particular, described rural areas that had inadequate clean water for handwashing. Ward-level officers mentioned the lack of mitigation resources for the general public, including masks, sanitizer, and handwashing stations.

Communication

The MoHCDGEC-issued guidelines recommended that frontline health care workers and community health workers be trained in risk communication. They indicated that health care workers should communicate with communities to identify potential cases of COVID-19, reduce social stigma and discrimination, and disseminate health-related messages (MoHCDGEC 2020).

Respondents uniformly agreed that a major challenge in the beginning of the pandemic was the public not taking COVID-19 seriously. A regional health officer explained: “So, initially when the disease entered the country there were conflicting views on how the disease is spread and it reached a point where citizens believed that people are simply speaking about the disease and it can't reach them. But, after seeing direct impacts from the patients and death, people started taking precautions.” A district health officer echoed this sentiment, saying that there was initially a “low community response [to the pandemic] because they thought the disease only attacks certain people, mostly white skinned and rich people.” A ward executive officer explained that some people still did not believe in the threat of the novel coronavirus because they did not observe COVID-19 deaths in their communities. Another ward officer indicated that citizens should be encouraged to take COVID-19 seriously because “it is reported every day from other nations and through mass media that corona caused a lot of deaths in their countries.” Ward-level officers also reported lacking funds to hold community meetings for educating the public.

Respondents agreed that most citizens had, since the beginning of the pandemic, changed their attitudes to acknowledge the severity of the coronavirus. However, they felt that, even among these citizens, they had recently started to relax their use of preventive measures.

On the other hand, fear of COVID-19 and related psychological distress were mentioned in a number of interviews, particularly as more cases began to be confirmed throughout the country. In some cases, this reflected citizens being triggered by memories of recent disease outbreaks. As one district official noted, “All burials that occurred before May 2020 were handled like Ebola related cases and it created fears to members of the general public.”

In summary, respondents mentioned significant challenges along each of the five domains of epidemic management. The primary challenges were insufficient laboratory capacity for testing and quarantining people with suspected COVID-19 (surveillance); insufficient isolation facilities and trained personnel for contact tracing (containment); fear and stigma of COVID-19–affected individuals (containment, protecting health workforce, communication); lack of supplies and resources to purchase PPE (protecting health workforce); cultural and social barriers to physical distancing (mitigation); inadequate resources for handwashing and mask wearing (mitigation); and not taking COVID-19 seriously (communication). Several of these challenges were the result of an absence of central government resources or support for COVID-19 management (i.e., inadequate testing, isolation facilities, PPE, etc.). In the next section, we describe how our respondents reported adapting to these challenges.

Adaptations to Challenges in Pandemic Response

Across levels of government, respondents stated that to respond to these many critical challenges, they needed more authority to adapt the central guidelines to their local situations. For instance, a ward official in Dodoma suggested his office should be “given [a] mandate to develop our own guidelines in collaboration with health workers since we know our environment and [people better].” This official went on to say that “it wasn't proper for the ministry to develop generic guidelines.” A regional health officer would have liked to have been consulted on the guidelines and given an opportunity to adjust the guidelines “based on local realities such as level of population and number of reported cases.”

Nearly all respondents stated that decentralization of authority should be accompanied by more resources for epidemic management. A district medical officer (DMO) recommended that districts receive funds to purchase supplies such as PPE, since waiting for regional distribution delayed providing health care to patients. When asked about the lessons they could learn, a regional health medical officer said, “Decentralization of regional teams to lower levels should go hand in hand with capacity building and sufficient supply of equipment.”

Nevertheless, without the authority or endorsement from the central administration and necessary resources, officials universally described taking matters into their own hands. Many mentioned how they adapted to the challenges, using the resources available to them, to promote public health. We describe their adaptations below along the five domains of managing epidemics.

