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The unequal distribution of administrative burden: A framework and an illustrative case study for understanding variation in people's experience of burdens



Recent studies have demonstrated that administrative burdens often reinforce existing social inequalities. However, less attention has been paid to explaining which factors cause variation in people's experience of administrative burden. This article builds upon an emerging body of literature on citizen factors to make two contributions. First, a theoretical framework is constructed to provide a coherent overview of existing economic (cost–benefit analyses and poverty costs) and behavioural explanations (human capital and decision‐making bias) for the unequal distribution of administrative burden. Furthermore, policy feedback is suggested as a possible intermediating variable to understand variations in people's capacity and willingness to engage in state‐citizen interactions and the bigger bite of administrative burden in low‐trust contexts. Second, a mixed method case study of non‐participation in Argentina's conditional cash transfer program is used to illustrate the relevance of the identified explanations prior to state‐citizen interaction.
The unequal distribution of administrative burden:
A framework and an illustrative case study for
understanding variation in people's experience
of burdens
Mariana Chudnovsky | Rik Peeters
División de Administración Pública, Centro de
Investigación y Docencia Económicas (CIDE),
Mexico City, Mexico
Rik Peeters, División de Administración
Pública, Centro de Investigación y Docencia
Económicas (CIDE), Carretera México-Toluca
3655, Colonia Lomas de Santa Fe, CP 01210,
Alcaldía Cuajimalpa, Mexico City, Mexico.
Recent studies have demonstrated that administrative bur-
dens often reinforce existing social inequalities. However,
less attention has been paid to explaining which factors
cause variation in people's experience of administrative bur-
den. This article builds upon an emerging body of literature
on citizen factors to make two contributions. First, a theo-
retical framework is constructed to provide a coherent
overview of existing economic (costbenefit analyses and
poverty costs) and behavioural explanations (human capital
and decision-making bias) for the unequal distribution of
administrative burden. Furthermore, policy feedback is
suggested as a possible intermediating variable to under-
stand variations in people's capacity and willingness to
engage in state-citizen interactions and the bigger bite of
administrative burden in low-trust contexts. Second, a
mixed method case study of non-participation in
Argentina's conditional cash transfer program is used to
illustrate the relevance of the identified explanations prior
to state-citizen interaction.
administrative burden, decision-making, human capital, policy
feedback, state-citizen interactions
Received: 25 February 2020 Revised: 6 June 2020 Accepted: 2 July 2020
DOI: 10.1111/spol.12639
Soc Policy Adm. 2020;116. © 2020 John Wiley & Sons Ltd 1
The literature on administrative burdens has, in recent years, identified how bureaucratic procedures and practices
can complicate the access to services and benefits for citizens (e.g. Burden et al., 2012; Heinrich, 2018; Moynihan,
Herd, & Harvey, 2015). The approach breaks away from rule- and organisational performance-focused red tape
studies (Heinrich, 2015) to address the way bureaucratic barriers affect citizenship, equity and democracy
(Moynihan & Herd, 2010, p.654; Nisar, 2018). Administrative burdens are both consequential and distributive
(Herd & Moynihan, 2018). An individual's experience of policy implementation as onerous(Burden, Canon, May-
er, & Moynihan, 2012, p. 741) can lead to learning, compliance and psychological costs (Moynihan et al., 2015) or
even to administrative exclusion(Brodkin & Majmundar, 2010) of access to rights, services and benefitswith
sometimes long-term consequences for social and economic participation (Heinrich, 2018). Furthermore, the experi-
ence of administrative burdens and their consequences are not equally distributed over the population (Heinrich &
Brill, 2015). Vulnerable target groups tend to have lower levels of take-up of social programs (Bhargava &
Manoli, 2015), show higher levels of exclusion and drop-out (Brodkin & Majmundar, 2010) and have more negative
state-citizen interactions (Barnes & Henly, 2018). Thereby, administrative burdens often reinforce existing
Most of the research has focused on demonstrating and conceptualising the various costs that citizens might
face in interactions with the state, while less attention has been paid to explaining burdens (Peeters, 2019) and the
variation in people's experience of burdens (Christensen, Aarøe, Baekgaard, Herd, & Moynihan, 2020). The aim of
this article is to contribute to our understanding of these issues. Here, an important distinction can be made between
state factorsand citizen factors(cf. Christensen et al., 2020; Heinrich, 2018, p. 217). State factors include adminis-
trative requirements, state capacity, policy design, frontline worker behaviour and other formal or informal elements
of policy implementation thateither deliberately or notraise barriers for people's access to rights and services
(Herd & Moynihan, 2018; Peeters, 2019). However, these factors cannot fully explain why why some people find
the same objective sets of rules or procedures more onerous or emotionally taxing than others(Christensen
et al., 2020, p. 132).
This article builds upon the emerging literature on citizen factors, which are closely related to the concept of
administrative burden and takes up the call to [investigate] empirically how reactions to burdens vary(Christensen
et al., 2020, p. 6). More specifically, two contributions are made: (a) refining the theoretical framework on explana-
tions for the unequal distribution of administrative burdens and (b) presenting empirical evidence to demonstrate the
relevance of this framework for assessing non-participation in social programs in Latin America. The analytical frame-
work is illustrated through a case study of Argentina's conditional cash transfer program. This, in itself, is a useful
contribution as well to a body of research that builds predominantly on data from developed countries.
The analytical framework builds upon an economic and a behavioural approach in the literature on variation in
people's experiences of administrative burden. Attitudes towards government and government programs are
suggested here as an additional element to incorporate well-known mechanisms of policy feedback(Moynihan &
Soss, 2014) and account for the bigger bite of administrative burden in low-trust and developmental contexts
(Heinrich & Brill, 2015). The relevance of this framework is demonstrated through an analysis of non-participation in
Argentina's Universal Child Benefit (AUHfor Asignación Universal por Hijo). The impact of citizen factors is measured
here as the non-take-up of a benefit targeted at the most vulnerable population. Data from a government survey
and 32 interviews with public officials and eligible non-participants show that a combination of socio-economic vul-
nerability, scarcity of time and human capital, and negative attitudes towards the state explain why vulnerable people
might not reach out to a social program specifically targeted at them. Lastly, the concluding section of this article dis-
cusses the importance of taking citizen factors into account for policy design and better understanding the citizen
experience of bureaucratic encounters (Lotta & Marques, 2019; Raaphorst & Van de Walle, 2018).
