The Evolution of Health and Welfare Policies in South Africa: Inherited Institutions, Fiscal Restraint, and the Deracialization of Social Policy in the Post-Apartheid Era

Article excerpt

  Institutions which have died as creeds sometimes continue,
  nevertheless, to survive as habits.
  --Richard H. Tawney, 1931 (1)

The central question in this essay is: Why is the social policy reform program of the post-apartheid African National Congress (ANC) government failing to achieve its egalitarian objectives? Many commentators locate the answer in the embrace of "neoliberal" economic and social policies by the ANC ruling party and the abandonment of its historical commitments to redistribution of the wealth of the country as contained in documents such as the 1955 Freedom Charter, which called for the sharing of "the national wealth of the country" among all South Africans. (2) By "neoliberalism," I refer to those economic strategies and political objectives that privilege the market over the state, and call for (1) the diminishing of the economic influence of the state through privatization of state assets, (2) the state becoming a non-intervening regulator of economic relations between capital and labor, (3) the reduction in social support for the poor and unemployed received through social security and other non-market mechanisms in favor of labor market based strategies such as public works programs, and (4) the erosion of the concept of "public good" through an increased emphasis in social and economic policy on "individual responsibility" for social goods, such as health and education.

The Growth, Employment and Re-distribution Strategy (GEAR), introduced by the government led by the ANC in 1996, had two main objectives. The first was to maintain internal fiscal restraint to eliminate rapidly the government deficit while, simultaneously, reprioritizing the existing national budget to meet social needs. Second, it aimed to implement economic reforms, such as lifting exchange controls, restructuring state assets, and developing a flexible labor market to facilitate a globally competitive, export-led growth path that would enable the economy to expand by 6 percent and create 400,000 jobs annually. (3) All these features of GEAR may reflect neoliberal underpinnings to the ANC government's development approach. It is problematic to suggest, however, that there was a singularly "correct" strategy to transform the inegalitarian nature of South African society, which the ANC had abandoned. I argue that transforming South African society is a more complex exercise than anticipated. It is conditioned by historical, institutional, and related fiscal arrangements inherited from the apartheid era, which have constrained, if not radically limited, the ability to transform the post-apartheid landscape.

To explain the limitations imposed by various inherited institutions in access to and the use of health and welfare services in the first post-apartheid government in South Africa, I use the concept "racial dualism." These inherited institutions limit the realization of social equity, whatever the particular strategy of transformation. A more interesting line of inquiry is to consider the manner in which the South African state, before and since the end of apartheid, has responded to these institutional limitations. In this essay I will review these institutional arrangements and their historical roots as they pertain to the reform of various aspects of health and welfare policies, and will attempt to demonstrate the manner in which current social policy problems in South Africa are neither new to the post-apartheid era nor mere consequences of this political change. The essay will also examine the shifts in the post-apartheid fiscal arrangements, which aimed to decentralize health service delivery in the context of a new system of provincial governments, which was institutionalized after the democratic elections in 1994. These changes have had the unintended consequence of creating a fiscal and administrative re-fragmentation of the post-apartheid nation-state in a manner similar in surprising respects to the specific and intentional racial fragmentation found under apartheid. …