Could you please send me a copy of your journal article. I am a PhD student researching on the the illness experience of breast cancer in the context of public health care.
The current problems with the South African school system are not very much different from those of other developing countries. The capitalist neo-liberal educational paraphernalia revolving around the centres of achievement, progress and consumption have not been able to ameliorate the current social ills in our societies with regard to access, inequality, unemployment and lack creativity and innovation. The system has provided a façade to legitimate hierarchy and the acceptance of the neoliberal ideals by the peasants and the working class as the natural order of things. The system has resulted in a pyramidal societal structure whereby the poor are condemned to the base of the society and those whose values are espoused by the system are elevated to the upper echelons of the society. Despite the repetitive failures of this system to bring transformation with a human face, it has become almost a fetish for even the comprador bourgeoisie have been baptised in the name of these values hence they have turned to manipulating the system in ways that suit their new interests but at the same time providing the basis for its continued existence. The system instead of liberating the people from the clutches of the demands of a capitalist economy, the neo-liberal school system sees to it that the system continues to churn out more certified matriculants thereby creating a reserve army of cheap and flexible labour force. Thus societies being led by the comprador bourgeoisie- most of whom now own the means of production and also control the profitable tender systems cannot be liberated by the current school system which is functional only to the capitalists as the basis for cheap labour to ensure realisation. In steady of the school system ensuring liberation and self-sufficiency among the citizens, the current system is based on the jug and mug relationship which baptises the young people in the name of docility and passivity. The students are made to accept bureaucracy and to stop to think for themselves. Thus the young people are made to consume ideas which have been churned out by others, ideas without any relevance to their lived realities. The system is not interactive, but the students are made to worship their teachers who are the agents of the capitalist system, with them as empty depositories. The system has failed to prepare the young people for real life whereby they could do things for themselves rather than depending on the capitalist economy as labourers for their sustenance. The school system teaches pupils discipline which means taking everything as ‘per book’ whilst any form of creativity or research that does not fit into the prescribed systems is regarded as deviant and the owner has to be excluded. Such a system prepares the pupils for their lives in a capitalist society as uncritical consumers of capitalist production. Thus the school system alienates just as the alienation of labour in a capitalist society as expounded by the Marxists.
Real societal transformation that is accommodative will not happen as a result of the unending capitalist quest for progress/growth of the economy but as a result of changes or shifts in the ideological material equipment which makes people creative, innovative and confident to make a living by doing things for themselves rather than depending on the capitalistic economic employment capacity whose reality is questionable. Thus the Public Positions Seminar on the merits and demerits of the current school system in South Africa reaffirmed the dysfunctional nature of the current system with its emphasis on credentials and certification as the only way to succeed in life. This belief mythicizes reality and has since been churning out huge numbers of certified matriculates incapable of doing things for themselves and could not be absorbed by the capitalist economy. In most of the cases it has been proven that certification is not a proof of competence. Thus certification will never be a substitute of experience hence Ivan IIIich’s call for a DE schooling society.
Important note however is the failure of the discussants and current scholarship to acknowledge the ideas of other people. Some of the ideas which were raised have their origin in Ivan IIIich’s compendium that is the DE schooling society of 1971, some of which were later on elaborated by Paulo Freire in his Pedagogy of the Oppressed of 1974. Thus according to IIIich the school system offers a packaged education and awards credentials for successful consumption of the packages. These packages are continually re-written and adjusted but the problems they are supposed to address remain. Thus to IIIich, this system is a commercial activity mirroring the marketing processes of the persuasion industry. Children are promised paradise by the continued consumption of these packages. As a solution to the dysfunctional system, IIIich proposes learning webs were by people with common interests would come together supported by the government and learn by doing things in an interactive way. However, countries differ, human beings are historical and our realities are particular historical conditions. As a country we are supposed to learn from other communities but most importantly from our historical trajectories with development. Our current struggle with ensuring justice is never separate from social economic justice underpinned by ideals of equality and equality of opportunity hence the idea of social levelling. In the equalisation of the conditions of our existence, our schools conditions should take precedence for these have a say on the subjects that are taught and how they are taught and the ways in which they bring about transformation. Communities in other countries have leaned towards solidarity economies with emphasises on the humanness of human beings rather than the unending capitalist quest for competition and progress. Thus the school system has been brought into an ecology that emphasises, inclusivity, communitarianism and community sovereignty rather than the alienating vices of the capitalist school systems. Success in a capitalist school system does not reflect intelligence or hard work but whose values are espoused by the system. Success in a capitalist system is not a result of success within the school system but is a reflection of who owns the means of production and one’s position within such a society. Thus this system has spawned multiple exclusions and only a few from the middle class with an insatiable appetite to consume resulting their conditioning at school is accepted whilst the vast majority are condemned to poverty. These are the few whom we see in places such as Mabonang, Braamfontein, and Newtown in Johannesburg. These are to be protected for their consumption form the basis of capitalist accumulation without which the system cannot survive. Thus an analysis of the working of the current school system outside the capitalist underpinnings will just cloud the realities which we are seeking to comprehend.
Reforms in South Africa have not brought about the much required transformation for the people can only be liberated with their reflective participation in the act of liberation. They have only been carried out at the level of repackaging the text books by the technocrats. The repackaging has not resulted in any fundamental changes with regard to people’s lives, for the problems they seek to solve are still with us but has ensured high returns to the technocrats. The pupils’ portfolios though a step in the direction, at present are just a miniature symbol of independence but manipulated in various ways for the generation of pass marks in a bid for the 100% pass rate. Critical subjects are no longer deemed so for many are forced to drop them for the schools to guarantee the 100% pass rate. The 100% fetish has impacted negatively on the production quality. There has been a misalignment of the reforms implemented and the diagnosed problems. This is a farce to keep the capitalist machine running. Paulo Freire noted correctly that to affirm that people should be free and yet to do nothing tangible to make this affirmation a reality is a farce. Thus the current school system based on the mug and jug relationship of the teacher and the student will not liberate us from the current predicament. What is required, are the structural changes taking in to consideration that everything is enmeshed in everything else.
I am in general agreement with the picture that Marie paints of post-apartheid urban policy and planning and its consequences. Much of post-apartheid urban policy – to the extent that there has been one – has resulted in greenfield public and private development and service delivery to under-served areas without confront spatial form. The result of this has been, in many instances, to actually accentuate spatial disparities rather than fundamentally confront them.
However, I would suggest that beyond these general statements, we need to be conscious of the fact that patterns of post-apartheid urban development vary quite substantially by city. A focus on the shift from “leafy suburbs” to elite “themed estates” might miss the changes that have taken place in the bulk of former minority suburbs in terms of a slow (at least in some cases), but nonetheless steady, change in race profile of residents. Further, at least in Durban, the trend has been for substantial former buffer areas of apartheid planning to be settled informally – with around 1/3 of the 250 odd informal settlements in these areas (some already subjected to in situ upgrades) and around a quarter of informal dwellers living in these areas. In Durban it has tended to be true that this has been at its most noticeable around former Indian residential areas such as Chatsworth, Shallcross and Resevoir Hills. It is also true that substantial portions of these buffer strips coincided with natural barriers to formal development such as river valleys and areas with quasi protected open space and what planners refer to as over-steep land. These continue to be invaded by informal settlers as the Municipality struggles to keep up. The fact that these areas are often traversed by major roads or are also in close proximity to existing or new employment notes makes informal settlement in them all the more desirable.
In Durban issues related to the Ingonyama Trust are also critical when looking at both existing and future urban development. Some of Durban’s largest townships such as Umlazi, KwaMashu, Ntuzuma and Mpumalanga were formerly part of the KwaZulu-Natal homeland and as such carry the designation of being R293 townships where tenure issues remain caught up in the Ingonyama Trust being the “custodian” of the land. This has substantial consequences on households, but also on the scope for effective planning interventions. Most recently it has been noted that on Durban’s peri-urban periphery areas under traditional authority have witnessed the fastest growth in densities (from a very low base).
In terms of the impact of the Development Facilitation Act from 1995, in setting up tribunals to determine planning approvals outside the Municipal decision making channels (eventually shown to be unconstitutional), it is undoubtedly true that this promoted sprawl for both low cost housing and elite projects. Although national policy frameworks and Municipal plans might have articulated a need for some measure of spatial justice, it was not possible in a context where interim local government structures competed for development and then the DFA tribunals often rejected Municipal concerns about forms of sprawl.
The outcomes of this, as Marie suggests, was further aggravated by a desire – certainly at provincial level and also at a national level – to control housing delivery in space through a failure to decentralize. The impacts of this have been accentuated in KZN where the Province has obsessed about rural housing and been somewhat less eager for projects in major urban centres.
I am somewhat less encouraged by SPLUMA’s reinforcing of the scope for local decision making authority of planning decisions. This is in part because SPLUMA seeks to replicate the tribunal approval system within the Municipal context which could, noting the balance of forces in the development terrain and the growing proximity of the political leadership with private development interests, actually continue to deliver outcomes similar to those of the DFA. As of yet no indication has been received of regulations governing how tribunals will be established and how appeals matters would be dealt with. This must also be seen in the light of attempts to reform the National Environmental Management Act to be more “pro-development” by cutting down on objection periods for developments where EIAs have been done. A number of national ministers have also expressed an eagerness for the Infrastructure Bill to avoid large scale strategic state projects being subjected to EIA and planning delays from local government. More recently it has been proposed that the mining minister be given discretionary powers over water and environmental approvals for mining rights and development applications. These tend to send very mixed signals and we are likely to see the intent of the Constitution being tested again in future.