2.1 |Citizen factors and administrative burden
As a starting point, two distinctions are identified to construct a framework for analysing variation in people's experi-
ence of administrative burdens. First, following Christensen et al. (2020) and Heinrich (2015, 2018; cf. Kahn, Katz, &
Gutek, 1976), a distinction can be made between governmental or state factors on the one hand and extra-
governmental or citizen factors on the other hand. State factors are elements and practices embedded in the policy
implementation (cf. Peeters, 2019), whereas citizen factors refer to characteristics of public service clients. Even
though both types of factors heavily influence each othersuch as low state outreach in areas where the economi-
cally most vulnerable people livethe focus in this article is primarily on citizen factors. Second, within the category
of citizen factors, Christensen and others (2020) distinguish between economic and behavioural approaches to
explain variation in the experience of administrative burdens. The model they present is used here and expanded to
provide a more comprehensive theoretical framework, whichmost importantlyadds the factor of attitudes
towards the state and the intermediary variable of policy feedback to better understand the relation between state
and citizen factors (Figure 1).
2.2 |Economic explanations
Starting with economic approaches to variation in the experience of administrative burden, citizens can make cost
benefit analyses to assess whether a benefit or service is worth going through bureaucratic ordeal mechanisms,has-
sleor sludge(Alatas et al., 2013; Sunstein, 2019; Thaler, 2018). The idea is that citizens seek to maximise utility
FIGURE 1 Explanations for the unequal distribution of administrative burden (based on Christensen et al., 2020,
p. 128) [Colour figure can be viewed at]
and, therefore, make rational trade-offs between opportunity costs and benefits (Tejerina, Ibarrarán, Benedetti, &
Buchbinder, 2014). A person's willingness to go through paperwork, waiting times or compliance criteria is relative to
the benefit this will generate. This implies that the bigger the relative benefit for a person, the more ordeal mecha-
nisms he or she is willing to endure. Following this assumption, the deliberate design of administrative burden can
function as a targeting or screening mechanism in social benefits (Nichols & Zeckhauser, 1982; Zeckhauser, 2019).
By introducing high compliance costs, citizens less needy of a financial benefit will select themselves out. This tech-
nique is often applied in mean-tested social programs (Das, Do, & Özler, 2005; Jalan & Ravallion, 2003). The idea is
to reduce errors of inclusion by making compliance costs high enough to ensure that people will only apply for a ben-
efit or stay in a program if they truly need it. Non-take-up and drop-out should, then, be a result of self-targeting by
the non-poor. The evidence of ordeal mechanisms as an efficient targeting mechanism is mixed (Christensen
et al., 2020, p. 129). There is evidence that wealthier beneficiaries indeed have higher drop-out rates (
Devoto, & Winters, 2008), however, the same goes for the poorest beneficiaries (González-Flores, Heracleous, &
Winters, 2012). Often, the most vulnerable target groups fail to overcome administrative burdens (Brodkin &
Majmundar, 2010; Deshpande & Li, 2019).
This indicates that additional factors are at play to explain variation in overcoming administrative burden beyond
mere rational costbenefit analyses. In economic research, and especially in studies on variation in take-up of social
programs (Currie, 2006), this has been explained by looking at the relative costs of living in poverty. It is, in many ways,
expensive to be poor. Compliance costs tend to be bigger for people in precarious conditions than for people who
can fall back on financial resources as a result of, for instance, transportation costs (Tejerina et al., 2014), the relative
value of a benefit (Currie, 2006) and the financial consequences of poor judgement (Banerjee & Mullainathan, 2010;
Carvalho, Meier, & Wang, 2016). Moreover, living in precarious or marginalised conditions increases the number of
daily time-consuming challenges and practical constraints people face, including long commutes, varying and infre-
quent income, organising bigger households, dealing with unreliable basic services (such as water and electricity) and
managing tight budgets for daily expenses (Banerjee & Mullainathan, 2010; Evans & Schamberg, 2009;
Mullainathan & Shafir, 2013).
2.3 |Behavioural explanations
In both studies on take-up and public administration literature, behavioural approaches are increasingly used to
understand human decision-making (Battaglio, Belardinelli, Bellé, & Cantarelli, 2019). They allow for the analysis of
public administration from the micro-level perspective of individual behaviour and attitudes, and attempt to grasp
the underlying psychology of individuals and groups (Grimmelikhuijsen, Jilke, Olsen, & Tummers, 2017). In this article,
first, we identify human capital as a key variable that influences people's ability to overcome administrative burdens.
Within this variable, a further distinction can be made between variance in people's cognitive resources and in
bureaucratic competence. Concerning the former, an individual's executive functioningis crucial for engaging in
purposeful, goal-directed, and future-oriented behavior(Suchy, 2009, p. 109). Christensen and others (2020) iden-
tify age, educational levels and mental and physical health as important factors for variance in cognitive resources.
Furthermore, living in poverty is associated with lower cognitive resources, which can elevate the stress of applying
for benefits (Baumberg, 2016) as well as increase learning costs to get information about government programs
(Chetty & Saez, 2013), understand procedural complexities (Hastings & Weinstein, 2008; Super, 2004), and deal with
language barriers or other application requirements (Watson, 2014).
A second element of human capital is people's bureaucratic competenceor knowledge of how bureaucracy and
public service provision works (e.g. Bisgaard, 2020; Danet & Hartman, 1972; Smith, 1988). Gordon (1975) distin-
guishes between knowledge about the functioning of bureaucracy on the one hand and practical and communicative
skills on the other hand. Almond and Verba (1963) distinguish between cognitive and evaluative dispositionsthe
former including both objective knowledge about bureaucracy and people's perception of their ability to influence it
(Danet & Hartman, 1972). These various aspects of bureaucratic competence affect people's ability to interact effec-
tively with the state.
A second type of behavioural explanations concerns how a person's resource scarcity influences his or her
daily decision-making (Madrian & Shea, 2001; Mani, Mullainathan, Shafir, & Zhao, 2013). The emerging literature
on poverty and decision-making shows that a person's resource scarcity creates a bias in daily decision-making
(Bhargava & Manoli, 2015). Everyday purchasing decisions are cognitively demanding, leaving people drained of
the cognitive resources needed for other tasks or decisions (Banerjee & Duflo, 2011, pp. 6870) and more vulner-
able to lapses of self-control (Spears, 2011). Moreover, scarcitytheexperienceofhaving less than you feel you
need(Mullainathan & Shafir, 2013, p. 4) creates a mindset focused on immediate needs rather than future
goals. Scarcity tends to perpetuate itself, because the psychology of poverty encourages people to make short-
term decisions that do not structurally improve their financial situation (Mullainathan & Shafir, 2013, p. 14). While
everyone is to a certain extent bounded in their rationality, this mechanism explains a common bias in people's
problem-solving capacities, emotional control, social regulation and ability to resist short-sighted temptations
(Beer, 2012; Diamond, 2013). Crucially for the study of administrative burden, this also affects people's willing-
ness to apply for social programs as well as their capacity to overcome associated compliance, learning and psy-
chological costs.
