Study context

South Africa is a resource-constrained setting with a high TB burden; the estimated incidence of TB in 2019 was 615 per 100 000, which is among the highest in the world [18]. Healthcare-acquired Mtb transmission is a growing concern in the country [19]. Earlier iterations of the WHO guidelines have been adapted to the local policy context in South Africa [20]. Further, in 2015 the South African National Infection Prevention and Control Strategy for TB, MDR-TB, XDR-TB [21] was established targeting the spread of TB and eradication of the TB epidemic by 2030. IPC is also one of the essential pillars of a major health system strengthening intervention to address current infrastructure, administrative and resource deficiencies in the quality of healthcare services, known as the Ideal Clinic Initiative (ICI) [22]. The ICI assumes reorganisation, integration of services (e.g., TB, HIV, STI, emergency, child and maternity) and improvement in safety and quality of care. In principle, these policy initiatives are intended to address long-standing structural and operational issues in healthcare settings that contribute to sub-optimal IPC and gaps in the continuity of TB care. However, the TB-IPC measures remain poorly implemented [23–25], calling for context-specific approaches to better embed IPC measures within South African clinic systems [26, 27].

KwaZulu-Natal Province (KZN) is one of the poorest provinces in South Africa [28] and one of four high-TB burden provinces, with an estimated drug-sensitive Mtb incidence of 525 per 100 000 population in 2017 [29]. The effective Mtb treatment coverage for KZN has been estimated at 56% for the 2016 to 2018 triennium [30]. Initiation and management of drug-sensitive TB have been decentralised to the clinic level, while the initiation and continuation of Multidrug-Resistant TB (MDR-TB) have been decentralised to Level 1/District Hospitals.

Ethics statement

Ethical approvals were granted by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (REF. BE082/18); the Research Ethics Committee of Queen Margaret University (REF. REP 0233), and the Observational/Interventions Research Ethics Committee of the London School of Hygiene & Tropical Medicine (REF. 14872).

Written gatekeeper permission to conduct the study was provided at the provincial level (Ref: KZ_201810_016) and from each of the three health districts within which the six clinics were located. Informed written consent for clinic participation in the study was sought from the clinic manager of each clinic, prior to the start of fieldwork/data collection. On entry to each clinic, researchers held an information session with all staff prior to the start of data collection. This was usually incorporated into the regular staff meeting, to inform clinic staff of all researcher activities while on site. All questions pertaining to the study purpose and processes were addressed in the information session and as they arose during the fieldwork. Members of staff engaged in informal conversations could thus be informed regarding the nature of the research and their participation to ensure transparency regarding the data collection generated through the ethnographic method. Individual written informed consent was obtained prior to each in-depth interview, including permission to audio-record the interview. Assurance of anonymity and confidentiality was provided for both clinic sites and individuals within each site. Assurance was also given regarding the freedom to withdraw from the study at any time, with no ensuing negative consequence.

Inclusivity in global research

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the (S1 Checklist).

Data sources and collection

Six primary health clinics were selected purposively to take account of the diversity of clinics across the province. Selection was based on the year of establishment and type of facility; governance structure; daily headcount and catchment population; the presence or absence of appointment systems and the extent of the decentralisation of DR-TB services. The purposive selection also accounted for rural and urban locations and whether health clinics were purpose-built or not. Table 2 presents descriptive data on selected clinics.

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Table 2. Description of clinics and data collection methods.

https://doi.org/10.1371/journal.pgph.0000964.t002

Working in pairs or small groups, five female researchers with training in public health and qualitative research, as applied to the study of health systems, conducted the fieldwork. We approached the clinic as a “dynamic site of interaction between humans, microbes, and materials” [26]. An ethnographic approach was adopted to explore the complex interactions of health facility structures, processes, and behaviours influencing TB-IPC practices within clinics. Over a period of 1 to 3 days in each facility visited, we collected data using unstructured and structured observations, in-depth semi-structured interviews with clinic managers and health workers, and informal conversations with health workers (Table 2). During their time in the clinics, researchers observed their surroundings and took notes on clinic features and processes pertinent to the implementation of TB-IPC. Interviews were conducted with relevant healthcare staff when possible and convenient. Using a guide that was loosely structured around the parameters of recommended TB-IPC measures, we conducted observations in each of the six facilities, in particular focusing on waiting rooms, reception areas and clinical consultation rooms. Observations in these spaces explored (a) the material differences in spatial layout; (b) workplace design and ventilation; (c) staff and patient movements around spaces and measures taken to encourage or discourage patient congregation (e.g., triaging, fast-tracking); (d) power dynamics and the interactions between staff members, patients, and staff members and amongst patients. Although our time in the facilities was limited, the relatively structured focus on observations allowed the researchers to capture pertinent features of clinic spaces, processes, interactions, and practices that had bearing on TB-IPC through fieldnotes.

