"This Is How We Work Here": Informal Logic and Social Order in Primary Health Care Services in Mexico City.

Abstract

People who work in health care facilities participate in a shared set of tacit agreements, attitudes, habits, and behaviors that contribute to the functioning of those institutions, but that can also cause conflict. This phenomenon has been addressed tangentially in the study of bureaucratic practices in governmental agencies, but it has not been carefully explored in the specific context of public health care centers. To this end, we analyzed a series of encounters among staff and patients, as well as the situations surrounding the services offered, in public primary care health centers in Mexico City, based on Erving Goffman's concepts of social order, encounter, and situation, and on the concepts of formal and informal logic. In a descriptive study over the course of 2 years, we carried out systematic observations in 19 health centers and conducted interviews with medical, technical, and administrative staff, and psychologists, social workers, and patients. We recorded these observations in field notes and performed reflexive analysis with readings on three different levels. Interviews were recorded, transcribed, and analyzed through identification of thematic categories and subcategories. Information related to encounters and situations from field notes and interviews was selected to triangulate the materials. We found the social order prevailing among staff to be based on a combination of status markers, such as educational level, seniority, and employee versus contractor status, which define the distribution of workloads, material resources, and space. Although this system generates conflicts, it also contributes to the smooth functioning of the health centers. The daily encounters and situations in all of these health centers allow for a set of informal practices that provide a temporary resolution of the contradictions posed by the institution for its workers.