Introduction: the legacy of apartheid
South Africa’s apartheid system repressed the social, economic and political lives of the majority of its citizens. It was a form of ‘racial capitalism’ that included both paternalism and a disregard for subaltern interests and aspirations. Most people lacked basic government services like housing, health care, water, sanitation and electricity. Black people were excluded from national and provincial government, and black municipalities had no power or democratic base: they were administrative agents of the white provincial governments. In the eyes of the apartheid government, there were no black urban poor. Anybody living on urban fringes without permission was there illegally and forcibly returned to the rural homelands. Whites benefited under job reservation laws, and once Nationalist party power was entrenched poor whites were almost unheard of.
The apartheid health system was one of the world’s most unequal, fragmented and wasteful. Fourteen racially differentiated health departments - ten for each Bantustan, three for the white, coloured and Indian populations, and one general affairs department -administered and duplicated services. Four provincial departments as well as 382 local authorities were also responsible for health issues. Even after desegregation in 1990, hospitals were still controlled by these segregated health departments. None of them catered for the black urban poor because, in theory, there were no black urban poor.
Apartheid ideology claimed to uphold western and Christian values, and encouraged a positivist view that conservative western knowledge systems were superior. This led to education and health systems that were imposed, top-down, authoritarian and disdainful of alternative ways of learning and healing. The present dispensation faces the problem of de-entrenching the knowledge and practices left behind after generations of this form of governance. The new policy discourse aims to empower previously disadvantaged people by addressing relations of power and knowledge, using a process of consultation through the devolution of power to local government.
This paper explores some of the contradictions inherent in both democratically changing social reality, and delivering practical changes in areas such as employment, housing, sanitation, health, and education. The focus is on building healthy cities that democratically accommodate the needs of the previously neglected urban poor. Foucault's  theoretical linking of knowledge production and the operation of power provides a useful framework for looking at a process of changing social reality. Relations of power are specific to different societies, being organised through relations of class, race, gender, religion, sexual preference and age, amongst others. However, alternative perceptions and forms of knowledge can challenge dominant knowledge systems [Weedon, 1987]. Within this actor-orientated paradigm the emphasis is on enabling poor individuals, households and communities to help themselves, with policies aimed at meeting basic needs and enhancing human development and empowerment.
What do we mean by the urban poor?
In mid-2000 South Africa’s estimated population was 43.68 million [South African Survey, 2000/2001:47], with 36.2% of economically active citizens unemployed -40.9% of the latter in urban areas [South African Survey, 2000/2001: 378-379]. This suggests that a significant population of South Africans could be categorised as the ‘urban poor’. However, there is a growing consensus - spearheaded by the work of Nobel prize winner Amaryta Sen - that aside from lack of income, poverty includes the inability to reach a minimum standard of living and well being as a result of deprivation of resources, opportunities and choices. Many South Africans’ continued poverty is intrinsically linked to the systematic entrenchment of discrimination during apartheid [Development Update, 2001:76].
Migrant labour was central to the political economy of South Africa for more than a century, and apartheid was in one important aspect the rationalised policy of labour migration. The policy restricted the movement of entire families to urban areas, and male circular migration was predominant. Although apartheid’s demise has changed the pressures and demands for labour, it remains unclear how these changes will affect future forms and patterns of labour migration. Current estimates are that more than 2.5 million legal, and many more illegal, migrants - from rural areas within South Africa and from neighbouring countries - work in South Africa’s mines, factories and farms. [Lurie, 2000: 343.].
Contemporary South Africa migration includes a significant shift of people from rural areas to informal settlements on the urban peripheries. Government’s response to this major problem has been to make forced removals a feature of life in South Africa once again. For example, in the Alexandra renewal project the euphemism for removal is the ‘de-densification of appropriate land.’ People who have built houses illegally in Alexandra are now being moved to outlying areas. Government argues that this is ‘not dumping people but assisting them. We are moving them from an area that is hazardous to their health and providing them with a piece of land. The previous government didn’t do that’. However, the people who are being moved to Diepsloot are angry because they have no access to electricity and running water as they had in Alexandra [The Sunday Independent, 24 June 2001].
The urban poor include growing numbers of street children and orphans. The Health Systems Trust estimates that AIDS would orphan more than 2 million children by 2005 [South African Survey 2000/2001]. Managing this development alone will require the joint efforts and resources of a number of government Departments such as Welfare, Education, Water Affairs and Housing.
The Transformation of Local Government: Defining `Urban.’
