Street-level implementers of population-based oral health policies: the case of water fluoridation supply in Brazil’s small towns

Background: Knowledge of conditions influencing the performance of street-level operators when implementing population-based policies could increase the understanding of local implementation dynamics. Objective: We analyzed how street-level operators claim to act to implement fluoridation policy in the water treatment units of small Brazilian municipalities and identified conditions shaping behavior against adherence to policy. Methods: A case study using narratives obtained through in-depth interviews with key informants in two pairs of municipalities with contrasting levels of implementation. Analysis identified themes in the data and in the street-level bureaucracy literature. Results: Institutional characteristics such as administrative fragility of local entities, low priority given locally to policy, poor physical structure of the water treatment plants, isolated working relations, low effectiveness of monitoring devices, and local actors’ uncertainties about the policy favored the expansion of the discretionary power of street-level operators configuring important barriers for water fluoridation. Conclusion: These data highlight the complexity of policy implementation and inform policymakers about the importance of inter-federal and inter-sectoral coordination when implementing population-based health policies in small towns.