Between the constitution and the clinic: Formal and de facto rights to healthcare

In no domain of global health has there been more talk of rights than in HIV/AIDS, yet little is known about how the right to HIV/AIDS care is mobilized at the clinic level. Drawing on interviews and field observations in the United States, South Africa, Thailand, and Uganda, we analyze the legal consciousness of caregivers in five HIV clinics. We identify three organizational factors—clinics' focus on the distribution rather than the adequacy of existing resources, the duties for caregivers that patients' rights create, and the dominant norms of exchange in healthcare—that help to explain the low penetration of formal rights talk into clinics despite its prevalence outside them. However, we also observe that within clinics, rights may accrue differently than public discourse about rights might lead us to expect. We find that patients often benefit from highly localized, tacit de facto rights that develop gradually over time with the support of state health infrastructure, clinic resources, and professional norms and commitments. These rights would be unlikely to stand up in a court of law but nevertheless have substantial impact on patients' access to care.