Surveillance

Respondents reported that they decentralized surveillance by involving ward/village leaders and community health workers in the surveillance process. Regional officers trained community health workers to help with COVID-19 surveillance. Several district officers reported increasing their capacity by mobilizing existing community health workers and training them to conduct surveillance. They did this without a specific mandate to do so in the central SOP (MoHCDGEC 2020). One DMO reported their innovative approach to surveillance that reached across government levels: “We created a WhatsApp [group] with the DMO, surveillance office, ward and village leaders for timely reporting and response. For example, when there is a new visitor in a village or a suspected case, it is shared on the WhatsApp group and the respective team acts in a timely manner.”

Ward officers also helped with surveillance. They “followed up at the street level to observe any suspected corona cases . . . in collaboration with health workers.” They also reported to ward executive officers any guests/travelers who were in their areas, as this village executive officer explains: “We gave information about corona suspects within our street. We reported about guests in our streets from outside the country or nearby regions to ward executive officers . . . the security officials.”

Containment

At the regional level, adaptations included the formation of emergency response teams trained to respond to COVID-19. Ongoing training was provided to health care workers who were managing COVID-19 patients. Respondents across levels linked COVID-19 patients and their relatives with community-based organizations and networks to access food and water during isolation.

Several district officers reported that, given the lack of resources from the central government, they mobilized resources from stakeholders in their communities, such as the Red Cross, to provide isolation space and food for quarantined patients. They also enlisted stakeholders and community health workers to conduct proper burials. One district health secretary described their efforts to mobilize resources for containment: “We looked for camp/hostels to accommodate Corona suspects and engaged in resources mobilization from stakeholders like procuring PPE. For example, X Hospital helped us with two ambulances and XX Hospital provided a space for patients' isolation.”

Health Worker Protections

Respondents described how they procured their own PPE and, in some cases, made their own hand sanitizer or handwashing stations. At the district level, respondents reported using local resources at their disposal, since they received inadequate supplies from the central government. For example, one community social welfare officer reported: “The general guidelines for health service providers required them to be fully protected with PPE when providing medical services to a person confirmed to have coronavirus. However, because of lack of PPE we decided to use masks and maintain social distance as a means of protection in order to save people's lives.”

Mitigation

Several district-level officers reported local manufacturing of hand sanitizers and face masks. Ward-level officers were the ones primarily charged with educating their communities and ensuring compliance with mask wearing and handwashing. Enforcement strategies they used included restricting people from entering clubs and bars. Despite no mandate to do so in the MoHCDGEC-issued SOP (2020), several ward officers levied fines on citizens who did not comply with restrictions and handwashing before entering a business and imposed restrictions to prevent congregating. As one ward executive officer described: “We started [mitigation measures] by hearing from media and through guidelines issued by the World Health Organization. Through all these I made some local arrangements before even the disease was reported in our country by restricting [people from gathering] in local brew clubs, bars and markets.” However, this respondent reported that he was later told by the central authorities to remove these restrictions on gathering in public places. This example highlights the tension between the central government's denialism and the local government initiatives.

Communication

Respondents unanimously agreed that their public education activities were their most effective adaptations. Although the MoHCDGEC-issued SOP mentioned community education as important for epidemic response, it did not detail specific strategies (MoHCDGEC 2020). Our respondents felt that collaboration with community leaders was critical for delivering effective public health education. Respondents described transmitting COVID-19 prevention information via leaflets and posters, mobile phones, local radio, public announcements (loudspeakers), and songs. Interviewees also stressed the importance of reaching places such as motorcycle depots, markets, and places of worship.

Interviewees felt that these efforts engendered a positive response from citizens, changed community attitudes about risk, enhanced adherence to mask wearing and social distancing, and lowered their fear for seeking COVID-19 treatment. They reported that the use of loudspeakers was very effective, as citizens socializing in the streets were easily reached. Respondents also felt that collaboration with volunteers and organizations, such as international NGOs and Tanzanian businesses, was key to the success of their public education efforts. Moreover, the use of fines, where applied, enhanced citizen cooperation.