As a further contribution to the existing theory, it is argued here that people's decision-making regarding the
state and social programs can also present a bias. Attitudes and expectations regarding the state have not yet
been explicitly used to explain the unequal distribution of administrative burdendespite research that indicates
the negative effect of waiting times (Mettler, 2002), intrusive bureaucratic procedures (Soss, 1999), arbitrary
enforcement (Heinrich, 2018) and other negative bureaucratic experiences (Moynihan & Soss, 2014) on people's
willingness to engage with the state (Bruch, Marx-Freere, & Soss, 2010) and on their orientations toward the
institutions and policies of government(Mettler & Soss, 2004, p. 62). As studies on public service performance
have also shown, the experienced quality of public services feeds back into assessments about the trustworthi-
ness of government in general (Berg & Johansson, 2019; Van Ryzin, 2011). People's expectations of government
performance are informed by previous interactions with the state (Kumlin, 2004), by prior beliefs regarding the
state (Baekgaard & Serritzlew, 2016) or by secondary information from experts, media and fellow citizens (Van
Ryzin, 2007).
2.4 |Policy feedback
In terms of our theoretical model, policy feedbackis introduced as a possible intermediating variable between the
outcomes of policies, services and programs on the one hand and various behavioural explanations on the other
hand. More specifically, it is assumed that previous experiences with bureaucracy or knowledge of how bureaucracy
works impactalbeit not fully explainpeople's attitudes regarding the state as well as their bureaucratic compe-
tence. Even though it can be argued that policy feedback mechanisms impact an even broader range of citizen fac-
tors, including people's wellbeing, social mobility and economic status, for the purposes of this article its specific
relevance for possible future state-citizen interactions is highlighted.
Since vulnerable people tend to have more negative bureaucratic experiences (Barnes & Henly, 2018; Soss,
Fording, & Schram, 2011), policy feedback can also help understand why they often experience higher administrative
burdens and why the bite of administrative burdens tends to be bigger in developing countries (Heinrich &
Brill, 2015). Policy feedback mechanisms make citizens(Mettler & Soss, 2004), shape citizen participation
(Campbell, 2012), and convey messages about someone's place in society and the way government works
(Wichowsky & Moynihan, 2008). Specifically for developing countries, negative feedback might also be produced by,
for instance, becoming a victim of corruption by street-level bureaucrats (Justesen & Bjørnskov, 2014) or by uncer-
tainty about whether you will get access to a public service (Auyero, 2011). Furthermore, there is often already a
structural lack of trust in government's ability to provide equal access to rights and services (Peeters et al., 2018;
Rothstein, 2013). For instance, in Argentinawhere the case study presented here is set64.3% of the population
has little or no trust in the state and 67.5% has little or no trust in national government (Latinobarómetro, 2015). This
is likely to decrease people's willingness to apply for government programs and engage in state-citizen interactions.
People in developing countries are more likely to develop or sustain psychological and motivational barriers for
engaging with the state because of their expectation that they will not be treated fairly, will face high administrative
burdens, or will not be able to get access to what they are entitled to (Peeters et al., 2018).
3.1 |Case setting
The relevance of the aforementioned analytical framework is illustrated through a case study of non-take-up in
Argentina's conditional cash transfer program (CCT): the AUH. A common problem in CCTs is the dependence on
means-tested targeting to identify their target population (Robles Aguilar, 2014). Confronted with limited state
capacity, governments often rely on aggregated municipal rather than precise individual income data and place bur-
dens on citizens to prove eligibility. This generates errors of inclusion (leakage of resources towards non-target pop-
ulation) and exclusion (target population that does not receive the program) (World Bank, 2015). CCTs in Latin
America reach, on average, only 42.6% of all poor individuals in households with childrenvarying from 85.9% in
Uruguay to 11.0% in Paraguay (Robles, Rubio, & Stampini, 2015, p. 8). Considering these issues, the AUH adopted a
more universal coverage and aims to be a social protection program for all poor families with children under 18 years
old with an informal job (Cruces & Gasparini, 2008). As a consequence, non-participation in the AUH is relatively low
for Latin American standards, but remains considerable: 18% of all eligible people does not participate. Moreover,
the most vulnerable target groups show the highest levels of non-participation (20% of the extreme poor are not
covered). Interestingly, 57% of non-participation takes place because beneficiaries do not apply for the program
(Chudnovsky & Peeters, 2020).
The AUH program provides an excellent case for illustrating the impact of factors that affect eligible citizens'
tendency to reach out for services and benefits from the state(Christensen et al., 2020, p. 130). The case allows for
a focus on exactly the factors at play prior to any citizen-state interaction. First, focalization is not a major concern
and errors of exclusion are, therefore, not a convincing explanation for non-take-up by vulnerable groups. Second,
the financial benefit per child is relatively generous. In 2015, the benefit per child was 17.7% of the minimum wage,
with a maximum of five children. This, combined with the relatively low enrollment burdens, makes it unlikely that
potential beneficiaries' rational costbenefit analyses can explain non-participation. Third, the most vulnerable target
groupthat would financially benefit the most from access to the programis overrepresented among the total pop-
ulation of eligible non-participants (Chudnovsky & Peeters, 2020). Fourth, the large number of non-participation
(57%) prior to any state-citizen interaction (Chudnovsky & Peeters, 2020) allows for an analysis of the factors that
cause non-take-up for a relatively easily obtainable benefit. And lastly, the setting in a low-trust country makes it
possible to include attitudes towards the statein the analysis.
The AUH covers around 3.6 million children, representing 28% of the population under the age of 18 in
Argentina. Eligibility for the AUH is automatically determined by government records and verified monthly by the
National Social Security Administration (ANSESfor Administración Nacional de la Seguridad Social). People qualify as
eligible if they are not formally employed (with an income less than the minimum wage) and have children younger
than 18 years old that reside in Argentina. Foreigners are eligible if they have at least 3 years of legal residence. The
government records are not free of registration errors, but these mostly consist of errors of inclusion: people with a
high income (for instance, through a pension) that are erroneously included as eligible. The system depends on the
self-declared income of citizens, which also implies a certain level of inaccuracy. There are, however, a few
administrative requirements for enrollment. These may be important, since research suggests that even apparently
low burdens can already have a significant impact on take-up (Judge-Golden, Smith, Mor, & Borrero, 2019).
Eligible citizens must provide the following information:
Children and parents must have an official identity document (DNIfor Documento Nacional de Identidad), which
is provided by the National Registry of Persons (RENAPER). Studies indicate that 1.6% of all people (or 168,000)
in urban areas between 0 and 17 do not have a DNI, with a child in the first socio-economic quartile having a 2.5
times higher probability of not having a DNI than their peers in the highest socioeconomic quartile (Tuñón,
Fourcade, González, & Reggini, 2012).
