Helen Schneider, Frederic le Marcis1, Julien Grard2, Loveday Penn-Kekana3, Duane Blaauw3,
School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; 1Department of Social Anthropology and
Ethnography, University of Bordeaux 2, Bordeaux, France; 2Ecole des Hautes E´ tudes en Sciences Sociales, Paris, France; 3Centre for Health
Policy, University of Witwatersrand, Johannesburg, South Africa; 4Institut de Recherche Interdisciplinaire sur les Enjeux Sociaux, EHESS, Paris
Objectives: To examine the various ways in which patients sought to inﬂuence the care they received in the
admission and adult medical services of a large urban, academic hospital in South Africa. These included the
steps taken by patients to increase their access to services and improve their experience of care.
Methods: Part of a qualitative study of rationing behaviour, the methods combined, observations, interviews
and a survey.
Results: Patient’s actions were oriented to two main goals: obtaining care and preserving their sense of self and
dignity. These actions shaped patients’ pathways in ﬁve key ways: meeting the entry criteria for admission;
presenting as a cooperative, expert patient; mobilizing social networks among health care staff; making use of
complaints mechanisms; and deploying narratives of resistance.
Conclusion: Patients made tactical use of small spaces at the margins of the health care system. Although, with
some exceptions, they had limited impact on the care received in the hospital, they highlight patients as active
players and point to the ways in which patient agency can be strengthened in the light of the shift towards chronic
disease care and greater patient involvement in care.
Journal of Health Services Research & Policy 2010: 1 – 6