Respondents described promoting public awareness of COVID-19, drawing on their experience managing other diseases. As a village officer stated: “We have sufficient experience in managing big diseases like HIV, cholera . . . so why should we be afraid of corona? This is a normal disease just like fever that we live with every day.” Many health officials also saw their role as first and foremost to lower psychological distress. Lowering psychological distress was mentioned in the MoHCDGEC-issued SOP (MoHCDGEC 2020). The SOP mentions that the psychosocial epidemic response team should reduce stigma and discrimination toward individuals with COVID-19 and should provide psychosocial support to those affected. As such, one hospital response officer saw their role as “reminding . . . the general public that corona is not like Ebola and can be managed with minimum wear of protections by health workers.” Ward officers engaged district officials to educate the public and lower stigma of individuals and COVID-19 isolation and treatment units.

Moreover, regional officers used mass media and local political/religious leaders to educate the public. Ward officers reported collaborating with health officials to provide public health education on the risks of the novel coronavirus and how citizens could protect themselves. One ward officer said they worked together with religious leaders so that the public would understand the dangers of large groups attending burials, a traditional practice. Several ward officers used donated PA systems with microphones to educate the public, and some used the radio. Public education was often done in collaboration with district officials who provided expert-written health communication leaflets on coronavirus prevention.

In summary, our respondents reported several ways they adapted to challenges by pursuing strategies they knew could control the spread of COVID-19. These strategies included involving local leaders and community health workers in the surveillance process (surveillance), forming emergency response teams and mobilizing community resources to provide isolation resources for quarantined patients (containment), procuring their own PPE (protecting health workers), manufacturing hand sanitizers and face masks for community members, enforcing mask wearing and handwashing (mitigation), restricting people from entering congregate spaces (mitigation), and collaborating with community and religious leaders to spread prevention information and lower stigma and fear of COVID-19 (communication). Some of our respondents' strategies were absent from the central government's guidelines (e.g., enlisting community health workers in surveillance), and other strategies were directly opposed by the government (e.g., restrictions on entering bars). Thus, in the next section, we explore to what extent local support for the ruling party affected both the challenges and adaptations they reported.

Challenges and Adaptations in the Context of Hegemonic Party Rule

As noted above, while the ruling CCM party has dominated national politics since independence, opposition parties have begun to make inroads at the local level. We therefore investigated whether and how the challenges faced by local health officials and corresponding adaptations varied between opposition- and CCM-led councils, and more generally how local officials responded to high-level denialism. Overall, we do not find that political party control at the local level affected the nature of challenges reported. Furthermore, praise for President Magufuli among our interviewees was widespread and did not seem to vary as a function of local political leadership.

Limited Impact of Local Political Control

While officials in some opposition districts expressed criticism of the government's limited response to COVID-19, we did not find much evidence to suggest that local political control played a significant role in determining local responses. For instance, the DMO in one opposition-led district felt that the government needed to do a better job of communicating the severity of the disease, so as to make their job easier: “[I would like to] request the government to continue insisting members of general public to take precautionary measures to manage corona, despite reopening of schools and borders. That will help health workers who are giving education about how to manage corona.”

The lack of autonomy in procurement was noted by the DMO in another opposition-led district. This official went on to express some frustration with the central government's downplaying of the seriousness of COVID-19, citing “a need of avoiding political interference on health issues.” The official went on to say, “The government move to reassure its people that the disease does not exist in Tanzania . . . has made people to live carelessly without taking any precautions and this could lead to new infections and serious impacts.”

However, such frustration was registered in some CCM-led districts as well, with one district health officer lamenting “high official leaders' statements about reported positive cases of animals and fruits and discouraging the use of masks.” This statement likely refers in part to a speech Magufuli made in early May, in which he suggested the country's caseload was overstated as a result of “compromised” test kits resulting in false positives. The president described samples that were taken from farm animals and a papaya and labeled with human names. He claimed the nonhuman samples tested positive, presenting this as evidence that labs were falsifying positive test results. Opposition politicians have suggested this statement was part of a broader campaign to minimize the scope of the pandemic in advance of the election (Peralta 2020).