Parents must provide family informationthat is, legal evidence of marriage as well as the child's birth certificate
and the variations required for divorced parents, foreigners or beneficiaries who are not related by blood to the
Parents must have access to the banking or post-office system to receive payments. ANSES automatically opens
a bank account or delivers to the beneficiary's closest post office.
3.2 |Method and data
Data was obtained from the Argentinian government's 2015 National Survey of Social Protection and Social Security
(ENAPROSS II, 2015) and from 32 interviews conducted between February and May 2019 with public officials and
citizens eligible for the AUH. The survey sample consists of more than 33,000 people and 10,000 households in five
of the country's provinces and the metropolitan area of Buenos Aires. It represents a total of 5,424,405 households
and 16,505,250 people in urban centres larger than 5,000 inhabitantsthereby not covering beneficiaries in rural
areas. The survey data regarding coverage and reasons for non-participation was obtained through a self-reported
questionnaire applied to a member of a preselected household identified as eligible by ANSES. The households are
part of a probabilistic sample based on data regarding vulnerability in Argentina's 2010 population census. The full
survey design can be accessed online at the Ministry of Labor´s website.
The interviews were semi-structured and held with 24 eligible citizens who have never applied for the AUH, five
ANSES officials, one RENAPER official, the director of Argentina's most important social organisation on citizen's
documentation (IADEPP), and the undersecretary of the Ministry of Labor in charge of conducting the ENAPROSS
survey. The eight public officials were selected because of their experience with and knowledge of the implementa-
tion of the AUH program. All these interviews were recorded and transcribed (see Data S1 for more details on inter-
viewees and interview protocol). Citizens were selected in two phases: (a) identification of several of the most
vulnerable settlements in greater Buenos Aires and (b) identification of eligible non-participants of the AUH through
information from local informants. The interviews with citizens were held in the following precarious settlements in
the province and city of Buenos Aires: Nuevo Amancay, Tigre, Pilar, La Cava and Villa 31. A snowball method was
used to select interviewees up to the point of theoretical saturation (Corbin & Strauss, 2008). In informal and familiar
settings, people were asked why they have never applied for the AUH. For privacy and security reasons, no audio
recordings could be made of these interviews. Instead, extensive notes were made during the interviews.
Data was analysed to illustrate the relevance of the aforementioned framework for explaining burdens in peo-
ple's tendency to reach out for social programs specifically targeted at them. The objective was not to analyse the
specific weight of each factor to explain non-participation in the AUH. Moreover, the analysis includes only the
group of eligible citizens that never applied for the AUH to allow a more precise focus on factors at play prior to any
state-citizen interaction. Therefore, the total survey sample of eligible non-participants for the AUH (1,058) was bro-
ken down in 232 respondents reported as drop-outs and 818 respondents that reported having never received the
benefit the latter further broken down in 207 respondents that unsuccessfully tried to enrol in the program
(enrollment failure) and 587 respondents (or 57% of the entire sample, representing over 200,000 people) that
never tried to enrol in the first place (no application). This last number is corrected for people that self-reported as
erroneously targeted as eligible (because of a higher income, for instance) or as no longer eligible (because of recent
formal employment, for instance). This leaves a total of 425 respondents for which statistics on beneficiary and
household characteristics as well as closed and open answers for the reasons for non-participation were analysed.
The following citizen factors are identified in the survey and interview data:
Indications for poverty costs: (a) survey statistics on the characteristics of eligible non-participants (income level
and levels of marginalisation to indicate economic vulnerability), (b) the closed and open answer section of the
survey where respondents indicate practical constraints (absence of one parent) and (c) interview answers on
practical constraints caused by vulnerability (living on the street, teen mothers, foreigners without documentation,
Indications for human capital: (a) survey statistics on the characteristics of eligible non-participants (educational
level), (b) closed and open answers from the survey that indicate learning costs,
and (c) interview answers that
refer to lower social and human capital.
Indications for decision-making bias
: (a) the closed and open answer section (attitudes and prejudices towards
the AUH and the state in general), (b) the closed and open answer section where respondents indicate scarcity-
influenced decisions, and (c) interview answers regarding a decision-making bias towards daily survival and low
expectations regarding the state.
4.1 |Data
A logit regression analysis of the ENAPROSS survey was used to identify relevant beneficiary characteristics to
explain non-take-up by eligible citizens for the AUH (dependent variable). Independent variables were selected based
on (a) survey questions that apply to the objective target group characteristics of the entire population between
0 and 17 years or to all households and (b) survey questions that indicate differing levels of vulnerability among the
entire target group. Following this strategy, three dimensions are constructed:
1. Income: three income levels are identified to measure the impact of economic vulnerability (Robles et al., 2015):
Extreme poverty: household with a Total Family Income (TFI)
smaller than the Basic Food Basket (BFB).
Moderate poverty: household with a TFI larger than the BFB but smaller than the Basic Total Basket (BTB).
Precarious income: household with a TFI between one and two BTB.
2. Scarcity: scarcity levels are measured through variables that reflect the indicators of the Argentinian index of
unsatisfied basic needs (NBI) (access to housing, sanitary conditions, access to education and economic capacity),
as developed by the Economic Commission for Latin America and the Caribbean (Feres & Mancero, 2001).
3. Marginalisation: a lack of maintenance of the public space (garbage removal, dirt, etc.) and public services (water,
electricity, etc.) is identified as an indicator of marginalised living conditions.
For each dimension, a separate logit analysis was performed. A more detailed overview of the variables used for
the logit regression in each dimension is provided in Data S1. Table 1 results indicate the marginal contribution of
each of the variables to a discrete change from 0 to 1.
The ENAPROSS survey contains a section on the reasons people give themselves for not participating in the
AUH. Table 2 presents the results of the closed answer categories.
The category othergives respondents the opportunity to provide an open answer. The total number of
235 open answers was analysed and coded as follows (see Data S1 for more information on the coding;
Table 3).
