Not just health: narrating access to post-apartheid care as a matter of restorative justice
Date
2016-10-25
Authors
Harris, Bronwyn
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Abstract
Rationale
Historically, South Africa’s health system perpetuated – in complex and multiple ways – the
oppression, neglect, and violations of colonialism and apartheid. The South African Truth and
Reconciliation Commission (SATRC) established that “millions of South Africans were denied
access to appropriate, affordable health care” and that the system itself was complicit in
sustaining the structural and physical violence of the past. Key recommendations were made for
reforming the health system. Yet, due to structural and political reasons, these reforms have not
been as far-reaching as was envisaged. Twenty one years into the country’s democracy, although
the right to access health care is constitutionally guaranteed, inequitable access barriers persist.
These disproportionately affect many who experienced the dispossession and structural violence
of apartheid - black, poor, rural and informal-urban communities- as well as newer marginalized
groups, including internal and cross-border migrants, and legal and undocumented refugees with
little access to health services and other state care. The social contract has formally changed from
apartheid to democracy but exclusion, including from health care, continues.
Transitional justice (TJ) processes are designed to support societies as they move from
authoritarianism towards democracy, using strategies of truth-telling, institutional
transformation, reparations, criminal prosecutions, and memorialisation. Most popularly
associated with the SATRC in South Africa, this approach seeks to restore justice to victims
through making individuals accountable, and with social and institutional reforms to ‘make
good’. Persistent barriers to health care (structural, institutional, and interpersonal) can thus be
seen to reveal the ‘unfinished work’, or perhaps more condemningly, the ‘disappointment’ of TJ
as much as they testify to unfulfilled human rights in a post-apartheid context. Yet there has been
limited engagement and ‘sensemaking’ between those seeking to reform health systems and
those designing TJ reforms.
Aim and methods
The aim of this thesis is to situate access to post-apartheid health care as a matter of restorative
justice, as part of South Africa’s broader transitional justice agenda to restore, or ‘bring’, justice
in the aftermath of apartheid. Conceptually, access is understood as a negotiation between
patients (households) and providers (health system) around the availability, affordability and
acceptability of care. It is seen as a political process, constantly conferred and translated by those
implementing and practising policies, often with consequences unintended by policy makers.
This research is nested in the Researching Equity in Access to Health Care (REACH)
project, a five year, multi-method study of equity in access to tuberculosis (TB) treatment,
antiretroviral therapy (ART), and maternal deliveries in several South African provinces,
including one rural (Bushbuckridge) and two urban health sub-districts (Cities of Johannesburg
and Cape Town). Between 2009 and 2010, access stories were collected from in-depth
interviews with 45 patients and 67 providers, and observations were carried out at 12 health
facilities. These stories have been analysed using a narrative approach for ‘making sense’ of
personal experience (stories) in relation to broader socio-political and cultural discourses
(narratives). In this approach, different theoretical lenses are drawn on as part of such
‘sensemaking’ - restorative practices and governmentality; critical social contract theory; and
street-level bureaucracy. These narratives have been theorized for continuities and changes with
South Africa’s past, and examples of ‘restorative practices’ (as more equitable and inclusive
ways of doing health care) have been sought. Additionally, theories of violence and trauma have
been introduced as a tentative step towards ‘making sense’ of the tragic murder of Harry
Nyathela (narrated in the Epilogue) – a haunting, seemingly ‘senseless’ death that fundamentally
undermines restorative justice.
Findings
While restorative provider engagements are expected in health policy, older authoritarian and
paternalistic norms persist in practice, undermining active, engaged citizenship and exacerbating
affordability and availability barriers to care (largely located in unaddressed structural violence
and poverty). Furthermore, institutional ‘logjams’ and outdated modes and infrastructures,
coupled with new epidemiological stresses, have created additional challenges for health system
transformation and those practicing care. Provider accountability remains ‘upward’ (to
managers), rather than ‘horizontal’ (to other providers) or ‘downward’ (to individual patients and
communities). Within this context of change and continuity, new identities, inclusions, and
exclusions from health care are produced, and the contradictions and disappointments of a
restorative TJ project are revealed.
Conclusions
Despite the SATRCs vision “to promote national unity and reconciliation in a spirit of
understanding that transcends the conflicts and divisions of the past,” this post-apartheid project
is incomplete and disappointing. Strengthening street-level accountability and engendering
respectful, empathetic provider practices - a restorative shift from older authoritarian modes - is
vital to improving access to services and contributing more generally to the restoration of justice
and health in society. A restorative approach to health care requires a health system that does
with providers as much as providers who do with patients. Yet, as with any regime of power,
vigilance is needed: what has changed and how? What has stayed the same and why? In
complex, subtle ways, power, violence, trauma, and suffering continue to find expression
overtime and in the everyday practices of health care, as well as daily life. Accountability
requires a collective ‘repairing’ of human relationships and a problematisation of power at the
interface of both patients and providers, and communities and the health system. For health
policies (including the proposed National Health Insurance system) to restoratively shift South
Africa’s story of ‘lack of access to health services’ towards one of ‘universal health coverage’, it
is important to conceptualise restorative justice and health system accountability as a matter for
collectives. A ‘sensemaking conversation’ that draws on lessons from both TJ, and health policy
and systems research is recommended to further locate and problematize access to health care as
a matter of restorative justice. And with this, an invitation to ‘haunting’, to seeking out and
listening to that which cannot be said yet cannot be forgotten.
Description
Thesis submitted for the degree: Doctor of Philosophy
Centre for Health Policy, School of Public Health
Faculty of Health Sciences
University of the Witwatersrand, Johannesburg
18 January 2016
Keywords
South African Truth and Reconciliation Commission, Health system, Post-apartheid, Researching Equity in Access to Health Care