We carried out semi-structured interviews with four clinic managers, a nursing service manager, a senior health worker, an IPC manager and two nurses, one specializing in TB. The interviews were aimed at gaining insights into participants’ roles and experiences in relation to TB-IPC within each clinic. Questions focused on (a) the nature of services provided to patients, (b) the current IPC plans and protocols regarding patient management, (c) environmental controls, (d) administrative and governance practices, (e) staff roles and responsibilities, (f) respiratory protection practices, (g) enablers and challenges to implementing IPC measures, and (h) individual risk perception and risk management. We held informal conversations around the local implementation of TB-IPC with six healthcare workers, including two TB nurses, a doctor, an IPC manager, an HR manager and a radiographer. Researchers captured the essence of these conversations through fieldnotes. These notes were integrated with the notes from our observations and formed the basis of ‘thick descriptions’.

Data analysis

‘Thick descriptions’ were created for the facilities visited, based on observations, fieldnotes, and informal conversations that researchers had during the visits to the six clinics, guided by an ethnographic approach [31]. These documents of between 15–20 pages included researchers’ hand-drawn maps, photographs of clinic spaces (without any identifying information or individuals in the images), and descriptive as well as reflective notes on the broader working environment, care processes, and IPC practices as observed at the six facilities. All semi-structured interviews were audio-recorded and transcribed verbatim. Data from thick descriptions and interviews were first read through and annotated through open coding by two of the authors (SA and KK) with expertise in global health and medical anthropology. Using a framework analysis approach, a coding framework was developed, informed by a systems-thinking perspective. Specifically, we drew on categories from a health policy and systems research framework [13] distinguishing between health system ‘hardware’ components including (i) human resources, (ii) organisational structure, (iii) medicines and technology; (iv) service infrastructure, (v) information systems, and (vi) financing and ‘software’ elements, described as (i) relationships and power, (ii) values and norms, (iii) interest and ideas. We defined what we meant by ‘hardware’ and ‘software’ as applied to TB-IPC (Table 3) based on Zwama et al., (2021) and De Bono et al. (2014), and then created a matrix that juxtaposed ‘hardware’ and ‘software’ elements shaping TB-IPC processes and practices as observed and recounted by the study participants.

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Table 3. Coding framework.

https://doi.org/10.1371/journal.pgph.0000964.t003

We used a deductive approach to manually code all textual data. A compare-and-contrast method was used to check the consistency of coded content. Displaying the coded segments in the matrix allowed us to interrogate our data for interactions within and across ‘hardware’ and ‘software’ dimensions. For the most part, this was a useful way of capturing systemic processes underlying TB-IPC in the clinic environment. However, coding also revealed the often arbitrary division between constituted ‘hardware’ and ‘software’. For instance, one element of systems ‘hardware’–governance–compromised both tangible elements such as committees, guidelines, and protocols for TB-IPC as well as intangible systems ‘software’–power relations and social hierarchies that characterised local manifestations of leadership, collegiality and normative practices. In presenting the findings, we eschewed a rigid distinction between ‘hardware’ and ‘software’ elements of TB-IPC by highlighting their dynamic interaction within clinic infrastructure, processes, and practice.

The primary care context of IPC implementation

“Fixing public health care will require a radical transformation, moving from a system organized at a district level, to a team-based approach focused on patients. Guidelines, of course, must be central to how care is organised, but those guidelines must be contextualised to the existing working conditions […]. Many doctors like myself are deeply anxious about these working conditions. But we are told that we must accept these organizational structures, ways of working, and performance goals expected at a district level.” [Doctor, informal conversation, Clinic 3]

The quote above reflects the frustrations that many clinic staff expressed with regard to a mismatch between goals and guidelines set at the district level and their implementation within the working environments of primary health clinics. The doctor refers specifically to problems in the organisation of care and working conditions, two features of clinics that are in turn linked to the availability of human and material resources, as well as management capacity.