TABLE 1 Results of logit regression
Dimension Independent variables
Non-take-up (dependent variable)
Average marginal effect (%) SE
Dimension 1: Income
Extreme poverty 18*** 0.06
Moderate poverty 11** 0.05
Precarious income 5 0.06
Obs: 791 Pseudo R
: 0.0275 Specificity: 100% Correctly classified: 70.92%
Dimension 2: Scarcity
Access to housing Overcrowded 1 attribute 6* 0.04
Overcrowded 2 attribute 12*** 0.04
Poor quality housing 3 0.04
Sanitary conditions Latrine 2 0.10
Access to education School assistance 10*** 0.04
Age 2*** 0.00
Economic capacity Size household 4*** 0.01
Low education 15*** 0.05
Medium education 17*** 0.05
Obs: 1,044 Pseudo R
: 0.0467 Specificity: 96.95% Correctly classified: 71.84%
Dimension 3: Marginalisation
Maintenance of public domain 12* 0.05
Obs: 767 Pseudo R
: 0.0000 Specificity: 100% Correctly classified: 70.40%
Note: The number of observations is not the same in all dimensions because the questions from which the variables have
different rates of non-response.
***p< .01.
**p< .05.
*p< .1.
Source: Own estimation based on ENAPROSS II.
TABLE 2 Reasons for non-participation prior to state-citizen interaction
Covered by
another social
eligible Disinterest
Does not
answer Other Total
Population (coefficient
of variation)
% of sample (coefficient
of variation)
Note: Two columns combine answer categories from the ENAPROSS survey. Column 2 (not eligible) includes the answers
beneficiary's income exceeds cap,beneficiary is a freelancer,beneficiary or child has a disability and is covered elsewhere,
beneficiary deducts support from income taxand beneficiary is a pensioner. Column 3 (disinterest) includes the answers
did not do the paperworkand disinterest.
Source: Own elaboration based on ENAPROSS II.
In the interviews, people mentioned reasons for not having the AUH benefit. In Table 4, a summary of the rea-
sons mentioned is presented in terms of poverty costs,human capital, and decision-making bias.
Several interviewees mentioned multiple reasons for not having the AUH, as summarised in Table 5.
4.2 |Analysis
In the following, the data is analysed in terms of the relationship between citizen factors and the experience of
administrative burden. Regarding the latter, where possible,
a distinction is made between compliance costs, learn-
ing costs and psychological costs, following the conceptualization of administrative burdens as developed by
Moynihan and others (2015).
4.2.1 |Poverty costs
The survey statistics indicate that living in poverty produces an increased burden for eligible people to apply to the
AUH. As the regression analysis shows, people living in extreme poverty have an 18% higher chance of not applying
and people living in moderate poverty an 11% higher chance as compared to the entire target population.
TABLE 3 Reasons for non-participationopen answers
Code # of answers Percentage
1. ID missing 43 18
2. Lack of time 24 10
3. Lack of information/incorrect information 32 14
4. Disinterest and prejudices 15 6
5. Father or mother is absent 34 15
6. Does not attend school 7 3
7. Problems with paperwork 9 4
8. Not eligible for AUH 39 16
9. In application procedure 6 3
10. Other 26 11
Total 235 100
Source: Own elaboration based on ENAPROSS II.
TABLE 4 Distribution of the analytical categories in the interviews (with examples)
# of interviews
that address
the problem Examples (quotes)
Poverty costs 13 I have no money to eat, less for the DNI
Human capital 11 I thought that I could not request the AUH and had not been informed
on the subject, so I do not know the necessary procedures
Decision-making bias 12 I spend my time helping in the community kitchen where I get food
for the children, what else can the poor ask for?
Furthermore, living in marginalised areas (12%) and scarcity in the access to basic goodsthrough the indicators
households overcrowdedby one (6%) and two attributes (12%)are also positively related to non-take-up. In the
open answers, single parent households (father or mother is absent) emerge as another indicator that complicates
take-up because of compliance costs, since both parents' documentation needs to be presented in order to obtain
the AUH benefit. Problems with paperworkare also often related to vulnerable circumstances, such as underage
parents and foreign nationality.
Lastly, the interview data confirms the increased experience of burdens for the most vulnerable target group.
Interviewees often mention compliance costs regarding the need to present the national identity document (DNI) in
order to access the AUH. Take, for instance, Blanca. She is 17 years old, has two children and is pregnant. She needs
the AUH benefit because she lives on the streets. However, she does not have an identity document (DNI). Milagros
is 16 years old and faces a similar problem. Her mother abandoned her when she told her she was pregnant. She
lives on the streets and neither she nor her two children have the DNI.
4.2.2 |Human capital
Survey statistics on educational levels indicate that levels of human capital impact non-take-up as well. Both low
(15%) and medium (17%) levels of education by the head of the family significantly increase the chance of non-take-
up. In the open answers, lack of information or incorrect information about the AUH can be associated with elevated
learning costs. Answers here include does not know about program,does not know how to do procedure, and
thought they were not eligible. In the interviews, several citizens also expressed the increased compliance and
learning costs they face because of lower human capital levels. For instance, Sabrina is 21 years old and lives with
her grandmother. She has three children and never applied for the AUH because she does not know how to read or
write and, therefore, cannot fill up the forms to obtain the benefit. Elsewhere, José, 28 years old, wrongly believes
that he needs to pay for obtaining the national identity document (DNI): I don't have a (credit) card to pay, I lost
mine and the mother left us []. I have no money to eat, less for the DNI.
TABLE 5 Number of analytical categories in the interviews (with examples)
# of interviews
that present
one or more
problems Examples (quotes)
One analytical
14 Poverty costs (7) Human capital (4) Decision-making bias (3)
My document is expired,
and I have not yet
renewed it since I do
not have the money to
do it
I do not know how to
read, and we live from
grandma's pension. She
says we do not need
[the AUH]
Wherever I go, they
already look at you
with contempt, so
they do not give you
Two analytical
8They say that I am not in the system [to get the DNI], but since I do not know
how to read or write we cannot do anything []. I went to social assistance,
from there they sent me to the psychologist, they think that because you are
poor you are crazy
(human capital and decision-making bias)
Three analytical
2They make you go from here to there too many times and for everything you
have to travel and we do not even have money to buy the public transport card.
We deal with what we have, it is easier to live like this than to beg them
(poverty costs, human capital and decision-making bias)
4.2.3 |Decision-making bias
In the survey's open answers, a lack of time is often associated with a focus on daily survival, as evidenced in answers
such as busy with other thingsand does not have time to apply’–revealing increased compliance costs because of a
decision-making bias. Moreover, children are sometimes taken out of school to help with the family economy (does not
attend school), which is supported by the survey statistics where school assistance shows a 10% lesser chance of non-
take-up. Lastly, the closed answer categories disinterest(16%) and does not know(18%) might also indicate a
decision-making bias. Even though this remains open for interpretation, the answers at least suggest that the AUH ben-
efit is not something people have given much thought nor plays a large role in their decision-making process. In the
interviews, several eligible non-participants explain how their daily struggle for survival impacts their decisions and per-
ception of compliance costs. For instance, Rosa and Julio, both 47 years old and with nine children, are Bolivians and
never applied for their DNI. They lost their documents and never tried to solve this situation.