Marie, drawing in part on Lefebvre’s work, argues for greater local autonomy and decentralization in the paper. However, the issue of enhanced local autonomy in planning and development matters remains somewhat clouded by other processes. Like Marie, I have been somewhat skeptical of the established “left” critique of decentralization as bringing with it threats of reduced redistribution. However, the South African experience has shown that a national state can be just as easily subjected to influences as a local state can be. In fact if we look at experiences in selected cities in Brazil, Peru and even India, one can see that a local left agenda can be constructed – perhaps with difficulty – in a context where a province/state and federal agenda might be less strident around issues of social justice. This perhaps depends on a much more fluid political culture – or a more highly contested political environment at different scales. Direct elections for mayors in Brazilian cities (as in places such as France) raise the status of city Mayors as important national nodes of political influence. In South Africa, despite the intent of the constitution to deliver us three relatively autonomous but interdependent spheres of government, we have a highly hierarchical political culture where, barring one or two exceptions, mayors in large cities are minor figures in the political structures of the ANC – with only a few serving city mayors having been elected to the ANC NEC in the past two decades and few if any former city mayors having risen to high office in the ANC. The culture of politics – and more especially that of the ANC – reinforces a notion of city political leadership as being directed from above. This means we cannot just rely on policy and legal changes around local autonomy. There is little in the way of local policy risk taking but city leadership on issues such as settlement planning and development. eThekwini political leadership value compliance awards from national local government on housing issues more than praise from local civic groups for local engagement.
In considering decentralization from the national centre to the local one must also confront the extent to which the local itself has been embroiled in projects to advance certain class interests. The settling in of a political establishment in many cities with very well paid politicians and political appointees has been an important element of how the ruling party has generated some form of hegemony. This has had a side effect of supporting formal and informal coalitions of elites (old and new) in driving municipal agendas towards the embracing of projects which can be highly contradictory in that they carry both redistributive and elite-driven patronage agendas.
Furthermore, if we take Lefebvre’s views into account we also have to look at within-city decentralization and the scope for forms of citizen-self organization of activities and processes. We do see citizens taking action in our cities – although it is not always welcomed – such as in informal settlement or protests. But the tendency has been for cities to not create decentralized forms of urban management and decision making where some level of co-determination with citizens is cultivated. We have centre-driven consultation processes such as those for IDPs or perhaps for budgets but the do not involved devolved decision making or any meaningful autonomy to areas within cities. Durban has explored Area Based Management – but more in the new public management sense then as a commitment to local level decentralized governance processes. Other cities (and Durban too) have also developed a range of urban improvement or city improvement district models where specialized management systems are put in place to recognize the selected areas as being “special” in one way or another. These might give some interests a greater local say over how an area is managed but they are by no means a solution being offered (or even appropriate) to the bulk of districts or precincts in a city. In fact these arrangements can be seen as lessening the scope for certain urban dwellers having less of a right to the city.
I would suggest that in thinking about our cities we must gain a better insight of how our politicians at all levels view the city. I have noted, over time, how anti-urban many of our politicians are – granted some are more so than others – but I have rarely seen an elected local, provincial or national politician singing the praises of urban life. You might consider this a mere product of the alienation from urban possibilities under apartheid or under the post-apartheid city arrangements that Marie has characterised. However, I think far to many of our politicians are comfortable with an idea of the city that is constituted of little more than tar roads, basic services, patterns of public housing and shopping malls along with some zones of exception. I do not know how else to phrase this but as a lack of ambition for the urban – not just perhaps in our dry policy documents with their drop down lists of technocrat’s utopian menu (sustainable, equitable ...) – but also critically in our political leaders framing of the commitment to the urban.
I thoroughly enjoyed the contributions given by Sue Parnell from UCT particularly when dealing with understanding the state’s role in urban planning. The state requires both political and technical muscle in order to resolve issues of sustainable urban development and determining who has the right to the city. For so long the working class has been excluded from using the city in the battle of anti-capitalist expansion as seen by citizens of Abahlali basemjondolo. Parnell provocatively remarked that until there is a single system, instead of a dual system that is conflicted between modernity and tradition, we will never achieve universal rights to the city. The state does not operate on its own in South Africa which makes the question on who has the right to the city a difficult question to tackle. Traditional leadership and other sectors in civil society have a pivotal role to play. The underlying tone of the discussion for me was that there needs to be real politics in play, a situation where social movements and other civil society organisations place greater pressure on government, in order to rectify the glaring disconnection between the local government, traditional leadership and NGOs. This goes back to the point made by Parnell that implicit in the notion of the ‘right to the city’ is an assumption that the state is solely responsible for delivering this right. I think these ties in with a later response given by Marie that greater responsibility needs to be shared amongst social movements, lawyers, and technical people to reverse the planning system of Apartheid and ensure better housing and service delivery. Even though there was much consensus on the disconnection on many levels, the pertinent question remains and that is how will this all be resolved?
The public positions seminar on urban spatial justice brought out a number of important insights with respect to policy, justice and inclusive development. However, to note is that, ‘designing a dream city is easy, rebuilding a living one takes imagination’ [Jane Jacobs]…The city is not a problem that can be solved. It is the eternal impossible question of how we strangers can live together. Rebuilding a living city – a city which jumbles together multiple and conflicting differences – therefore requires less a utopian plan than a poetics of political imagination (Donald, 1997: 182).Though the seminar critiqued urban spatial injustices in relation to neo-liberalism’s demand to open up new spaces for accumulation and to protect the old spaces to maximise the same, the seminar did not however go beyond these , to look at the more cardinal and critical issues important in the generation of urban spaces-the unfairness involved. The discussion missed the importance of the alliance between bankers, financiers and developers- a critical alliance-a force that shapes the built environment .Even the critical Marxists theorists were unable to perceive the crucial link between urban space generation and the accumulation space. The Marxian theory has a blind spot when it comes to looking at matters of the city, spatial competition and the production of urban space-all reflecting the Poverty of theory. Thus the Marxists have not managed to integrate an understanding of processes of urbanisation and built environment formation into a general theory of and into the laws of the motion of capital. This is despite the fact the all crises in the world 1929, 1973, 1987, 2000 and the recent financial crisis all were rooted in asset accumulation and collapses of the property market. Thus the Marxist theory is content in explaining these crises in terms of tendency of the rate of profit to fall, under consumption and over-accumulation. However, without an understanding of the capital formation and the profit realisation processes now is being spearheaded by neo-liberalism it would be impossible to comprehend the growth of exclusionary cities and of informal settlements. With its bid on opening up new spaces for capital accumulation through new kinds of dispossession such as the privatisation of basic amenities, neo-liberalism has caused many hardships for the poor sending many of them into the informal sector. The growth of informal settlements occurred within the accumulation processes marked concomitantly with the growth of gated communities and expensive waterfront settlements especially in Johannesburg. Again despite the neo-liberal call by De Soto for a city with many small traders, a city that integrates the informal and extra-legal activities into the mainstream the greater neo-liberal forces have devised other means of social exclusion now based on the ability to pay (consume). Thus the growing gentrification currently being witnessed in Johannesburg in such places as Braamfontein, Newtown and Mabonang all spawned exclusion based on the ability to consume. Neo-liberalism is about profit and its designs are for ‘cool cities’ capable of attracting FDI, tourists and the middle class for consumption. As capitalist mode of production, it is associated with the need to accelerate the realisation process and not the need to improve the human condition. Thus artists, the academia and other members of the middle class with the potential to consume have to be ‘protected from’ being disturbed by the poor in these places. These views have blocked the development of compact cities with the capacity of mixed settlements and accommodation spaces promoting social integration. The divisionistic approach to city development has led to a number of protests, even wars worldwide as the poor tried to gain their citizenship and other opportunities by invading the cities. This exemplified by the crisis that ensued following the Indian government’s neo-liberal false solutions to Dharavi informal settlement in Mumbai in 2010.Instead of involving the poor in crafting solutions to urban settlements utopian plans, as the Indian government tried to solve the poor’s access unintentionally furthered their dispossession and the accumulation of capital by the capitalist. However, a realistic approach by the Brazilian government of Dilma Rousseff has greatly improved the conditions of the poor by taking an integrated approach through the involvement of the poor, their representatives, NGOs and the government in working out solutions to the growth of informal settlements in the cities. This approach was able to shift the towns and cities away from urban goals, visions and stratagems of the northward looking and prostrated elite to the far more demanding objectives of achieving inclusive, equitable and sustainable cities. Thus despite the existence of the New national spatial planning legislation of 2013 which seems highly contradictory, as humanity ‘we either uphold through our planning interventions and thinking the Right to Inequality and Wealth’ or ‘the right to freedom from Want/Poverty -to stop civilising, exterminating and bombing the natives; to stop keeping the Poor Poor; and to rethink the status Quo’ (Khan Firoz, 2014)
The discussion that took place around the Right to the City confirmed that our cities can only truly be changed by confronting the problem of urban exclusion from all of its many angles. Policy prescriptions frequently rest on the illusion that purely technical solutions can help to change our cities for the better, neglecting the persistent political dimensions which relegate the poor to the margins and squalid interstices of our cities. Political engagement is therefore crucial to the success of any efforts to etch the Right to the City on our urban landscapes. But this does not mean that the technical dimensions should be ignored. What emerged clearly in the discussion was the need to combine a multiplicity of perspectives which all too often remain compartmentalised – the political, technical, economic, and legal. An instructive example of the benefits of a more holistic approach can be found in Brazil, where the inscription of the Right to the City into the legal code was achieved thanks to the work of progressive lawyers who, in conjunction with mechanisms for popular participation, attempted to translate political aspirations into technical formulations. The discussion also focused on the potential merits of decentralizing urban planning functions, prompting questions as to whether this devolution of power is possible under the present political and policy context, and, crucially, whether bolstering local government actors is in fact desirable in the first place. Can municipal officials really be trusted to deliver a progressive urban vision? Might traditional leadership present an obstacle to this vision? The debate around the Right to the City prompted difficult questions which cut to the heart of how our entire democracy functions, a debate which urgently needs to be continued with broadened participation.
