title: Negotiating care: patient tactics at an urban South African hospital.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. helen.schneider@uct.ac.za
authors.forename: Helen
authors.initials: H
authors.lastname: Schneider
authors.forename: Frederic
authors.initials: F
authors.lastname: le Marcis
authors.forename: Julien
authors.initials: J
authors.lastname: Grard
authors.forename: Loveday
authors.initials: L
authors.lastname: Penn-Kekana
authors.forename: Duane
authors.initials: D
authors.lastname: Blaauw
authors.forename: Didier
authors.initials: D
authors.lastname: Fassin
mesh_terms: D000046:Academic Medical Centers / Q000458:organization & administration*; D000328:Adult; D001294:Attitude to Health; D003625:Data Collection; D005260:Female; D006297:Health Services Accessibility; D006786:Hospitals, Urban / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D017008:Negotiating / Q000379:methods*; D019370:Observation; D010358:Patient Participation / Q000523:psychology; D011369:Professional-Patient Relations; D036301:Qualitative Research; D011787:Quality of Health Care; D013019:South Africa