Disinterest in obtaining the AUH benefit can also indicate a sign of negative attitudes towards the state and gov-
ernment programs. In the open answer category disinterest and prejudicesanswers include does not like bureaucratic
procedures,never appliedand no interest. In the interviews, public officials confirm the existence of negative atti-
tudes towards the state. According to the undersecretary in charge of ENAPROSS, there is fear of contact with the
state among the poorest. They are afraid that the state will take something awayfrom them and are afraid of punish-
ment for not having a DNI or a permanent address. The police representsthe face of the state for most of the vulnera-
ble population, which further generates stigma (and fear) towards the state. Negative attitudes were also mentioned in
the interviews at the ANSES central offices and with eligible non-participants, who tend to see interactions with the
state as a problem rather than a solution. Consistent with the notion that citizen factors already exist prior to state-citi-
zen interactions (Christensen et al., 2020, p. 130), these attitudes reduce people's willingness to apply for the AUH,
regardless of how high or low the administrative burdens in the actual application procedure might be.
Many people in Nuevo Amancay, Tigre, Pilar, Villa 31 and La Cava live under conditions of extreme poverty.
Most neighbourhoods do not have drainage, nor paved roads. They are not connected to the public electricity net-
work and there is no garbage collection. Every time it rains heavily, their streets and houses are flooded. Houses are
made of precarious materials, many of them without a proper roof, with clay floors and without adequate bathrooms.
These are marginal neighbourhoods in which the houses are built with waste materials that their owners put
together from the street and where people live with few economic resources. Many people depend on community
kitchens. For these people, the state is far away’–both geographically and metaphorically. For instance, Dionisia,
39 years old and with five children, relies on her neighbours instead of on the state. She helps in the community
kitchen, where she obtains food for herself and her children. She says she would rather ask local politicians for a job
when they visit the neighbourhood than to go to an ANSES office: when we go there, they treat us as indigents.
Administrative burdens are an individual's experience of policy implementation as onerous(Burden et al., 2012,
p. 741), but the jury is still out on what exactly explains the higher burdens (Moynihan et al., 2015), higher levels of
administrative exclusion(Brodkin & Majmundar, 2010) and lower levels of take-up (Bhargava & Manoli, 2015)
among vulnerable target groups of government programs. What determines the experience of a burden cannot solely
be attributed to state factors, such as the design characteristics of government programs and bureaucratic proce-
dures, but also depends on citizen factors that shape people's capacity and willingness to engage in bureaucratic
encounters and apply for social programs. The analysis and findings presented here make two contributions.
First, it builds upon existing contributions (Christensen et al., 2020; Heinrich, 2018) to refine the theoretical frame-
work on explanations for the unequal distribution of administrative burdens. A distinction is made between economic
and behavioural explanations. The former includes rational trade-offs regarding the costbenefit of going through
ordeal mechanisms as well as the relatively higher costs of living in economic vulnerability. The behavioural approach,
by contrast, looks at the psychology of decision-making and at variations in human capital. Furthermore, policy feedback
is suggested as a possible intermediating variable between policy outcomes on the one hand and people's willingness to
interact with the state and apply for government programs on the other hand. This also helps understand the bigger bite
of administrative burden in low-trust and developmental contexts (Heinrich & Brill, 2015) and is consistent with the
notion that citizen factors exist prior to any state-citizen interaction (Christensen et al., 2020, p. 130).
Second, the findings of a case study of non-take-up in Argentina's conditional cash transfer program illustrate
the relevance of the theoretical framework. Data from a government survey and from interviews with civil servants
and eligible non-participants demonstrate that citizen factors affect eligible citizens' tendency to reach out for ser-
vices and benefits from the state(Christensen et al., 2020, p. 130). Evidence for both economic and behavioural
explanations was found, which suggests the importance of incorporating multiple factors in the analysis of variance
in people's willingness to apply and their capacity to overcome administrative burdens. More research is needed to
measure the relative impact of each individual factor in different contexts (which the data presented here does not
allow for). Furthermore, future studies should also focus on the interplay between state factors and citizen factors
and on policy feedback mechanisms to improve our understanding of the causes of the unequal distribution of
administrative burden.
Lastly, investigating empirically how reactions to burdens vary(Christensen et al., 2020, p. 132) not only helps
to explain the distributive nature of administrative burden (Herd & Moynihan, 2018), but can also lead to relevant
insights for policy makers. Even though citizen factors already exist prior to any state-citizen interaction, improving
bureaucratic encounters (Lotta & Marques, 2019; Raaphorst & Van de Walle, 2018) can have a significant impact on
take-up of social programs. Understanding the role of the citizen in bureaucratic encounters and how seemingly low
burdens can have a disproportionately negative effect on vulnerable target groups can be incorporated in audits that
look at the citizen experience of government programs and bureaucratic procedures (cf. Sunstein, 2019). Subse-
quently, actions can be taken to mitigate the impact of citizen factors on program take-upboth at the level of policy
design and at the level of state-citizen interactions. Exclusion from benefits has both immediate and long-term
effects on social mobility and intergenerational poverty (Heinrich, 2018). Improving the experience of state-citizen
interactions is, therefore, a key democratic concern.
The authors declare no conflicts of interest.
Mariana Chudnovsky
Rik Peeters
Although learning costs are, in principle, not limited to people with lower social and human capital, the survey analysis sug-
gest that a lack of knowledge about the AUH program is more prevalent among the most vulnerable target groups. The
AUH is well-known in Argentina and has a simple application procedure, which is also reflected in the relatively high levels
of coverage as compared to similar programs in the region.
Note that the intermediating variable in the theoretical framework policy feedbackwas not directly tested. This remains
a theoretical assumption in our framework which future research will need to confirm or disconfirm. However, the evi-
dence presented here for negative attitudes towards the state as a contributing factor to non-take-up presents a strong
indication of policy feedback mechanisms at play.
The economic rational choice explanation is not taken into account because the combination of relatively low enrollment
burdens, high financial benefit and an overrepresentation of exclusion by the most vulnerable target group is assumed to
exclude this explanation.
The Total Family Income (TFI) is calculated after deduction of transfers received from the AUH. This allows us to estimate
the actual level of vulnerability pre-transfer for each family.
Since the case study focuses on the reasons people have for not applying to the AUH in the first place, not all findings can
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Innovations in digital government are changing state–citizen interactions. While often seen as means to increase government efficiency and reduce compliance costs for citizens, a growing body of literature suggests citizens may also experience administrative burdens in such interactions. This article aims to provide some cohesion to the existing research and makes three specific contributions. First, it carves out a conceptual common ground by identifying digital administrative burdens and digital bureaucratic encounters as specific objects of study. Second, automated administrative decision making, digital interactions, and data-assisted decision making are identified as contemporary practices of particular relevance for future studies on the intersection of digital government and administrative burden. Studies suggest learning costs and psychological costs may be especially prevalent in digital bureaucratic encounters and that they often have distributive effects. Third, the article concludes with the formulation of several research themes for the further development of the field.