Who owns the land in and around cities? It would be fascinating to see a map of property ownership in cities, what parts of the city are in fact public and what are private. What problems come up when the government wants to purchase land for the ‘public good’ in cities? Expropriation is difficult and takes a long time if there is no agreement within government itself on what the public interest is. Huchzermayer made the point in her paper that ‘In the absence of any definition of these interests, economic growth and global competitiveness framed as national or public interest irrespective of the spatial configuration they demand, may continue to trump municipal level plans to redress urban spatial imbalances.’ Even the apartheid government with its profound commitment to spatial segregation had within its different departments, and different parts of the public, conflicting ideas of how to use land for the public interest. I can use an example from my own research. When the Native Affairs Department wanted to buy white-owned farms to extend the rural reserves in a particularly fertile part of the old Northern Transvaal it fought with the Department of Lands and white farmers associations for decades over what the public interest was: good land for Africans in the context of spatial segregation? Or protection of water sources and conservation of mountain slopes? Or allowing white farmers to use the land for commercial farming for which the land was eminently suitable, which would contribute to economic growth? The NAD had the power to expropriate… but only once it was agreed that their proposed use of the land was in the public interest – a question which generated reams of letters and reports over almost a twenty year period. This delayed the essential process at the time of ensuring that Africans being evicted from farms in their thousands had a place to go in the context of a segregated society. The task of spatial integration in cities may be just as difficult, generating as much conflict and bureaucratic inertia. And so far there is not as much political zeal for integrating the poor into cities as there was for segregation during apartheid.
Interestingly, rather than blaming indolence as many often do, Huchzermeyer highlights the persistent political impetus behind the unintegrated city in South Africa. Here class has been a key spatial cleavage. She argues that provincial authorities overrode municipal spatial planning initiatives as the provinces vied with each other for economic and political prestige. The private sector was given pride of place in a bid to encourage investment. And to win electoral support, provincial authorities rolled out low cost housing on the urban periphery.
Panellists questioned, however, if municipalities would do a better job if left to their own devices. An argument in favour of local autonomy is that municipalities keep a closer ear to the ground and are thus more responsive to the demands of communities who would otherwise struggle to make their voice heard, such as informal settlement organisations. But whether this is really the case is open to debate, particularly in the absence of solid evidence. Glen Robbins mentioned that in some circles, local autonomy is thought to undermine progressive agendas. The presence of predatory elites who clamber for power at the local level is one inhibiting factor. Audience members suggested that more attention be paid to “secondary” cities booming, for instance, in the Limpopo province, where traditional authorities have tried to exercise influence over the emergent sites of power.
It was suggested that we move away from a tightly tiered conception of governance. The idea of “multiscalar” governance, currently in vogue, considers networks ranging from neighbourhood to the global level. But one objection from the panel was that very often this meant that interests were aligned on a policy basis to the neglect of stakeholder engagement and relationship building.
Another concern among many it seemed, was how much of the problem was legal and how much political. Sue Parnell argued that decentralisation often means that the fiscus doesn’t follow project funding, resulting in the increased use of outsourcing by local authorities. She suggested that it is impossible to uncouple planning from finances. Since political priorities determine the allocation of funds, financing is a political question, and it is thus not possible to divorce the technical from the political.
It also emerged that more attention needed to be paid to the actual conditions and historical trajectories of South African cities, if urban theories are to inform policy. The persistent bifurcation of the city and the countryside is particularly relevant, which means that for many urban dwellers the countryside remains a place of social and cultural life. This is bolstered by a long history of migrant labour. As such, as Parnell suggested, until there is a unitary rather than a dual system there will never be a universal right to the city.
The Public Positions discussion on the State of the health system in South Africa brought to the fore some of the cardinal issues pertaining to the efficiency of the health system which need to be addressed as a matter of urgency for the enjoyment of equality by all as provided in the constitution of the republic. However, an understanding of the dynamics of our health system would not be possible without comprehension of the evolution of our health system since the days of apartheid. Reference should be made to the work of Sidney Kark and some of his disciples such as Susser. Kark’s work(1949) questioned the germ theory and the scientific model as the basis for understanding and explaining the prevalence of TB and syphilis among the Africans especially migrant labourers.Kark called for the psycho-socio-environmental approach, holistic in its nature and emphasising prevention rather than curing. He realised that the prevalence of TB and syphilis among the African population in South Africa had more to do with their lived conditions than any other factors. He therefore called for more resources for African health and for the bio-medical and the psycho-socio-environmental approaches to health, diseases and illness to complement each other. This vision was far ahead of its time and did not go down well with the apartheid government. Contrary to the propositions of Kark and later on other progressive minds such as Susser, the apartheid regime instituted a system that was highly variegated and racially segmented with emphasis being on curing rather than prevention. Thus, there was a national health system, a provincial, all with overlapping functions, uncoordinated and difficult to monitor for accountability, running parallel to Bantustans which were deemed independent and not eligible for support by the state. Resources and health services were concentrated in the cities for persons of white descent only. This was the system that was inherited by the democratic government in 1994. South Africa now has what could be considered the best health framework, which acknowledges the importance of preventative care and bringing good services to people in rural areas. However, the Achilles heel still lies in implementation. Clinics have been erected throughout the country but have remained white elephants – under-equipped and understaffed offering no service. Some patterns have repeated themselves: Many doctors left South Africa as a result of apartheid health policies, and now many are leaving as a result of difficult working environments and poor remuneration. Many people died of TB and syphilis as a result of the orientation of the apartheid system and many today are dying of AIDS as a result of the lack of an efficient public health system. Despite the recognition and recommendation by the UN and the WHO at the Alma Ata conference (1978) of the importance of the traditional healing system and other Complementary and Alternative Medicines, these systems have not been integrated and still operate outside the mainstream despite being used by 90% of the black people in South Africa. And what of changing the living conditions of the poor? Government departments have not been working as an integrated whole in providing more houses, improving the economic welfare of the people, in training more health workers and in promoting living conditions. In our structural system, calls for improved health conditions by concentration of medical resources in the urban centers are just like mopping the floors whilst the tape is running. Implementation of a preventative health system should be taken more seriously to reduce factors that expose people to diseases.
We often forget that it is the human aspect that carries out the function of healthcare delivery. During the talk on Monday, it was of great surprise to me that there are no statistics on issues such as the infection rates of healthcare workers. As a guilty accomplice, I had never really considered the well-being of a healthcare worker. This in part because I have always had unconsciously a romanticized notion of the role of a healthcare worker i.e. they are there to save lives and therefore they should be willing to give up just about anything in the fight to do so. But Mark reminded us that healthcare workers are human beings too, they deserve the very same dignity that our constitution gives them. It should then be that the dignity of these workers should be of paramount importance to not only our government, but society as a whole. On the other hand Dr Ayanda Ntsaluba raised the issue of healthcare workers failing to respect the dignity of the poor people they treat. Ntsaluba also went on to say that issues such as a counterproductive working environment cannot be used as an excuse for the poor service delivery on the part of the healthcare workers. This makes the notion of social justice in our healthcare system of even more importance as it feeds into many aspects of our society. The failure of one aspect such as ensuring that the working conditions of healthcare workers feeds into the quality of service received by poor people. It serves as a reminder that the one’s human experience is not complete without reciprocating and interacting with other human beings.
Provincial healthcare expenditure represented 97% of total budgeted health expenditure in 2013/14. The total budgeted health expenditure was R137.7 billion, representing 12.6% of total government expenditure in the year. The question: Is the provincial public healthcare leadership, who have access to a significant proportion of the national budget, managing healthcare is a manner that ensures social justice for the people in the provinces? It is my observation that the nature of healthcare leadership in the provinces is not consistent but disparate. For instance, the Western Cape developed the Healthcare 2030 planning framework to provide a better patient experience and quality healthcare recently. The framework enables health workers to engage on the ways to improve healthcare within a defined timeframe. The most recent patient satisfaction surveys in the province showed 87% of patients were satisfied with their hospital experience in District Health Services. These results indicate that committed leadership in the public sector can achieve desired outcomes and that public healthcare can be delivered in an equitable manner.
My comment was on the shared interest to succeed from people in
government, civil society and even the private sector. I personally was
surprised to meet stakeholders from the private healthcare sector who
spoke exactly the same way as my activist friends and hearing their
history it makes sense that there is a shared interest. When we speak of
issues of human capital in the health sector there's definitely shared
interest but my view is there's mistrust between the sectors. How do we
build trust and mend eroded relationships while acknowledge there'll be
areas of contention that might not be resolved.
