Ritual and the organisation of care in primary care clinics in Cape Town, South Africa.

Few sociological studies have examined care organisation in primary health settings in low- and middle-income countries. This paper explores the organisation of health care work in primary care clinics in Cape Town, South Africa, by analysing two elements of clinic organisation as rituals. The first is a formal, policy-driven element of care: directly observed therapy for tuberculosis patients. The second is an informal ritual, seemingly separate from the clinical work of the team: morning prayers in the clinic. We draw on data from an ethnography in which seven clinics providing care to people with tuberculosis were theoretically sampled for study. These data include participant observation of clinic sessions, and interviews and group discussions with providers and patients, which were analysed using approaches drawn from grounded theory. Our findings suggest that rather than seeing the ritualised aspects of clinic activities as merely traditional elements of care that potentially interfere with the application of good practice, it is essential to understand their symbolic values if their contribution to health care organisation is to be recognised. While both staff and patients participate in these rituals, these performances do not demonstrate or facilitate cohesion across these groups but rather embody the conflicting values of patients and staff in these clinics. As such, rituals act to reinforce asymmetrical relations of power between different constituencies, and to strengthen conventional modes of provider-patient interaction.