I. The Municipal System
Since South Africa’s first democratic elections were held, its system of governance changed radically. At the time of change, political parties and analysts agreed that strong provincial governance was critical for effective service delivery. The outcome was constitutionally guaranteed autonomous provincial governance, and municipalities becoming directly responsible for the provision of services to the urban poor. The wall-to-wall entities created by the Municipal Demarcation Act of 1998, with powers and responsibilities to deliver health services, replaced a mixed-up system of municipal, local, rural and homeland councils. There are three municipal categories: metropolitan [unicities]; district municipalities; and local municipalities. Several local municipalities make up one district municipality [Nicholson, 2001].
This system is expected to increase municipal powers, responsibilities and accountability. For example, local government now takes responsibility for providing health services. The transformed local governments have greater political status in the attempt to address the empowerment of previously disadvantaged people. However, there is still no solution to long-standing problems such as lack of adequate finance, capacity and skilled administrators.
II. Primary Health Care
The new national devolutionary approach to public health is based on principles of primary health care within a District Health system, replacing the apartheid’s emphasis on a curative bio-medical approach using hospital-based care, medicine, and advanced technology. The new approach attempts to employ principles of consultation and local empowerment by giving more power and responsibility to municipalities:
Resources must be distributed equitably, meaning that those areas with the least resources should be given the most assistance.
Communities should meet their different needs by being involved in the planning, provision and monitoring of health services.
A greater emphasis should be placed on services that help prevent disease and promote good quality health. This is a shift away from curative services.
Technology must be appropriate to the level of health care. For example, this would mean ensuring that all clinics have fridges for the storage of vaccines before equipping them with high-tech facilities.
There should be a multi-sectoral approach to health. In the Primary Health Care approach the provision of nutrition, education, clean water and shelter become central to health care delivery. So, for example, the department of Water Affairs and Education are important role players within the health system [Nicholson, 2000:26].
This offers communities a more developmental approach to health, in which they are not merely passive recipients; resources and finances shift away from high-tech tertiary hospitals to primary level services; and specialist doctors would play a more supportive role to nurses in clinics. The development of professional nurses who can manage clinics is key to this system.
III. Health Delivery: The District Health System
With the demarcation of municipal boundaries completed, the boundaries of the 180 health districts must be aligned with the new municipalities. For the district health system to work effectively it is important to get the size of the district right. It should be large enough to contain the full range of health services including a district hospital, but small enough to allow efficient service delivery and community involvement. The urban poor are often migrants, making planning and effective delivery a serious challenge. Many are ‘squatting’ illegally on non-residential land on which there is no proper provision for sanitation and water. The shifting nature of these communities also makes it difficult to implement the principle of giving them any real say over their own health care
Challenges in implementing the system
I. Financing local government
Introducing the new Health System is not without its problems, and its integration with the new local government system is by no means complete. Many South African municipalities are in a serious financial crisis. By mid-June 1999 an estimated 633 of the 843 local authorities had debts in excess of R9.3 billion which, together with serious capacity problems, impacted on their ability to deliver services [Reconstruct, 1999]. Part of the plan for financing local government was that wealthy communities within the new municipalities would finance the development of poorer communities. With a few exceptions, this has rarely worked because of the huge disparities in service provision inherited from apartheid. At the time of writing residents in the uThekwini [Durban] unicity are protesting over massive rates increases imposed without consultation. There are many rates and service-fee defaulters, and a number of municipalities have suffered from poor financial management. In some of the poorest areas, local government has little chance of raising revenue. It is still not clear how municipalities will be financed, but many may remain dependent on national revenues for some time [Nicholson, 2000].
II. Financing the Primary Health Care System
The re-allocation of resources to the primary health care system means that hospitals throughout South Africa have suffered. In July 1999, a provincial commission of enquiry in Gauteng investigated hospital care practices at several provincial hospitals [Chris Hani Baragwanath, Sebokeng Academic, Natalspruit, and Tembisa ] after complaints from both health workers and patients. Financial constraints were identified as the core problem. The commission noted that public hospitals lack capacity and infrastructure for coping with growing demand. Hospital managers cited the provision of free primary health care and treatment of children under five, as well as the demand for abortion, as causes of greater pressure on the system. The HIV/AIDS epidemic is also putting undue pressure on available resources for health delivery. [South Africa Survey, 2000/2001:237 -238]
However, as clinics become better staffed and better equipped they are beginning to take the pressure off the hospitals. A spokesman for the KZN Department of Health reported that the number of unbooked mothers delivering in hospitals dropped by 80% in 2000, and that while maternal mortality rates dropped significantly at clinics they increased in hospitals indicating that the referral system is starting to work. Unfortunately, the AIDS epidemic has significantly affected the new system, making it difficult to assess how well it is working [McGlew, 2001].