And are there currently spaces where these stakeholders are meeting on
"neutral territory"?
For the public positions seminars I try to write a brief summary of the discussion that took place, the issues raised and arguments people made. This is obviously my own take on it, and we would like to invite everyone who attended the seminar, or who visits this page and has read Mark's paper, to make their own comment on the topic. If I've misrepresented things that were said, don't hesitate to respond.
It's important to keep a public debate going and that is what we hope to do here.
In the paper Mark Heywood presented at Monday evening’s seminar, he wrote, ‘Health care systems are a complex eco-system’. Each dimension of the system impacts on others in complicated ways. Although it wasn't the key argument of Mark's paper, this was perhaps the clearest overall message of the event on Monday. Everyone tried to answer the question - where does the fundamental problem in South Africa’s failing health care system lie? The panelists, and many people in the audience, made convincing arguments trying to make sense of the underlying problems in the system. There are many.
Some questioned whether the current multi-level model we use is the right one. Primary care is the bottom rung – serving the most people and addressing the majority of health care needs, which can normally be dealt with by nurses and clinicians. The higher rungs deal with more serious and complex health problems needing specialist care. But, as Laurel Baldwin Ragaven pointed out, ordinary people distrust primary healthcare facilities – they want to be able to see doctors and specialists. And why shouldn’t they? Why do they need to go through an underfunded clinic before they can see a doctor? The inequitable care for the poor in rural areas, where the majority of people live but where the least money is spent, is an unaddressed legacy of apartheid. The current model may not adequately address that.
We also have a strange and apparently very rigid divide between the relatively well-functioning private healthcare system and the crisis-ridden public healthcare system. Prof Jill Murray asked what effect the existence of an enormous private healthcare system has on the public healthcare system. She argued that it must be negative, mentioning in particular the drain of good doctors from public to private hospitals, and the temptation for doctors in the public sector to moonlight in the private sector. If we are going to talk about social justice in the healthcare system, then this big issue needs to be addressed. The panellists, and others, including Brian Ruff from Discovery Health, argued that the private healthcare sector is here to stay, but agreed that the great divide between public and private needs to be bridged. Greater co-operation between the two sectors, sharing information and knowledge, making resources available, perhaps greater integration, would be good for both.
How much power do we give to provinces? This was another question raised about the current model we have. Brian Ruff commented that the federal system has been the biggest problem in healthcare. Dr Ayanda Ntsaluba argued that the system may be too devolved, there are too many centres of power that keep on re-interpreting policy, and no one centre strong enough to drive policy. He certainly wasn’t advocating for one dominant party, but perhaps more direction.
Many people asked questions about the implementation of policy. In his paper Heywood emphasised the need to provide social justice to healthcare workers, particularly those in the primary care level, who experience incredibly difficult working conditions and are exposed to all manner of disease – the rate of TB infection in health care workers for example is shocking but not well enough understood or dealt with. Healthcare workers can only take care of others once they have had their own, quite basic, needs taken care of.
Who are the healthcare workers we’re talking about? Where do they come from and what are their needs? Laurel Baldwin-Ragaven brought up this question and pointed out that the majority of healthcare workers in the primary level are black African women who come from the local community. They face problems like being arrested, not being paid for months. How are they coping?
Ayanda Ntsaluba agreed with this aspect of Mark’s analysis but he and some others raised a very challenging point about the attitudes that people working in the public service have towards the poor. The users of public healthcare are perceived as indigent and poor, and despite all of the promises of a new democratic South Africa - that everyone would be treated with dignity - attitudes towards the indigent and poor have not changed much. They are still denied dignity by people who view them with distaste. Ntsaluba argued that healthcare workers need to take responsibility. ‘It doesn’t matter how much we feel my rights are violated as a healthcare worker’ Ntsaluba remarked, healthcare workers ‘can’t transmit that frustration to the most vulnerable in the system’. Negative attitude towards the poor are manifested in the blatant abuse of the users of public health.
Who are the users of public health? We need to understand them more. This is perhaps one of the advantages of an emphasis on getting the primary care model right. Primary care is the grassroots level of healthcare; a first stop where the full range of health problems of a local community presents itself. However, Dr Martin Smith emphasised, for the healthcare system to be most effective the different levels of care need to be more integrated. The specialists in healthcare need to play a larger role in primary health care - which presently is not the case, the assumption being that the specialities belong in the higher levels of healthcare. Dr Smith gave the example that, as a surgeon, he has seen many cases of pancreatis in people from marginalised rural communities. This is a condition linked to heavy drinking, and there is a clear role for preventative care, which should be happening at the primary level. As a surgeon, a professional ‘at the rockface’, he argued that health professionals need to be able to make decisions about the healthcare system, which is presently too bureaucratised and has ‘lost [a] sense of core business’.
Perhaps this is a good place to bring out another issue that was raised by various people in different ways –what about leadership and management? Are they listening to doctors and others who are daily in the firing line? Mark Heywood pointed out that if you ask doctors and nurses how to improve the system, they have lots of ideas. The problem is that they are ignored by leaders. Every now and then the government, or leadership, plans a forum or committee meeting where the voices of professionals and people will be heard – but these are token events put together at the last minute and the findings are ignored. Politicians, MECs, need to be held accountable. Are people getting leadership positions in healthcare for the right reasons? Larry Kramer, an Aids activist, once said to Mark, ‘there’s nothing in this bloody AIDS mess that isn’t political’. Mark said the same about public health.
Brian Ruff spoke more on the importance of information gathering and transmission. He said that of all things troubling the public healthcare system right now, lack of modern management, underinvestment in IT, lack of measurement, poor data collection, lack of sharing of information between the public and private sector, and between different levels of healthcare professionals, are critical. These problems contribute to a situation where healthcare workers, such as nurses, do not understand what they are dealing with when presented with patients. There is a lot of confusion amongst healthcare workers which could be dealt with if information about patients was managed better. Information gathered about patients, about conditions of hospitals, would also contribute to a better understanding of local context, which is important for management to do what needs doing.
Understanding local context is important in planning as well. ‘Cookie cutter models’ as Brian called them, do not understand local context, and this is where problems lie. Ayanda expressed some reservation over the idea of going back to the drawing board to begin more planning. There was nothing wrong with the policies they chose in 1998/99. The problem was that policymakers were ‘operating in an idealised system’. They didn’t know that corruption would emerge over time. They also imagined public health in isolation from other factors, such as the existence of a significant private healthcare system. Perhaps this was a call for more pragmatism in implementing policy.
Another question raised was – what is the role of the University? Are medical schools bringing the right people through the system? If you bring bright students from rural areas to the city and educate them, will they go back to rural areas where they are most needed? Do medical students have a social conscience? Are the medical schools equipping students with the skills they need to enter a healthcare system in crisis? Should they need to? Or should universities be able to focus on the core business of creating doctors who know how to treat people? Neo Mkhaba, a med student who formed an advocate group with other concerned students, discussed the challenges she faced. Amongst other things, she hinted at the work burden of med students with the memorable line, ‘you have to triage your knowledge’. How does one balance learning how to treat a patient, with learning what to do when the hospital runs out of stock on essential items?
Why is the public not more angry? Why is there no groundswell of popular discontent, a strong civil society holding government to account? Deborah Baron, a health activist, pointed out that civil society is itself divided on how to approach questions of advocacy and activism. She wanted to launch a campaign ‘strengthening healthcare is sexy’ – to encourage people to get involved more in raising issues. Jenny Grice said that some healthcare issues, like AIDS, have stigma attached and can’t be made sexy. As a result, companies often drive health campaigns on behalf of their workers.
The seminar was alarming in many ways. Some people seemed to feel that we are nearing a point of no return. But there were other voices who offered a more positive perspective. Ayanda reminded us that while things are pretty bleak, there has been progress in the quality of healthcare offered to many in South Africa, such as those living in the rural former Transkei, where he comes from. It also became clear that there is common purpose between those in government, those in private health and activists in improving the public healthcare system, as Busi Dlamini of Democracy Works pointed out. Everyone wants to build trust between these bodies. There are a lot of good people in government, private health, and activists who have a genuine desire to improve the system. South Africa also has many excellent people working in the healthcare system – doctors, nurses, who are committed and skilled, but demoralised. Melvyn of the Department of Health made the point most strongly that things aren’t as ‘doom and gloom’ as those in the room were suggesting. The Department of Health has the best Minister in the Cabinet. There is good leadership. Important things are happening. Perhaps there could be less battering going on? It is demoralising for those who are responsible for improving public health. Melvyn also brought one of the other threads of the debate out in the spotlight again. How to prioritise? In an ordinary day he has to deal with diverse sets of needs – a mother with an autistic child, an institution for the mentally ill, a conference on kidney transplants and dialysis – none of them prioritised by the government but all important. There is a contradiction between the need to prioritise certain things, and the need to deliver healthcare to all people. Neo’s triage analogy works here too.
More than any other topic we’ve had in the Public Positions Seminar Series, healthcare is the only one which is genuinely, as Shireen Hassim remarked, a question of life and death. Government needs to find a solution. But there was a subtext running through the seminar which I think is important to highlight – good ideas have unintended and sometimes contradictory consequences. To try to ensure we don’t keep falling into traps, policymakers have to open their eyes to the realities of South African health care and not wish some of them away, pretend they don’t exist, and base planning on idealism. ‘Cookie cutter’ models don’t work. Monitoring and evaluation needs to be taken seriously. It is critical to gather more information about the healthcare system, how it works, who is using it and who works in it. I think there is a case to be made for pragmatic, evidence based, context specific, policy making.