Praise and Acquiescence: Toeing the Party Line

On the whole, criticism of the official response was limited among our respondents. Rather, our interviewees lauded the president's role in reducing fear and stigma. For instance, the health secretary in one CCM-led district noted, “we learned from our top leaders like President John Pombe Magufuli that fear can bring greater impacts than the disease itself.” A street-level officer in another CCM district echoed this and went on to say that treating COVID-19 as a “normal” disease meant “we avoided economic threats like hunger and stagnation of other developmental activities.”

Such statements were not limited to ruling-party strongholds, however. As a street-level official in an opposition-held district noted, “Top government official leaders' statements like the president help to lower fears and challenges in managing corona.” A ward-level official in another opposition district stated, “Our president decided not to close borders with other countries, allowing all economic activities to take place and reopening of universities and schools. This helped citizens to see corona disease as normal as other diseases.” Officials at the regional level also lauded Magufuli's role in lowering fear among the general public. Such widespread praise for Magufuli may reflect the fact that the majority of our interviewees were appointed rather than elected officials and rely on the central government for their salaries.

Beyond praising the president, local officials in both ruling-party strongholds and opposition-led districts expressed support for traditional remedies—in line with Magufuli's advice on disease management. As one ward officer in Morogoro explained: “We can be independent when dealing with pandemics like corona by using traditional ways, prayers and alternative treatments such as kujifukiza (steam inhalation), the use of lemons, and drinking tangawizi (ginger).”

In Arusha, the other more rural region, one ward officer articulated support as follows: “We should also strive to have innovative solutions for treatment and vaccines for COVID-19 using our local remedies instead of depending on everything from other countries.” This echoed Magufuli's characterization of Western public officials and donors as “imperialist” in calling for Tanzania to follow the WHO guidelines and international best practices (Patterson and Balogun 2021). Nevertheless, one district medical officer in Arusha disagreed with the use of natural remedies, stating, “The use of local remedies like kujifukiza should be an alternative, not a priority, treatment in response to corona disease. [We should] only use medical treatments from health institutions.”

In the more urban regions of Tanzania, there was less uniform support for traditional remedies as treatment for COVID-19. In Dodoma, one ward officer who was against their use stated, “Traditional remedies without proper guidelines might threaten human life because in our ward there was one death caused by traditional remedies where the person's skin and internal organs burnt.” In Dar es Salaam, one ward officer and two district officers commented that traditional remedies should be included as part of the package of tools to “help manage” the novel coronavirus, but they were less emphatic about their use as a sole treatment for COVID-19.

More generally, these responses illustrate how local officials adapt pragmatically in the context of authoritarian governance—and, particularly, a context of high-level denialism. Our interviewees did not appear to see their actions as going against the president. Rather, they tended to interpret his statements as helping reduce fear and allowing life to go back to normal.

Discussion: “Making Policy” at the Street Level

Our interviews provide a number of important insights about the role of street-level bureaucrats and other local officials in responding to COVID-19. When resources and detailed guidance were not forthcoming, many local health officials took it upon themselves to develop appropriate solutions, working to engage other local bureaucrats as well as influential community leaders. The seriousness with which local health officials addressed COVID-19 stands in contrast to the relatively limited response of the central government. The actions of local officials align with Peter Hupe and Michael Hill's (2007: 282) maxim that “street-level bureaucrats see themselves as professionals . . . [and] discretion is filled by rules professionals impose upon themselves.” In our context, these “rules” reflected knowledge and experience developed in managing prior disease outbreaks such as Ebola and HIV/AIDS. Such experience is not unique to Tanzania—over the past decade, 41 African countries have gone through at least one epidemic, including Ebola in West Africa and the Democratic Republic of Congo, and recurrent Lassa fever outbreaks in Nigeria (Otu et al. 2020). Further research is needed to determine the extent to which experiences with controlling these other diseases informed local responses in other African countries.