The purpose of this article is to highlight meta-ethnography – the interpretive synthesis of ethnographic studies on a given theme – as a useful tool in the study of social policy and public administration. We claim this approach can maximise the impact of rich idiographic research to enable theory-refining and evidence-building efforts in the field. We illustrate these benefits through reference to a worked example focused on public encounters with social security in advanced liberal democracies. We show how we drew together 49 ethnographic studies from a variety of disciplines to identify repertoires of response that citizens exercise in their encounters with the contemporary welfare state. Through this analysis, we demonstrate how meta-ethnography can shed new light on topical contemporary debates about administrative burden. We conclude by reflecting on the prospects and limits of this technique for broader use in the field.
Public services represent a key means by which societies seek to reduce inequalities. However, some people may experience administrative procedures as more burdensome than others, creating inequality within programs intended to be equity‐enhancing. Prior work has found human capital (e.g., education and conditions like scarcity) to affect burden and take‐up. We build on this by examining the role of health in the form of attention disorders, pain, anxiety, and depression in the context of tax reporting in Denmark and college financial aid in Oklahoma, USA. Across cases, attention disorders and pain are associated with more burdensome experiences and in the financial aid case, they are associated with reduced take‐up as well. Individuals suffering from multiple health problems have the most negative experiences and lowest take‐up. The results suggest that extra support may be needed for people suffering from health problems in order to reduce inequities in experiences and outcomes. This article is protected by copyright. All rights reserved.
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Financial scarcity is a fundamental condition for recipients of social welfare. We draw on scarcity theory to suggest that the condition of scarce resources may have a range of important psychological consequences for how welfare recipients’ cope with their problems, navigate citizen-state interactions, for their perceived ability to deal with their problems, and for their psychological well-being. In a field experiment using Danish unemployed social assistance recipients (N = 2,637), we test the psychological consequences of scarcity by randomly assigning recipients to be surveyed either shortly before payment of their social assistance benefits, shortly after, or mid-month. We find no impact of the scarcity manipulation and thus our main findings run counter to the idea that short-term changes in scarce financial conditions influence the mindsets of social welfare recipients. However, a series of exploratory cross-sectional regressions show that subjective scarcity, i.e. ‘the feeling of having too little’, is associated with an increased focus on solving problems, but negatively associated with psychological well-being, sense of mastery, and job search self-efficacy. We conclude that these correlates may reflect more long-term consequences of scarcity but that more and stronger causal evidence is needed given the cross-sectional nature of these data.
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What does a government do when it decides to make a public service as burdensome as possible? We consider this question in the context of immigration policy during the Trump administration. The case demonstrates the deliberate and governmentwide use of administrative burdens to make legal processes of immigration confusing, demanding, and stressful. Many of these changes occurred via what we characterize as formal administrative directives, a level of policy implementation that falls between high-level formal executive legal powers, such as executive orders or rules, and street-level discretion, pointing to the importance of processes such as memos and training as an understudied space of using burdens to make policy. The case challenges the standard portrayal of the principal–agent dilemma, given that the political principals engaged in a disruption of public services akin to sabotage, while the bureaucratic agents remained largely quiescent. The outcome was a system of racialized burdens, where changes were targeted at racially marginalized immigrants. The case also highlights the use of fear as a particular type of psychological cost.
Objectives Participation in the Supplemental Nutrition Assistance Program (SNAP) among eligible adults 60 and older is much lower than among the younger population, and rates continue to decline throughout the life course while at the same time the risk of cognitive impairment increases. Due to the high administrative burden associated with SNAP eligibility processes, cognitive impairment may be associated with low uptake of SNAP among the low-income older adult population, particularly among more socially disadvantaged groups (females, Blacks, and those living alone). We provide new evidence that changes in cognitive functioning are associated with reductions in the probability of SNAP take-up among eligible older adults. Methods Using panel data from the Health and Retirement Study, we estimate linear probability fixed-effects models to assess the effect of cognitive decline on the likelihood of SNAP participation among eligible adults aged 60 and above, controlling for observed characteristics that change over time as well as individual, time, and state fixed effects. Results Reduced levels of cognitive functioning that rise to the classification of dementia were strongly associated with reductions in the probability of SNAP take-up among eligible older adults. Results were particularly salient for females and those living alone. Discussion One barrier to SNAP take-up among older adults may be cognitive impairment with the size of effect differing by gender and living arrangement. Policymakers may want to consider initiatives to increase SNAP participation among older adults, including a focus on further simplification of eligibility and recertification processes that reduce administrative burden.
Despite its usefulness for analysing the social equity footprint of policies and documenting citizens’ experiences of accessing social services, the present conceptualisation of administrative burden does not differentiate between necessary and unnecessary administrative burdens. As existing research tends to focus only on negative aspects of administrative burdens, it does not adequately account for their use as a countervailing force to achieve legitimate public values and prevent misuse of public resources. Using a public values accounting approach, this article outlines a framework to analyse the costs and benefits associated with public service delivery. In this formulation, administrative burden conceptualised as the monetary, time and psychological costs experienced by relevant stakeholders are balanced against specific public value benefits that a policy is supposed to achieve. In addition to allowing a more balanced analysis of costs and benefits associated with different policies, this approach helps identify illegitimate administrative burdens, that do not contribute to achieving relevant public values or can be reduced without compromising relevant public values. This approach not only contributes to adding more nuance and dimensionality to the theory of administrative burden but also increases its relevance to policymakers and other stakeholders.
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Más allá de la focalización de la política pública: incidencia de factores extra-organizacionales en la falta de cobertura de ciudadanos elegibles en la Asignación Universal por Hijo en Argentina Resumen El actual programa "bandera" de transferencias monetarias condicionadas de Argentina (Asignación Universal por Hijo) se diferencia de otros programas de América Latina porque se presenta como derecho de la niñez y tiene una orientación más universal. Una de las características principales del diseño del programa es que presenta escasas cargas administrativas para obtenerlo. Sin embargo, encontramos que existe una importante proporción de la población elegible que no tiene el beneficio que les corresponde y que, además, está conformada por los ciudadanos más pobres. Mostramos que la condición de vulnerabilidad, así como las experiencias negativas de retroalimentación de políticas públicas (policy feedback), afectan tanto su capacidad como su voluntad de postular al programa. Palabras clave: cargas administrativas; transferencias monetarias condicionadas; vulnerabilidad Beyond focalization: extra-organizational factors in the non-participation of eligible citizens in Argentina´s conditional cash transfer program Abstract We examine the Argentina's social conditional cash transfer program, the Asignación Universal por Hijo, which has low organizational burdens for accessing the social benefit. However, we find that it still significant numbers of non-take-up. Specialized literature often attributed this to problems in the design of programs and procedures. Nevertheless, we state that these organizational factors do not, by themselves, explain why vulnerable people tend to have lower levels of participation and sometimes not even apply for programs targeted at them. We show that citizens' vulnerability and negative policy feedback affect their capacity and willingness to apply.