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The current problems with the South African school system are not very much different from those of other developing countries. The capitalist neo-liberal educational paraphernalia revolving around the centres of achievement, progress and consumption have not been able to ameliorate the current social ills in our societies with regard to access, inequality, unemployment and lack creativity and innovation. The system has provided a façade to legitimate hierarchy and the acceptance of the neoliberal ideals by the peasants and the working class as the natural order of things. The system has resulted in a pyramidal societal structure whereby the poor are condemned to the base of the society and those whose values are espoused by the system are elevated to the upper echelons of the society. Despite the repetitive failures of this system to bring transformation with a human face, it has become almost a fetish for even the comprador bourgeoisie have been baptised in the name of these values hence they have turned to manipulating the system in ways that suit their new interests but at the same time providing the basis for its continued existence. The system instead of liberating the people from the clutches of the demands of a capitalist economy, the neo-liberal school system sees to it that the system continues to churn out more certified matriculants thereby creating a reserve army of cheap and flexible labour force. Thus societies being led by the comprador bourgeoisie- most of whom now own the means of production and also control the profitable tender systems cannot be liberated by the current school system which is functional only to the capitalists as the basis for cheap labour to ensure realisation. In steady of the school system ensuring liberation and self-sufficiency among the citizens, the current system is based on the jug and mug relationship which baptises the young people in the name of docility and passivity. The students are made to accept bureaucracy and to stop to think for themselves. Thus the young people are made to consume ideas which have been churned out by others, ideas without any relevance to their lived realities. The system is not interactive, but the students are made to worship their teachers who are the agents of the capitalist system, with them as empty depositories. The system has failed to prepare the young people for real life whereby they could do things for themselves rather than depending on the capitalist economy as labourers for their sustenance. The school system teaches pupils discipline which means taking everything as ‘per book’ whilst any form of creativity or research that does not fit into the prescribed systems is regarded as deviant and the owner has to be excluded. Such a system prepares the pupils for their lives in a capitalist society as uncritical consumers of capitalist production. Thus the school system alienates just as the alienation of labour in a capitalist society as expounded by the Marxists.
Real societal transformation that is accommodative will not happen as a result of the unending capitalist quest for progress/growth of the economy but as a result of changes or shifts in the ideological material equipment which makes people creative, innovative and confident to make a living by doing things for themselves rather than depending on the capitalistic economic employment capacity whose reality is questionable. Thus the Public Positions Seminar on the merits and demerits of the current school system in South Africa reaffirmed the dysfunctional nature of the current system with its emphasis on credentials and certification as the only way to succeed in life. This belief mythicizes reality and has since been churning out huge numbers of certified matriculates incapable of doing things for themselves and could not be absorbed by the capitalist economy. In most of the cases it has been proven that certification is not a proof of competence. Thus certification will never be a substitute of experience hence Ivan IIIich’s call for a DE schooling society.
Important note however is the failure of the discussants and current scholarship to acknowledge the ideas of other people. Some of the ideas which were raised have their origin in Ivan IIIich’s compendium that is the DE schooling society of 1971, some of which were later on elaborated by Paulo Freire in his Pedagogy of the Oppressed of 1974. Thus according to IIIich the school system offers a packaged education and awards credentials for successful consumption of the packages. These packages are continually re-written and adjusted but the problems they are supposed to address remain. Thus to IIIich, this system is a commercial activity mirroring the marketing processes of the persuasion industry. Children are promised paradise by the continued consumption of these packages. As a solution to the dysfunctional system, IIIich proposes learning webs were by people with common interests would come together supported by the government and learn by doing things in an interactive way. However, countries differ, human beings are historical and our realities are particular historical conditions. As a country we are supposed to learn from other communities but most importantly from our historical trajectories with development. Our current struggle with ensuring justice is never separate from social economic justice underpinned by ideals of equality and equality of opportunity hence the idea of social levelling. In the equalisation of the conditions of our existence, our schools conditions should take precedence for these have a say on the subjects that are taught and how they are taught and the ways in which they bring about transformation. Communities in other countries have leaned towards solidarity economies with emphasises on the humanness of human beings rather than the unending capitalist quest for competition and progress. Thus the school system has been brought into an ecology that emphasises, inclusivity, communitarianism and community sovereignty rather than the alienating vices of the capitalist school systems. Success in a capitalist school system does not reflect intelligence or hard work but whose values are espoused by the system. Success in a capitalist system is not a result of success within the school system but is a reflection of who owns the means of production and one’s position within such a society. Thus this system has spawned multiple exclusions and only a few from the middle class with an insatiable appetite to consume resulting their conditioning at school is accepted whilst the vast majority are condemned to poverty. These are the few whom we see in places such as Mabonang, Braamfontein, and Newtown in Johannesburg. These are to be protected for their consumption form the basis of capitalist accumulation without which the system cannot survive. Thus an analysis of the working of the current school system outside the capitalist underpinnings will just cloud the realities which we are seeking to comprehend.
Reforms in South Africa have not brought about the much required transformation for the people can only be liberated with their reflective participation in the act of liberation. They have only been carried out at the level of repackaging the text books by the technocrats. The repackaging has not resulted in any fundamental changes with regard to people’s lives, for the problems they seek to solve are still with us but has ensured high returns to the technocrats. The pupils’ portfolios though a step in the direction, at present are just a miniature symbol of independence but manipulated in various ways for the generation of pass marks in a bid for the 100% pass rate. Critical subjects are no longer deemed so for many are forced to drop them for the schools to guarantee the 100% pass rate. The 100% fetish has impacted negatively on the production quality. There has been a misalignment of the reforms implemented and the diagnosed problems. This is a farce to keep the capitalist machine running. Paulo Freire noted correctly that to affirm that people should be free and yet to do nothing tangible to make this affirmation a reality is a farce. Thus the current school system based on the mug and jug relationship of the teacher and the student will not liberate us from the current predicament. What is required, are the structural changes taking in to consideration that everything is enmeshed in everything else.
I am in general agreement with the picture that Marie paints of post-apartheid urban policy and planning and its consequences. Much of post-apartheid urban policy – to the extent that there has been one – has resulted in greenfield public and private development and service delivery to under-served areas without confront spatial form. The result of this has been, in many instances, to actually accentuate spatial disparities rather than fundamentally confront them.
However, I would suggest that beyond these general statements, we need to be conscious of the fact that patterns of post-apartheid urban development vary quite substantially by city. A focus on the shift from “leafy suburbs” to elite “themed estates” might miss the changes that have taken place in the bulk of former minority suburbs in terms of a slow (at least in some cases), but nonetheless steady, change in race profile of residents. Further, at least in Durban, the trend has been for substantial former buffer areas of apartheid planning to be settled informally – with around 1/3 of the 250 odd informal settlements in these areas (some already subjected to in situ upgrades) and around a quarter of informal dwellers living in these areas. In Durban it has tended to be true that this has been at its most noticeable around former Indian residential areas such as Chatsworth, Shallcross and Resevoir Hills. It is also true that substantial portions of these buffer strips coincided with natural barriers to formal development such as river valleys and areas with quasi protected open space and what planners refer to as over-steep land. These continue to be invaded by informal settlers as the Municipality struggles to keep up. The fact that these areas are often traversed by major roads or are also in close proximity to existing or new employment notes makes informal settlement in them all the more desirable.
In Durban issues related to the Ingonyama Trust are also critical when looking at both existing and future urban development. Some of Durban’s largest townships such as Umlazi, KwaMashu, Ntuzuma and Mpumalanga were formerly part of the KwaZulu-Natal homeland and as such carry the designation of being R293 townships where tenure issues remain caught up in the Ingonyama Trust being the “custodian” of the land. This has substantial consequences on households, but also on the scope for effective planning interventions. Most recently it has been noted that on Durban’s peri-urban periphery areas under traditional authority have witnessed the fastest growth in densities (from a very low base).
In terms of the impact of the Development Facilitation Act from 1995, in setting up tribunals to determine planning approvals outside the Municipal decision making channels (eventually shown to be unconstitutional), it is undoubtedly true that this promoted sprawl for both low cost housing and elite projects. Although national policy frameworks and Municipal plans might have articulated a need for some measure of spatial justice, it was not possible in a context where interim local government structures competed for development and then the DFA tribunals often rejected Municipal concerns about forms of sprawl.
The outcomes of this, as Marie suggests, was further aggravated by a desire – certainly at provincial level and also at a national level – to control housing delivery in space through a failure to decentralize. The impacts of this have been accentuated in KZN where the Province has obsessed about rural housing and been somewhat less eager for projects in major urban centres.
I am somewhat less encouraged by SPLUMA’s reinforcing of the scope for local decision making authority of planning decisions. This is in part because SPLUMA seeks to replicate the tribunal approval system within the Municipal context which could, noting the balance of forces in the development terrain and the growing proximity of the political leadership with private development interests, actually continue to deliver outcomes similar to those of the DFA. As of yet no indication has been received of regulations governing how tribunals will be established and how appeals matters would be dealt with. This must also be seen in the light of attempts to reform the National Environmental Management Act to be more “pro-development” by cutting down on objection periods for developments where EIAs have been done. A number of national ministers have also expressed an eagerness for the Infrastructure Bill to avoid large scale strategic state projects being subjected to EIA and planning delays from local government. More recently it has been proposed that the mining minister be given discretionary powers over water and environmental approvals for mining rights and development applications. These tend to send very mixed signals and we are likely to see the intent of the Constitution being tested again in future.