In many clinics, managers were confronted with persistent human resource gaps that affected the delivery of services and uptake of interventions. The funding for filling staff vacancies and procurement of necessary material goods and services followed bureaucratic procedures involving the submission of lengthy forms to affiliated district hospitals and approval of funding by a committee overseeing general clinic spending. Ironically, a clinic manager described how staff shortages contributed to missing the important “cash flow meeting” where the clinic’s budget had to be negotiated and approved.

“We are allowed to be a part of the cash flow committee. The only problem is, there is the hospital cash flow and there is the clinic cash flow. Yeah, so at times you will find that we are supposed to have a clinic cash flow and …I’m held up at work due to staff shortage. I cannot attend that cash flow.”

[Clinic manager, interview, Clinic 2]

“They only gave me budget in March, with a bureaucracy of ratifying posts and everything. Even today, I have not appointed anybody, but I have done everything in terms of interviews and everything.”

[Nursing service manager, interview; Clinic 4]

These challenges were described as longstanding and set within the lack of decentralised power over clinic allocation of funds and spending. Policies and procedures were developed and enforced at the provincial level, with little consideration given to local needs and concerns at the clinic level. A clinic manager lamented the lack of responsiveness of hospital management towards requests articulated for specific basic equipment.

“It’s rare where they [management at the hospital] accept our requests because of the functional cost saving that we have to make as a Department. Like we need a backup generator. We don’t have a backup generator, and they [at the hospital] say it’s too expensive for now.

[Clinic manager, interview, Clinic 6].

The organisation of care in this setting was also seen to be subject to the vagaries of donor funding, changes in disease priorities and in health policy. For example, the manager of Clinic 4 described how the withdrawal of funding for HIV through an external NGO led to a loss of critical administrative staff including data entry clerks. This had a knock-on effect on filing systems and patient flow. In another clinic, the manager described the challenges of meeting the targets of the ICI, which had unintended negative consequences for both the workflow and patient flow.

Front-line staff talked about tensions in the workplace, leading to high staff turnover and understaffing, and further impacting job satisfaction. For example, many health workers referred to unmanageable daily workloads leading to fatigue and the feeling that they were overlooked by management.

"I feel exhausted, tired and sleepy, because to nurse more than 100 patients per day, sometimes you become very exhausted …. Other people think you need to walk around to do heavy work, then you become tired. But to sit down and talk, it’s very exhausting. I enjoy talking to patients […] but if it’s 100, or 70, or 80 [patients], sometimes it’s too much.

[Nurse, interview; Clinic 2]

Staff expressed feeling excluded from participation in decision-making on matters related to their daily practice. The management style was described as “top-down’, contributing to the feeling of powerlessness. In Clinic 4, one health worker commented:

“I am tired of a “dead-end job”, where I can make no difference. There is no hope. I want to be in a job where I can see that what I do makes a difference. Where I can reflect on myself and modify my actions to make the outcomes different”.

[Health worker, informal conversation; Clinic 4]

However, staff in Clinic 6 talked at length about the new clinic manager perceived as a “breath of fresh air” in the way things were run in the clinic, including some aspects of normative organisational behaviour around IPC. They described the management style as inclusive, responsive and attuned to clinic needs. Staff were often praised for their good performance and professional commitment. This had a positive effect on staff general morale and practice, which, in turn, helped to attain “the Ideal clinic gold status”.

“Our clinic manager is responsive to staff concerns and requests. He is inclusive in decision-making and implementing changes after discussions with us. He asks for solutions from us as a team, considers our perspective and shares information with us”.

[Health worker, informal conversation; Clinic 6]

Managerial measures

Managerial functions underpinning stewardship of TB-IPC are most visibly embodied in the presence of infection control plans, dedicated focal persons and committees for TB-IPC. In all clinics visited, managers affirmed that IPC protocols, which TB-IPC measures are part of, were easily accessible to all health workers. In some clinics, IPC committees were formed, or IPC champions were assigned the responsibility of monitoring the implementation of IPC protocols. However, there was ambivalence about the effectiveness of IPC committees:

“They have committees on paper, because I don’t remember…..I think it was in 2018, early, when we had a meeting with them [IPC committee]. We do have them on paper. When the auditors ask—Who are the committees for IPC, I will pull the file and show you, because we have appointed people. But in terms of minutes and everything no, it’s not that active like they should be.”