Our study also highlights the limitations of relying solely on external accounts of policy implementation. Outside observers have framed Tanzania's inaction on COVID-19 as “distressing” (Makoni 2021), and in February 2021 the WHO director-general publicly called for Tanzania to disclose and share COVID-19 surveillance data and to engage in containment and mitigation measures, including vaccination (WHO 2021). However, our respondents reported mostly favorable interpretations of high-level denialism, which they interpreted as helping reduce fear and stigma and shielding Tanzania from the negative consequences of lockdowns seen in neighboring countries. Paradoxically, the government's downplaying of the pandemic may have enhanced the scope of local adaptation to some degree, if local officials were not being monitored in terms of their ability to implement a particular set of policies.

We must also note that these adaptations (and reports thereof) were undertaken in a highly constrained decision space—a function of Tanzanian local authorities' reliance on the central government for resources and guidance (Kigume and Maluka 2019). Local autonomy has been further constrained since Magufuli took office after campaigning on the slogan “Hapa kazi tu!” (“strictly business” or “work only”). Under the guise of reducing government waste and inefficiency, his first weeks in office were characterized by a series of high-level firings. Stringent control mechanisms were subsequently introduced in various agencies to promote greater accountability to the central government (Kapinga and Gores 2020). Public disciplinary actions have engendered a culture of fear throughout the civil service (Andreoni 2017; Kessy 2020), arguably limiting the ability of local officials to act according to their own professional norms and craft locally appropriate solutions.

Challenges similar to those described above feature in a number of hegemonic party regimes, where opposition-led local governments can present a threat to the stability of the ruling party (Jakli and Stenberg 2020; McLellan 2020). Further research is needed to understand how street-level bureaucrats navigate these circumstances in times of crisis and otherwise. Specifically, future investigations should investigate what determines how much leeway SLBs have to use their discretion—whether in service of the public good (e.g., implementing public health policy when the executive leader is flouting best practices) or for ill (failing to implement effective measures). Future research could explore factors such as the extent of ruling-party dominance and whether local jurisdictions raise their own revenues as opposed to depending on transfers from the central government as well as the degree of aid dependence and overall state capacity to implement government directives. A better understanding of local institutional arrangements and autonomy in nondemocratic contexts is critical for understanding what drives health outcomes in much of the world, given that nearly 70% of the world's population currently lives under autocracy (Alizada et al. 2021).

Finally, we note that the picture presented in this article is necessarily limited. Our interviewees' interpretations cannot be taken to represent Tanzanian public opinion or that of local health officials more generally. In addition, our study does not include the perspectives of citizens or data on their health outcomes. Local officials reported that awareness-raising campaigns were effective, but we cannot confirm this without data from community members. Moreover, data limitations—and in particular the fact that the Tanzanian government stopped reporting on COVID-19 cases and deaths—make it difficult to gauge the overall efficacy of local adaptations. Future research is needed to fill these gaps and will require innovation in contexts where the government is not forthcoming with information.

Conclusion

To date, the literature on COVID-19 containment and mitigation (and on government responses to disease outbreaks more generally) has focused primarily on explaining variation across rather than within countries. However, given decentralization reforms worldwide, much of the work of disease management is carried out at the local government level. As such, focusing on the central government level may limit our understanding of whether and how policies are implemented. Whereas prior studies have blamed policy-implementation gaps on street-level discretion, we show how local officials “make policy” that can help fill a void of central government leadership.

In highlighting the experiences of local bureaucrats, we provide an important perspective that is often missing from the literature on health politics and policy, particularly in studies of low-income settings. Documenting the particular challenges local officials face, and adaptations they make in light of those challenges, contributes to a small but growing literature on the role of local bureaucrats in management and policy implementation in the global South. Our study suggests that scaling up the capacity of and resources for street-level bureaucrats to manage a public health emergency, especially in countries with limited central government response, may be highly strategic.

Acknowledgments

We gratefully acknowledge Lekumok Kironyi and Andrea Jameson Kidulile for their vital role in interviewing Tanzanian officials; Katie Leis for her assistance with coding and analyzing the data; and participants at the 2020 African Studies Association Annual Meeting for their feedback on an earlier draft. We also acknowledge Scott L. Greer, Elizabeth J. King, Elize Massard da Fonseca, and André Peralta-Santos for inviting us to contribute to their book, Coronavirus Politics, on which this article builds.

Notes

References