Marie, drawing in part on Lefebvre’s work, argues for greater local autonomy and decentralization in the paper. However, the issue of enhanced local autonomy in planning and development matters remains somewhat clouded by other processes. Like Marie, I have been somewhat skeptical of the established “left” critique of decentralization as bringing with it threats of reduced redistribution. However, the South African experience has shown that a national state can be just as easily subjected to influences as a local state can be. In fact if we look at experiences in selected cities in Brazil, Peru and even India, one can see that a local left agenda can be constructed – perhaps with difficulty – in a context where a province/state and federal agenda might be less strident around issues of social justice. This perhaps depends on a much more fluid political culture – or a more highly contested political environment at different scales. Direct elections for mayors in Brazilian cities (as in places such as France) raise the status of city Mayors as important national nodes of political influence. In South Africa, despite the intent of the constitution to deliver us three relatively autonomous but interdependent spheres of government, we have a highly hierarchical political culture where, barring one or two exceptions, mayors in large cities are minor figures in the political structures of the ANC – with only a few serving city mayors having been elected to the ANC NEC in the past two decades and few if any former city mayors having risen to high office in the ANC. The culture of politics – and more especially that of the ANC – reinforces a notion of city political leadership as being directed from above. This means we cannot just rely on policy and legal changes around local autonomy. There is little in the way of local policy risk taking but city leadership on issues such as settlement planning and development. eThekwini political leadership value compliance awards from national local government on housing issues more than praise from local civic groups for local engagement.
In considering decentralization from the national centre to the local one must also confront the extent to which the local itself has been embroiled in projects to advance certain class interests. The settling in of a political establishment in many cities with very well paid politicians and political appointees has been an important element of how the ruling party has generated some form of hegemony. This has had a side effect of supporting formal and informal coalitions of elites (old and new) in driving municipal agendas towards the embracing of projects which can be highly contradictory in that they carry both redistributive and elite-driven patronage agendas.
Furthermore, if we take Lefebvre’s views into account we also have to look at within-city decentralization and the scope for forms of citizen-self organization of activities and processes. We do see citizens taking action in our cities – although it is not always welcomed – such as in informal settlement or protests. But the tendency has been for cities to not create decentralized forms of urban management and decision making where some level of co-determination with citizens is cultivated. We have centre-driven consultation processes such as those for IDPs or perhaps for budgets but the do not involved devolved decision making or any meaningful autonomy to areas within cities. Durban has explored Area Based Management – but more in the new public management sense then as a commitment to local level decentralized governance processes. Other cities (and Durban too) have also developed a range of urban improvement or city improvement district models where specialized management systems are put in place to recognize the selected areas as being “special” in one way or another. These might give some interests a greater local say over how an area is managed but they are by no means a solution being offered (or even appropriate) to the bulk of districts or precincts in a city. In fact these arrangements can be seen as lessening the scope for certain urban dwellers having less of a right to the city.
I would suggest that in thinking about our cities we must gain a better insight of how our politicians at all levels view the city. I have noted, over time, how anti-urban many of our politicians are – granted some are more so than others – but I have rarely seen an elected local, provincial or national politician singing the praises of urban life. You might consider this a mere product of the alienation from urban possibilities under apartheid or under the post-apartheid city arrangements that Marie has characterised. However, I think far to many of our politicians are comfortable with an idea of the city that is constituted of little more than tar roads, basic services, patterns of public housing and shopping malls along with some zones of exception. I do not know how else to phrase this but as a lack of ambition for the urban – not just perhaps in our dry policy documents with their drop down lists of technocrat’s utopian menu (sustainable, equitable ...) – but also critically in our political leaders framing of the commitment to the urban.
I thoroughly enjoyed the contributions given by Sue Parnell from UCT particularly when dealing with understanding the state’s role in urban planning. The state requires both political and technical muscle in order to resolve issues of sustainable urban development and determining who has the right to the city. For so long the working class has been excluded from using the city in the battle of anti-capitalist expansion as seen by citizens of Abahlali basemjondolo. Parnell provocatively remarked that until there is a single system, instead of a dual system that is conflicted between modernity and tradition, we will never achieve universal rights to the city. The state does not operate on its own in South Africa which makes the question on who has the right to the city a difficult question to tackle. Traditional leadership and other sectors in civil society have a pivotal role to play. The underlying tone of the discussion for me was that there needs to be real politics in play, a situation where social movements and other civil society organisations place greater pressure on government, in order to rectify the glaring disconnection between the local government, traditional leadership and NGOs. This goes back to the point made by Parnell that implicit in the notion of the ‘right to the city’ is an assumption that the state is solely responsible for delivering this right. I think these ties in with a later response given by Marie that greater responsibility needs to be shared amongst social movements, lawyers, and technical people to reverse the planning system of Apartheid and ensure better housing and service delivery. Even though there was much consensus on the disconnection on many levels, the pertinent question remains and that is how will this all be resolved?
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The public positions seminar on urban spatial justice brought out a number of important insights with respect to policy, justice and inclusive development. However, to note is that, ‘designing a dream city is easy, rebuilding a living one takes imagination’ [Jane Jacobs]…The city is not a problem that can be solved. It is the eternal impossible question of how we strangers can live together. Rebuilding a living city – a city which jumbles together multiple and conflicting differences – therefore requires less a utopian plan than a poetics of political imagination (Donald, 1997: 182).Though the seminar critiqued urban spatial injustices in relation to neo-liberalism’s demand to open up new spaces for accumulation and to protect the old spaces to maximise the same, the seminar did not however go beyond these , to look at the more cardinal and critical issues important in the generation of urban spaces-the unfairness involved. The discussion missed the importance of the alliance between bankers, financiers and developers- a critical alliance-a force that shapes the built environment .Even the critical Marxists theorists were unable to perceive the crucial link between urban space generation and the accumulation space. The Marxian theory has a blind spot when it comes to looking at matters of the city, spatial competition and the production of urban space-all reflecting the Poverty of theory. Thus the Marxists have not managed to integrate an understanding of processes of urbanisation and built environment formation into a general theory of and into the laws of the motion of capital. This is despite the fact the all crises in the world 1929, 1973, 1987, 2000 and the recent financial crisis all were rooted in asset accumulation and collapses of the property market. Thus the Marxist theory is content in explaining these crises in terms of tendency of the rate of profit to fall, under consumption and over-accumulation. However, without an understanding of the capital formation and the profit realisation processes now is being spearheaded by neo-liberalism it would be impossible to comprehend the growth of exclusionary cities and of informal settlements. With its bid on opening up new spaces for capital accumulation through new kinds of dispossession such as the privatisation of basic amenities, neo-liberalism has caused many hardships for the poor sending many of them into the informal sector. The growth of informal settlements occurred within the accumulation processes marked concomitantly with the growth of gated communities and expensive waterfront settlements especially in Johannesburg. Again despite the neo-liberal call by De Soto for a city with many small traders, a city that integrates the informal and extra-legal activities into the mainstream the greater neo-liberal forces have devised other means of social exclusion now based on the ability to pay (consume). Thus the growing gentrification currently being witnessed in Johannesburg in such places as Braamfontein, Newtown and Mabonang all spawned exclusion based on the ability to consume. Neo-liberalism is about profit and its designs are for ‘cool cities’ capable of attracting FDI, tourists and the middle class for consumption. As capitalist mode of production, it is associated with the need to accelerate the realisation process and not the need to improve the human condition. Thus artists, the academia and other members of the middle class with the potential to consume have to be ‘protected from’ being disturbed by the poor in these places. These views have blocked the development of compact cities with the capacity of mixed settlements and accommodation spaces promoting social integration. The divisionistic approach to city development has led to a number of protests, even wars worldwide as the poor tried to gain their citizenship and other opportunities by invading the cities. This exemplified by the crisis that ensued following the Indian government’s neo-liberal false solutions to Dharavi informal settlement in Mumbai in 2010.Instead of involving the poor in crafting solutions to urban settlements utopian plans, as the Indian government tried to solve the poor’s access unintentionally furthered their dispossession and the accumulation of capital by the capitalist. However, a realistic approach by the Brazilian government of Dilma Rousseff has greatly improved the conditions of the poor by taking an integrated approach through the involvement of the poor, their representatives, NGOs and the government in working out solutions to the growth of informal settlements in the cities. This approach was able to shift the towns and cities away from urban goals, visions and stratagems of the northward looking and prostrated elite to the far more demanding objectives of achieving inclusive, equitable and sustainable cities. Thus despite the existence of the New national spatial planning legislation of 2013 which seems highly contradictory, as humanity ‘we either uphold through our planning interventions and thinking the Right to Inequality and Wealth’ or ‘the right to freedom from Want/Poverty -to stop civilising, exterminating and bombing the natives; to stop keeping the Poor Poor; and to rethink the status Quo’ (Khan Firoz, 2014)
The discussion that took place around the Right to the City confirmed that our cities can only truly be changed by confronting the problem of urban exclusion from all of its many angles. Policy prescriptions frequently rest on the illusion that purely technical solutions can help to change our cities for the better, neglecting the persistent political dimensions which relegate the poor to the margins and squalid interstices of our cities. Political engagement is therefore crucial to the success of any efforts to etch the Right to the City on our urban landscapes. But this does not mean that the technical dimensions should be ignored. What emerged clearly in the discussion was the need to combine a multiplicity of perspectives which all too often remain compartmentalised – the political, technical, economic, and legal. An instructive example of the benefits of a more holistic approach can be found in Brazil, where the inscription of the Right to the City into the legal code was achieved thanks to the work of progressive lawyers who, in conjunction with mechanisms for popular participation, attempted to translate political aspirations into technical formulations. The discussion also focused on the potential merits of decentralizing urban planning functions, prompting questions as to whether this devolution of power is possible under the present political and policy context, and, crucially, whether bolstering local government actors is in fact desirable in the first place. Can municipal officials really be trusted to deliver a progressive urban vision? Might traditional leadership present an obstacle to this vision? The debate around the Right to the City prompted difficult questions which cut to the heart of how our entire democracy functions, a debate which urgently needs to be continued with broadened participation.