[Health worker, interview; Clinic 4]

Similarly, the effectiveness of designated IPC champions was not always evident. For example, one of the IPC champions we met was unaware of the checklist of TB-IPC measures they were tasked with monitoring. In Clinic 3, the IPC manager mentioned that TB-IPC guidelines were an integral part of the general IPC file, but that these had last been reviewed in 2012. While this manager was aware that routine monitoring of TB-IPC measures was meant to occur every six months, the most recent TB-IPC checklist had been completed 18 months prior to our visit.

Clinic managers highlighted the lack of earmarked funding for IPC activities—“no, in our financial expenditures there is no specific budget for IPC” [Clinic manager interview, facility 6]–which impacted the availability and frequency of staff training. In one clinic, a nurse mentioned that staff training was contingent on provincial funding:

“We are waiting for the budget, because we are closing the previous year now at the end of this month [March 2019]. So, we are hoping that they [Department of Health] will appoint the service provider to come and assist in terms of training and programming system.”

[Nurse, interview; Clinic 4]

In Clinic 6, the TB nurse reported that she had last received training on TB eight years ago. She recalled that the training had “covered the basics” including personal protective equipment (PPE) and that she was subsequently able to offer in-service training on the use of N95 masks. However, as shown in a later section, the sustained impact of this training is not evident. IPC is an area that is neglected, yet an easy target for unwelcome audit exercises:

“There is an IPC team at the district hospital. They told her about training 2 years ago and she still hasn’t heard from them until today. When the minister of health comes for a visit, that’s when they [district hospital IPC team] come the day before to stand behind you and ask all the questions about things that they have never told you about”.

[TB nurse, interview; Clinic 2].

Screening and follow-up investigations for TB in staff also fall under the remit of clinic management. However, we observed uneven attention to occupational health and the safety of front-line staff. An IPC manager from one of the clinics admitted they felt short of facility-based surveillance of HCAI, including periodic screening of staff for active TB.

“TB screening is supposed to be done annually for all staff, and for some staff at high risk, it should be done every six months. Staff are often busy and delay coming for their assessment or re-schedule.”

[IPC manager, interview, Clinic 4]

Conversely, the manager in Clinic 6 reported that they had initiated regular TB screening of staff. This measure was intended to improve on past practice, when only new staff, or those working in secondary hospitals and not primary care, were screened for TB. TB notification among the staff was, however, noted to be a rare event.

“….we do it [screening] here around April, where we take sputum for all the staff and we do GXP [GeneXpert]. If the results come back positive, we refer [the staff] to the Hospital. But since I came here in September 2015, no one has been diagnosed with TB among the staff members”.

[Clinic manager, interview, Clinic 6]

Administrative controls

Administrative measures for TB IPC are largely concerned with the logistics of organising patient flow and services in ways that reduce the risk of exposure to undiagnosed TB. In all except one clinic, health workers talked about how acute staff shortages and frequent staff rotations affected timely case identification and triaging of patients for undiagnosed TB. In Clinic 2, the registering nurses were seeing two streams of patients at the same time in the same room due to staff shortages. In Clinic 5, the triage nurse was pulled in temporarily for processing the results of blood tests. In Clinic 3, the manager described triaging as a “grey area” not only because of staff non-availability but because of restrictions on who was permitted to triage:

“There is no one who is able to pitch in and say—‘I will be able [to triage].’ We have tried all doors, but the staff availability we don’t have. We’ve tried with Mr [name of Security Guard]. But he is not clinical, and we cannot use him. But with emergencies they are trying.”

[Clinic manager, interview; Clinic 3]

Waiting areas in most clinics were often overcrowded, particularly in the morning hours early in the week, when queues started to build up from four in the morning. Commonly, there was limited signage to guide patients through clinics, contributing to patients’ congregating in confined spaces and thus increasing the risk of TB transmission. Most clinics did not have functional appointment systems or were only starting to introduce them.

“Patients come any time. But now, what we are encouraging is the booking system because we have seen that we have got floods and floods of clients, and there is no control over who is coming and from where… …there may be the abuse of services and the booking system may bring that accountability”.