III. The Relationship between provincial and local government
The devolution of power to local government calls for a clearer distinction between provincial and municipal powers. The powers of provinces in relation to delivering health services are fairly deeply entrenched. The KwaZulu-Natal provincial Department of Health has direct control of 62 hospitals and 500 clinics, all funded and run separately from the unicity and district municipal clinics. The long-term aim is for municipalities to provide all delivery, and for the province to build capacity, monitor the delivery of health services and provide strategic and policy direction. However, there has been no decision on how to manage the staffing and financial implications of this change. For example, the transfer of health workers becomes complicated, because provinces and the municipalities offer different conditions of service.
IV. The National Government’s shift towards centralisation
One response to a lack of capacity and delivery at local level has been for the State to take more control over the provinces, a debate within both party and government that has intensified during Thabo Mbeki’s presidency. A recurring feature in the debate on the devolution of provincial powers has been whether national government had given the provinces enough powers to bolster their capacity and ability to deliver. Some argue that provinces act largely as implementing agencies for central government, which sets the direction in health, education, and welfare. This tends to stifle the development of talent and energy at the provincial and local levels, and central government is accused of undermining its own principles of grass roots capacity building and participation. [Development Update, 2001:12 -14].
V. The role of traditional leaders
A major issue during the negotiations preceding the 1994 elections was how to reconcile traditional institutions with the new democratic order. At the local and district level in rural areas the amakhosi [traditional leaders] were accorded ex-officio status. However, legislative inertia surrounding the precise roles and functions of traditional authorities has largely reduced constitutional bodies for traditional leaders to ceremonial entities. Traditional leaders have voiced serious concerns about the transformation of local government, mobilising against the changes expected to follow local government elections in 2000. Some compromises were reached, but the impasse between government and traditional leaders remains.
These difficulties are inherent when transforming to democracy from a hierarchical, authoritarian system of governance. Traditional leaders played a political and administrative role in the former homelands and self-governing territories. Colonial and apartheid legislation conferred on them the standing of local bureaucrats. However, pre-colonial institutions were themselves inherently patriarchal and hierarchical, with leaders claiming inherited rights to rule. It remains to be seen how much support will be given to traditional leaders who resist the new discourse of representative elective democratic governance.
VI. Traditional Healers
Traditional healers’ holistic and cosmological emphasis on health has played a significant role in resisting the bio-medical health model. Widely held and espoused in both rural and urban areas, traditional medicine is pivotal to indigenous social structure and religion. Practitioners are thus highly resistant to change, having maintained individual and social equilibrium for generations. Traditional healers are an example of Foucault’s thesis about the production of knowledge, its relation to power, and the ability to resist alternative forms of knowledge.
In South Africa, bio-medical practitioners still tend to scorn traditional medicine, advising people against healers’ advice and medicines. Others seem to have reconciled these two systems, however, and recently government has taken significant steps to recognise the contribution of alternative healers towards health delivery. First, they are often more accessible; second, they live and work in the community; and, thirdly, although they are not cheap, they are a source of comfort and care for many. On the other hand, some practices, such as sharing razor blades, are clearly dangerous in the context of the HIV/AIDS epidemic, and healers need to be persuaded to change in this regard.
VII. The HIV/AIDS Epidemic
Like most of sub-Saharan Africa, South Africa has been hard hit by HIV/AIDS. The government’s responses suggest that HIV/AIDS education programmes have paid insufficient attention to Foucault’s linkage between knowledge production, social practice, and ways of being. In spite of concerted education and communication campaigns the epidemic has not been contained. Sectors of the South African population, including the State President, have either consciously or unconsciously resisted valid bio-medical explanations of HIV/AIDS and ways of preventing infection.
Local government responses to the epidemic are unsatisfactory, suggesting some kind of resistance to the information about the disease. In his HIV/AIDS impact report to the Durban unicity council [Mercury, 27 June] Mr Bheki Nene noted that the council’s responses to the epidemic have been uncoordinated, fragmented, ad hoc, and sectorally focussed. Many sectors had only recently responded to the impact of the disease, while others were yet to respond. The report recommended that an AIDS co-ordinating committee should head the implementation of a council action plan.
Campaigns that overcome this resistance have to employ methodologies that accommodate the participants’ belief systems, and which also promote community participation in planning, providing and monitoring health services. However, Winifred Bikaako  cautions against uncritical use of Western style participatory principles and practices. External objectives and organisational methodologies often dominate these methodologies, not necessarily increasing local autonomy and eliminating dependence. Although traditional ‘pre-western’ organisational forms, often hierarchical in structure, clearly conflict with group approaches, they remain part of the social reality to be changed.
South Africa’s new health system is decentralised, emphasising Primary Health Care delivered at district level. The approach is equity driven, to cater for both the urban and rural poor. However, there are challenges to implementing the approach, and provinces and local governments need to co-operate with commitment and integrity for the system to fall into place.
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