Who owns the land in and around cities? It would be fascinating to see a map of property ownership in cities, what parts of the city are in fact public and what are private. What problems come up when the government wants to purchase land for the ‘public good’ in cities? Expropriation is difficult and takes a long time if there is no agreement within government itself on what the public interest is. Huchzermayer made the point in her paper that ‘In the absence of any definition of these interests, economic growth and global competitiveness framed as national or public interest irrespective of the spatial configuration they demand, may continue to trump municipal level plans to redress urban spatial imbalances.’ Even the apartheid government with its profound commitment to spatial segregation had within its different departments, and different parts of the public, conflicting ideas of how to use land for the public interest. I can use an example from my own research. When the Native Affairs Department wanted to buy white-owned farms to extend the rural reserves in a particularly fertile part of the old Northern Transvaal it fought with the Department of Lands and white farmers associations for decades over what the public interest was: good land for Africans in the context of spatial segregation? Or protection of water sources and conservation of mountain slopes? Or allowing white farmers to use the land for commercial farming for which the land was eminently suitable, which would contribute to economic growth? The NAD had the power to expropriate… but only once it was agreed that their proposed use of the land was in the public interest – a question which generated reams of letters and reports over almost a twenty year period. This delayed the essential process at the time of ensuring that Africans being evicted from farms in their thousands had a place to go in the context of a segregated society. The task of spatial integration in cities may be just as difficult, generating as much conflict and bureaucratic inertia. And so far there is not as much political zeal for integrating the poor into cities as there was for segregation during apartheid.
Interestingly, rather than blaming indolence as many often do, Huchzermeyer highlights the persistent political impetus behind the unintegrated city in South Africa. Here class has been a key spatial cleavage. She argues that provincial authorities overrode municipal spatial planning initiatives as the provinces vied with each other for economic and political prestige. The private sector was given pride of place in a bid to encourage investment. And to win electoral support, provincial authorities rolled out low cost housing on the urban periphery.
Panellists questioned, however, if municipalities would do a better job if left to their own devices. An argument in favour of local autonomy is that municipalities keep a closer ear to the ground and are thus more responsive to the demands of communities who would otherwise struggle to make their voice heard, such as informal settlement organisations. But whether this is really the case is open to debate, particularly in the absence of solid evidence. Glen Robbins mentioned that in some circles, local autonomy is thought to undermine progressive agendas. The presence of predatory elites who clamber for power at the local level is one inhibiting factor. Audience members suggested that more attention be paid to “secondary” cities booming, for instance, in the Limpopo province, where traditional authorities have tried to exercise influence over the emergent sites of power.
It was suggested that we move away from a tightly tiered conception of governance. The idea of “multiscalar” governance, currently in vogue, considers networks ranging from neighbourhood to the global level. But one objection from the panel was that very often this meant that interests were aligned on a policy basis to the neglect of stakeholder engagement and relationship building.
Another concern among many it seemed, was how much of the problem was legal and how much political. Sue Parnell argued that decentralisation often means that the fiscus doesn’t follow project funding, resulting in the increased use of outsourcing by local authorities. She suggested that it is impossible to uncouple planning from finances. Since political priorities determine the allocation of funds, financing is a political question, and it is thus not possible to divorce the technical from the political.
It also emerged that more attention needed to be paid to the actual conditions and historical trajectories of South African cities, if urban theories are to inform policy. The persistent bifurcation of the city and the countryside is particularly relevant, which means that for many urban dwellers the countryside remains a place of social and cultural life. This is bolstered by a long history of migrant labour. As such, as Parnell suggested, until there is a unitary rather than a dual system there will never be a universal right to the city.
The Public Positions discussion on the State of the health system in South Africa brought to the fore some of the cardinal issues pertaining to the efficiency of the health system which need to be addressed as a matter of urgency for the enjoyment of equality by all as provided in the constitution of the republic. However, an understanding of the dynamics of our health system would not be possible without comprehension of the evolution of our health system since the days of apartheid. Reference should be made to the work of Sidney Kark and some of his disciples such as Susser. Kark’s work(1949) questioned the germ theory and the scientific model as the basis for understanding and explaining the prevalence of TB and syphilis among the Africans especially migrant labourers.Kark called for the psycho-socio-environmental approach, holistic in its nature and emphasising prevention rather than curing. He realised that the prevalence of TB and syphilis among the African population in South Africa had more to do with their lived conditions than any other factors. He therefore called for more resources for African health and for the bio-medical and the psycho-socio-environmental approaches to health, diseases and illness to complement each other. This vision was far ahead of its time and did not go down well with the apartheid government. Contrary to the propositions of Kark and later on other progressive minds such as Susser, the apartheid regime instituted a system that was highly variegated and racially segmented with emphasis being on curing rather than prevention. Thus, there was a national health system, a provincial, all with overlapping functions, uncoordinated and difficult to monitor for accountability, running parallel to Bantustans which were deemed independent and not eligible for support by the state. Resources and health services were concentrated in the cities for persons of white descent only. This was the system that was inherited by the democratic government in 1994. South Africa now has what could be considered the best health framework, which acknowledges the importance of preventative care and bringing good services to people in rural areas. However, the Achilles heel still lies in implementation. Clinics have been erected throughout the country but have remained white elephants – under-equipped and understaffed offering no service. Some patterns have repeated themselves: Many doctors left South Africa as a result of apartheid health policies, and now many are leaving as a result of difficult working environments and poor remuneration. Many people died of TB and syphilis as a result of the orientation of the apartheid system and many today are dying of AIDS as a result of the lack of an efficient public health system. Despite the recognition and recommendation by the UN and the WHO at the Alma Ata conference (1978) of the importance of the traditional healing system and other Complementary and Alternative Medicines, these systems have not been integrated and still operate outside the mainstream despite being used by 90% of the black people in South Africa. And what of changing the living conditions of the poor? Government departments have not been working as an integrated whole in providing more houses, improving the economic welfare of the people, in training more health workers and in promoting living conditions. In our structural system, calls for improved health conditions by concentration of medical resources in the urban centers are just like mopping the floors whilst the tape is running. Implementation of a preventative health system should be taken more seriously to reduce factors that expose people to diseases.
We often forget that it is the human aspect that carries out the function of healthcare delivery. During the talk on Monday, it was of great surprise to me that there are no statistics on issues such as the infection rates of healthcare workers. As a guilty accomplice, I had never really considered the well-being of a healthcare worker. This in part because I have always had unconsciously a romanticized notion of the role of a healthcare worker i.e. they are there to save lives and therefore they should be willing to give up just about anything in the fight to do so. But Mark reminded us that healthcare workers are human beings too, they deserve the very same dignity that our constitution gives them. It should then be that the dignity of these workers should be of paramount importance to not only our government, but society as a whole. On the other hand Dr Ayanda Ntsaluba raised the issue of healthcare workers failing to respect the dignity of the poor people they treat. Ntsaluba also went on to say that issues such as a counterproductive working environment cannot be used as an excuse for the poor service delivery on the part of the healthcare workers. This makes the notion of social justice in our healthcare system of even more importance as it feeds into many aspects of our society. The failure of one aspect such as ensuring that the working conditions of healthcare workers feeds into the quality of service received by poor people. It serves as a reminder that the one’s human experience is not complete without reciprocating and interacting with other human beings.
Here are links to the reports mentioned in Mark Heywood's Paper
ANC, A National Health Plan for South Africa, May 1994: http://whqlibdoc.who.int/publications/1994/0958386714.pdf
National Department of Health et al, National Health Facilities Baseline Audit – National Summary Report, 2012: http://www.hst.org.za/sites/default/files/NHFA_webready_0.pdf
http://www.who.int/publications/almaata_declaration_en.pdf
August 2014 article by the health news service Health-e, on
what is happening in the Gert Sibande district of Mpumalanga
http://www.health-e.org.za/2014/08/22/nhi-pilot-district-also-shows-sign...
MP Matsoso and B Fryatt, National Health Insurance: The first 18 months,
The National Department of Health, 2012
http://reference.sabinet.co.za/webx/access/electronic_journals/healthr/h...
M Matsoso, Preamble in National Department of Health, HRH SA, Human
Resources for Health South Africa, HRH Strategy for the Health Sector, 2012/13 –
2016/17
http://www.ruralrehab.co.za/uploads/3/0/9/0/3090989/human_resources_for_...
National Planning Commission, The National Development Plan - 2030,
http://www.npconline.co.za/MediaLib/Downloads/Downloads/NDP%202030%20-%2...