[Clinic manager, interview; Clinic 3]

Clinic managers referred to cultural norms around health-seeking behaviour that were unconducive for setting up formal appointment systems. There was also awareness from service providers that patients relying on public sector clinics are also likely to be reliant on public transport, which in many instances is limited and does not adhere to reliable schedules. This can make it challenging to stick to rigid appointment times and requires services to adapt to contextual realities. Patients were accustomed to waiting many hours and, therefore, did not stick to appointment times out of fear of missing their turn. As a result, as reported by one clinic manager, “patients are given return dates and not times. Patients need to become accustomed to returning on the appointed date before getting them accustomed to an appointment time”. [Clinic manager, interview; Clinic 1]

In some cases, the adoption of a streamlined centralised filing system in response to an ICI policy directive had negative consequences for the patient flow:

“That’s why we see these long queues. It’s the influx of patients. […] We did not plan for that. So even with the appointment system we did not step their appointments. They were just given the same date. So, we had an influx of patients that were coming in on one day, more than 700 to 800 a day. It was very difficult. The waiting time was long. Some patients would come at 5:00am. They will be sitting there with no cards until 16:00pm, and then would be told that: ‘We can’t find your file. You have to open a new file.’

[Nurse, interview; Clinic 4].

A number of clinics relied on the manual retrieval of folders and manual recording of patient data further contributing to waiting times. In Clinic 4, equipment for electronic recording was available; however, the gaps in logistics and training stalled their integration into care practice.

“We have got the equipment [59 computers], but our computers are not programmed, and staff is not trained, so we are waiting now for the Department [of Health] to send the trainers … At the moment everything is just manual paperwork.

[Health worker, interview; Clinic 4]

The implementation of administrative measures for TB-IPC involves managing the organisation of care effectively, which in turn is closely interlinked with human resources, information systems and organisational behaviour practices.

Environmental controls

Measures to improve the environment for prevention of Mtb transmission generally focus on the clinic space and material infrastructure, yet the use of space, and the movement of people and air within clinic spaces are influenced by the organisational and behavioural norms. Staff across all the clinics were well aware of crowded waiting areas and poorly ventilated clinic spaces as “hot spots” for transmission of Mtb. However, in some cases, inconsistent use of clinic spaces designated for particular services increased the risk of MTb transmission. For example, in one clinic, the labour ward was interchangeably used for patient consultations; in another, a room intended for TB care was being used for integrated management of childhood illnesses. In some clinics, patients did not have appropriate spaces to produce sputum samples, challenging basic tenets of biosafety:

““If you see there—a room we are using currently for children >5….but the way it was built it was meant for TB, as there is an area at the back for coughing. If I tell the patient to go and cough outside, he will go anywhere. So that are some of the gaps I have identified that we need to have sort of an area [for coughing]…”

[Clinic manager, interview; Clinic 6].

“I think this facility needs a well-ventilated coughing booth, instead of allowing patients to cough outside behind the bathrooms. That is the designated area for now, but you will find patients producing sputum anywhere they see fit. Now, I prefer the patient to produce the sputum at home”

[Senior health worker, informal conversation, Clinic 3].

In Clinic 3, one doctor described how he was lobbying to have a TB testing laboratory and equipment to speed up the reporting of individuals’ test results. Current arrangements meant that the patient had to return for test results after 48 hours, contributing to high rates of loss-to-follow-up and the failure to initiate individuals on treatment in a timely manner.

Generally, however, many clinic staff expressed being powerless to influence the allocation of space for clinic services. Decisions regarding the use of clinic space and procurement of equipment fell under district-level management:

I requested for the park home whereby they are going to separate TB patients; and they [management at the hospital] found it as a financial burden and said: “Let’s try our partners [NGO]. Maybe they would provide you with the park home.” Our supportive partner is [name of NGO]; but until now—nothing!”

[Clinic manager, interview, Clinic 6].

A key environmental control for TB-IPC is ventilation. We observed that few clinics kept windows and doors open, limiting indoor air circulation. Ensuring adequate natural and mechanical ventilation often conflicted with perceived levels of personal comfort. For instance, most clinics were equipped with fans and air-conditioners which were used on very hot and humid days, while windows and doors were kept closed in confined spaces. The use of mechanical ventilation was often reduced to a minimum to comply with cost-saving requests imposed by leadership.

In other clinics, the equipment for mechanical ventilation was not functional. A sense of apathy regarding the possibility of getting equipment repaired was pervasive:

“The fans are not working, and the ventilators are not functional.…. the maintenance is provided by the guy from district….Yes, reported [equipment is dysfunctional]. Ummmmm. Eish… I don’t remember [when last reported].

[Health worker, interview; Clinic 5]

Ultraviolet (UV) lights were absent in the majority of observed clinics. In Clinic 3, the IPC manager noted that UV lights are: “…expensive to purchase and the maintenance is an issue. The DOH [Department of Health] doesn’t want to invest in them”. More generally, slow and bureaucratic procurement tender systems led to delays and in some cases, provision of sub-standard items:

“You want something of quality, but they are always only accepting the cheaper solution. For instance, there was a time that we used gloves that broke easily and did not fit properly. This led to an incident.”