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Most research on administrative burdens focuses on measuring their impact on citizens' access to services and benefits. This article fills a theoretical gap and provides a framework for understanding the organizational origins of administrative burden. Based on an extensive literature review, the explanations are organized according to their level of intentionality (deliberate hidden politics or unintended consequences) and their level of formality (designed into formal procedures or caused by informal organizational practices). The analysis suggests that administrative burdens are often firmly rooted in a political economy of deeply engrained structures and behavioral patterns in public administration.
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Consumers, employees, students and others are often subjected to ‘sludge’: excessive or unjustified frictions, such as paperwork burdens, that cost time or money; that may make life difficult to navigate; that may be frustrating, stigmatizing or humiliating; and that might end up depriving people of access to important goods, opportunities and services. Because of behavioral biases and cognitive scarcity, sludge can have much more harmful effects than private and public institutions anticipate. To protect consumers, investors, employees and others, firms and private and public institutions should regularly conduct Sludge Audits to catalogue the costs of sludge and to decide when and how to reduce it. Sludge often has costs far in excess of benefits, and it can hurt the most vulnerable members of society.
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One means by which the state reinforces inequality is by imposing administrative burdens that loom larger for citizens with lower levels of human capital. Integrating insights from various disciplines, this article focuses on one aspect of human capital: cognitive resources. The authors outline a model that explains how burdens and cognitive resources, especially executive functioning, interrelate. The article then presents illustrative examples, highlighting three common life factors—scarcity, health problems, and age‐related cognitive decline. These factors create a human capital catch‐22, increasing people's likelihood of needing state assistance while simultaneously undermining the cognitive resources required to negotiate the burdens they encounter while seeking such assistance. The result is to reduce access to state benefits and increase inequality. The article concludes by calling for scholars of behavioral public administration and public administration more generally to incorporate more attention to human capital into their research.
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Welfare service experiences are known to shape citizens' trust in public institutions and their support of the welfare state. But, there is poor understanding of how this relationship is shaped in systems of mixed provision, that is, welfare states that use public in-house as well as contracted private providers for publically funded services. Drawing on the notion of system trust this article provides a theoretical account of how mixed-provision welfare systems condition the relationship between service experience and trust, affecting the legitimacy of the state. Utilizing a random-ized vignette experiment with participants in a general citizen survey in Sweden, we investigate whether it matters for the formation of institutional trust if the welfare service is provided by a public or third-party private provider. The main result show that the spillover of trust from positive service experiences with the provider to trust in public institutions is higher in cases of public service provision. Thus, the possibility of using welfare services to build trust in the welfare system seems to be greater when public provision is used.
We study the effect of application costs on the targeting of disability programs. We identify these effects using the closings of Social Security Administration field offices, which provide assistance with filing disability applications. Closings lead to a persistent 16 percent decline in the number of disability recipients in surrounding areas, with the largest effects for applicants with moderately severe conditions and low education levels. Disability applications fall by only 10 percent, implying that the closings reduce targeting efficiency based on current eligibility standards. Increased congestion at neighboring offices appears more important as a channel than higher travel or information costs. (JEL H55, I13, I18, J14)
Policy implementation is an interactive process between citizens and street‐level bureaucrats. Although the literature has already addressed different factors that influence discretion, there is still a gap in understanding if and how bureaucrats' relational profiles affect policy implementation. This article analyses bureaucrats' interactions and the relational environments in which they exercise their discretion. The hypothesis is that bureaucrats' different relational profiles specify policy implementation at the street level. We study bureaucrats in a Brazilian health care programme involving community workers that requires regular visits to beneficiary families' homes. The research departs from ethnography and network analyses with workers from three very different contexts. We analyse bureaucrats' practices, the discursive styles mobilized in their interactions, and their personal networks. The results show that organizational factors are central to explain variations in practices, and their relational profiles highly influence the discursive styles used by bureaucrats in their interactions with citizens. The article concludes that relational elements can affect the exercise of discretion and influence interactions at the street level and should be incorporated more systematically in the implementation literature.
Importance The Veterans Affairs (VA) health care system is the largest integrated health care system in the United States. Like most US health plans, the VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). However, 12-month OCP dispensing has been shown to improve continuation of use, decrease coverage gaps, and reduce unintended pregnancy in other practice settings. Objective To estimate the financial and reproductive health implications for the VA of implementing a 12-month OCP dispensing option, with the goal of informing policy change. Design, Setting, and Participants A decision model from the VA payer perspective was developed to estimate incremental costs to the health care system of allowing the option to receive a 12-month supply of OCPs up front, compared with the standard 3-month maximum, during a 1-year time horizon. A model cohort of 24 309 reproductive-aged, heterosexually active, female VA enrollees who wish to avoid pregnancy for at least 1 year was assumed. Probabilities of continuation of OCP use, coverage gaps, pregnancy, and pregnancy outcomes were drawn from published data. Costs of OCP provision and pregnancy-related care and the number of women using OCPs were drawn from VA administrative data. One-way and probabilistic sensitivity analyses were performed to assess model robustness. Main Outcomes and Measures Incremental per-woman and total costs to the VA of allowing for 12-month dispensing of OCPs compared with standard 3-month dispensing. Results The 12-month OCP dispensing option, modeled from the VA health system perspective using a cohort of 240 309 women, resulted in anticipated VA annual cost savings of $87.12 per woman compared with the cost of 3-month dispensing, or an estimated total savings of $2 117 800 annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies per 1000 women per year with 12-month dispensing, or 583 unintended pregnancies averted annually. Expected cost savings with 12-month dispensing were sensitive to changes in the probability of OCP coverage gaps with 3-month dispensing, the probability of pregnancy during coverage gaps, and the proportion of pregnancies paid for by the VA. When simultaneously varying all variables across plausible ranges, the 12-month strategy was cost saving in 95.4% of model iterations. Conclusions and Relevance Adoption of a 12-month OCP dispensing option is expected to produce substantial cost savings for the VA while better supporting reproductive autonomy and reducing unintended pregnancy among women veterans.