"You must make a plan [...] or some story": re-appropriating community health work in Cape Town

This paper investigates community health workers’ negotiation between the prescribed ‘manual’ for care and the lived realities of their field, exploring how standards of public health are re-appropriated through the micro-politics of everyday practice. What inventiveness, agency and tactical manoeuvres are woven between abstract ideals and situational demands and what are the implications for our understanding of carework? Using in-depth qualitative methods, the paper investigates the practice of care amongst a cohort of fifteen community health workers, serving as antiretroviral adherence supporters in two Cape Town primary healthcare clinics. It shows community health work, as a model for care, to be complex and demanding – a composite of practices prescribed by a range of institutions with diverging interests. This onerous care manual is expected to be delivered by a cadre of lay health workers positioned at the interface between communities and clinics - with minimal training, limited resources and little authority. Within this demanding occupational terrain, careworkers have crafted space for agency and tactics. Through a series of improvisations, respondents mediate between the often-incongruent demands of patients, employers, funders, and state policy, whilst also negotiating their own self-care and aspirations for upward mobility. In a policy context that has sought to standardise, systematise and regulate carework, this practice is contrastingly inventive and adaptive. The makeshift, unplanned, and chancy nature of carework is often far from its original design, calling into question how the success of this model should be understood.