[IPC manager, informal conversation, Clinic 3]

Personal respiratory protection

We observed variable responses to the use of personal respiratory protection in clinic spaces. We note two interacting themes–the low perceived risk of TB acquisition and organisational normative practices around PPE that contributed to poor compliance with personal respiratory protection measures. PPE including N95 particulate respirators and surgical masks were in sufficient supply across all clinics, however, these were not consistently in use when required.

“We have masks, but you know, nobody wants to wear a mask the whole day sitting there. But we do have in all the service areas. We have got the N95 and the surgical masks. We are supposed to be using the N95 masks in all the service areas and then the surgical mask whenever dealing with the patient”.

[Clinic manager, interview; Clinic 1]

“It’s a challenge to wear a mask, because other HCWs may think that you are making them look bad, and so do patients. If it is a uniform measure, it would have been easier.”

[Speech therapist, informal conversation; Clinic 2]

In one clinic, an occupational health nurse reported periodic assessments to evaluate the acquisition risk for TB and other infections. Assessments included checks on staff’s wearing of N95 respirators; non-compliance was recorded in books in case staff developed TB, implying this was largely viewed as a matter of individual choice and responsibility.

We noted that respiratory protection programmes were not effectively operationalised and training of staff on respiratory protection was sporadic. One staff member recalled undergoing no practical training on donning or removing PPE. Another staff member had misperceptions about the types of face-coverings:

“The N95 mask protects the nurse from getting an infection from the patient but does not protect the patient from getting infected by the nurse.”

[Nurse, interview; Clinic 1]

The same staff member also reported disposing of N95 masks after each use as soon as practically possible, suggesting a potential lack of awareness on proper usage, disposal and reuse of respiratory protective devices.

We probed staff on the perceived risk of contracting TB; staff expressed the (fallacious) opinion that hospital-acquired TB was a rare event or that the risk of TB was located in specific spaces or patients (e.g., patients taking MDR-TB treatment, which was not delivered in these clinics). A TB nurse reported that mask-wearing was not a working norm or practice but guided by staff members’ “own judgement of risk” as well as their threshold of discomfort in wearing a mask:

“I have never contracted any infection. Actually, we are supposed to wear masks. But …I personally fail to wear a mask because it creates a mist on my glasses, then I cannot see. If it happens that I touch the patient, I do wash my hands. Even before. There is a spray.”

[Senior health worker, interview; Clinic 5]

Mask-wearing, therefore, was not seen as an institutional norm and enacted collective behaviour but rather, an individual choice based on the perceived risk of acquiring infection. Linked to the lack of a distinct ethos of patient and health worker safety with regards to the transmission of TB, it is perhaps not surprising that staff developed alternative narratives of personal protection. When asked how they protected themselves, practices such as “keeping a good distance from patients”, “having a good healthy breakfast” and “asking for protection from God” indicate that for some health workers, the risk of contracting TB might be inherent to working in this setting but not perceived as an imminent personal threat requiring concerted action.

Limitations

Our work focused on the implementation of TB-IPC in six clinics and in one province; the findings may not be generalizable to other provinces of South Africa. However, this is inherent to our method: ethnography does not aim to achieve generalisability, but rather an in-depth analysis of the meaning of practices and interactions in context. Our findings are transferable in that they indicate what dynamics must be considered when studying the implementation of TB-IPC, or indeed IPC practice more generally. At the same time, we recognise the complex dynamic that plays itself out in individual clinic settings is unique, and the balance of forces in each setting is differently nuanced, which means interventions to modify ‘software’ issues discussed in this paper need careful co-adaptation.

We had limited contextual data collected through direct observations from Clinic 5. We, however, believe that in-depth accounts from a senior health worker provided rich and detailed descriptions of TB-IPC practices in this clinic. Interpretation of our findings was influenced by researchers’ individual perspectives, inherent to an ethnographic approach, yet at the same time balanced through consultation and discussion with the wider multi-disciplinary team that we are part of.

Finally, our fieldwork was undertaken before the global outbreak of COVID-19, and some IPC practices in clinics, for example, mask-wearing, are likely to have changed as a result of new directives. Nonetheless, our insights on the wider dynamics of systems hardware and software remain important for sustaining and improving TB-IPC practices in resource-constrained TB-burdened settings.