Provincial healthcare expenditure represented 97% of total budgeted health expenditure in 2013/14. The total budgeted health expenditure was R137.7 billion, representing 12.6% of total government expenditure in the year. The question: Is the provincial public healthcare leadership, who have access to a significant proportion of the national budget, managing healthcare is a manner that ensures social justice for the people in the provinces? It is my observation that the nature of healthcare leadership in the provinces is not consistent but disparate. For instance, the Western Cape developed the Healthcare 2030 planning framework to provide a better patient experience and quality healthcare recently. The framework enables health workers to engage on the ways to improve healthcare within a defined timeframe. The most recent patient satisfaction surveys in the province showed 87% of patients were satisfied with their hospital experience in District Health Services. These results indicate that committed leadership in the public sector can achieve desired outcomes and that public healthcare can be delivered in an equitable manner.
My comment was on the shared interest to succeed from people in
government, civil society and even the private sector. I personally was
surprised to meet stakeholders from the private healthcare sector who
spoke exactly the same way as my activist friends and hearing their
history it makes sense that there is a shared interest. When we speak of
issues of human capital in the health sector there's definitely shared
interest but my view is there's mistrust between the sectors. How do we
build trust and mend eroded relationships while acknowledge there'll be
areas of contention that might not be resolved.
And are there currently spaces where these stakeholders are meeting on
"neutral territory"?
For the public positions seminars I try to write a brief summary of the discussion that took place, the issues raised and arguments people made. This is obviously my own take on it, and we would like to invite everyone who attended the seminar, or who visits this page and has read Mark's paper, to make their own comment on the topic. If I've misrepresented things that were said, don't hesitate to respond.
It's important to keep a public debate going and that is what we hope to do here.
In the paper Mark Heywood presented at Monday evening’s seminar, he wrote, ‘Health care systems are a complex eco-system’. Each dimension of the system impacts on others in complicated ways. Although it wasn't the key argument of Mark's paper, this was perhaps the clearest overall message of the event on Monday. Everyone tried to answer the question - where does the fundamental problem in South Africa’s failing health care system lie? The panelists, and many people in the audience, made convincing arguments trying to make sense of the underlying problems in the system. There are many.
Some questioned whether the current multi-level model we use is the right one. Primary care is the bottom rung – serving the most people and addressing the majority of health care needs, which can normally be dealt with by nurses and clinicians. The higher rungs deal with more serious and complex health problems needing specialist care. But, as Laurel Baldwin Ragaven pointed out, ordinary people distrust primary healthcare facilities – they want to be able to see doctors and specialists. And why shouldn’t they? Why do they need to go through an underfunded clinic before they can see a doctor? The inequitable care for the poor in rural areas, where the majority of people live but where the least money is spent, is an unaddressed legacy of apartheid. The current model may not adequately address that.
We also have a strange and apparently very rigid divide between the relatively well-functioning private healthcare system and the crisis-ridden public healthcare system. Prof Jill Murray asked what effect the existence of an enormous private healthcare system has on the public healthcare system. She argued that it must be negative, mentioning in particular the drain of good doctors from public to private hospitals, and the temptation for doctors in the public sector to moonlight in the private sector. If we are going to talk about social justice in the healthcare system, then this big issue needs to be addressed. The panellists, and others, including Brian Ruff from Discovery Health, argued that the private healthcare sector is here to stay, but agreed that the great divide between public and private needs to be bridged. Greater co-operation between the two sectors, sharing information and knowledge, making resources available, perhaps greater integration, would be good for both.
How much power do we give to provinces? This was another question raised about the current model we have. Brian Ruff commented that the federal system has been the biggest problem in healthcare. Dr Ayanda Ntsaluba argued that the system may be too devolved, there are too many centres of power that keep on re-interpreting policy, and no one centre strong enough to drive policy. He certainly wasn’t advocating for one dominant party, but perhaps more direction.
Many people asked questions about the implementation of policy. In his paper Heywood emphasised the need to provide social justice to healthcare workers, particularly those in the primary care level, who experience incredibly difficult working conditions and are exposed to all manner of disease – the rate of TB infection in health care workers for example is shocking but not well enough understood or dealt with. Healthcare workers can only take care of others once they have had their own, quite basic, needs taken care of.
Who are the healthcare workers we’re talking about? Where do they come from and what are their needs? Laurel Baldwin-Ragaven brought up this question and pointed out that the majority of healthcare workers in the primary level are black African women who come from the local community. They face problems like being arrested, not being paid for months. How are they coping?
Ayanda Ntsaluba agreed with this aspect of Mark’s analysis but he and some others raised a very challenging point about the attitudes that people working in the public service have towards the poor. The users of public healthcare are perceived as indigent and poor, and despite all of the promises of a new democratic South Africa - that everyone would be treated with dignity - attitudes towards the indigent and poor have not changed much. They are still denied dignity by people who view them with distaste. Ntsaluba argued that healthcare workers need to take responsibility. ‘It doesn’t matter how much we feel my rights are violated as a healthcare worker’ Ntsaluba remarked, healthcare workers ‘can’t transmit that frustration to the most vulnerable in the system’. Negative attitude towards the poor are manifested in the blatant abuse of the users of public health.
Who are the users of public health? We need to understand them more. This is perhaps one of the advantages of an emphasis on getting the primary care model right. Primary care is the grassroots level of healthcare; a first stop where the full range of health problems of a local community presents itself. However, Dr Martin Smith emphasised, for the healthcare system to be most effective the different levels of care need to be more integrated. The specialists in healthcare need to play a larger role in primary health care - which presently is not the case, the assumption being that the specialities belong in the higher levels of healthcare. Dr Smith gave the example that, as a surgeon, he has seen many cases of pancreatis in people from marginalised rural communities. This is a condition linked to heavy drinking, and there is a clear role for preventative care, which should be happening at the primary level. As a surgeon, a professional ‘at the rockface’, he argued that health professionals need to be able to make decisions about the healthcare system, which is presently too bureaucratised and has ‘lost [a] sense of core business’.
Perhaps this is a good place to bring out another issue that was raised by various people in different ways –what about leadership and management? Are they listening to doctors and others who are daily in the firing line? Mark Heywood pointed out that if you ask doctors and nurses how to improve the system, they have lots of ideas. The problem is that they are ignored by leaders. Every now and then the government, or leadership, plans a forum or committee meeting where the voices of professionals and people will be heard – but these are token events put together at the last minute and the findings are ignored. Politicians, MECs, need to be held accountable. Are people getting leadership positions in healthcare for the right reasons? Larry Kramer, an Aids activist, once said to Mark, ‘there’s nothing in this bloody AIDS mess that isn’t political’. Mark said the same about public health.
Brian Ruff spoke more on the importance of information gathering and transmission. He said that of all things troubling the public healthcare system right now, lack of modern management, underinvestment in IT, lack of measurement, poor data collection, lack of sharing of information between the public and private sector, and between different levels of healthcare professionals, are critical. These problems contribute to a situation where healthcare workers, such as nurses, do not understand what they are dealing with when presented with patients. There is a lot of confusion amongst healthcare workers which could be dealt with if information about patients was managed better. Information gathered about patients, about conditions of hospitals, would also contribute to a better understanding of local context, which is important for management to do what needs doing.
Understanding local context is important in planning as well. ‘Cookie cutter models’ as Brian called them, do not understand local context, and this is where problems lie. Ayanda expressed some reservation over the idea of going back to the drawing board to begin more planning. There was nothing wrong with the policies they chose in 1998/99. The problem was that policymakers were ‘operating in an idealised system’. They didn’t know that corruption would emerge over time. They also imagined public health in isolation from other factors, such as the existence of a significant private healthcare system. Perhaps this was a call for more pragmatism in implementing policy.
Another question raised was – what is the role of the University? Are medical schools bringing the right people through the system? If you bring bright students from rural areas to the city and educate them, will they go back to rural areas where they are most needed? Do medical students have a social conscience? Are the medical schools equipping students with the skills they need to enter a healthcare system in crisis? Should they need to? Or should universities be able to focus on the core business of creating doctors who know how to treat people? Neo Mkhaba, a med student who formed an advocate group with other concerned students, discussed the challenges she faced. Amongst other things, she hinted at the work burden of med students with the memorable line, ‘you have to triage your knowledge’. How does one balance learning how to treat a patient, with learning what to do when the hospital runs out of stock on essential items?
Why is the public not more angry? Why is there no groundswell of popular discontent, a strong civil society holding government to account? Deborah Baron, a health activist, pointed out that civil society is itself divided on how to approach questions of advocacy and activism. She wanted to launch a campaign ‘strengthening healthcare is sexy’ – to encourage people to get involved more in raising issues. Jenny Grice said that some healthcare issues, like AIDS, have stigma attached and can’t be made sexy. As a result, companies often drive health campaigns on behalf of their workers.
The seminar was alarming in many ways. Some people seemed to feel that we are nearing a point of no return. But there were other voices who offered a more positive perspective. Ayanda reminded us that while things are pretty bleak, there has been progress in the quality of healthcare offered to many in South Africa, such as those living in the rural former Transkei, where he comes from. It also became clear that there is common purpose between those in government, those in private health and activists in improving the public healthcare system, as Busi Dlamini of Democracy Works pointed out. Everyone wants to build trust between these bodies. There are a lot of good people in government, private health, and activists who have a genuine desire to improve the system. South Africa also has many excellent people working in the healthcare system – doctors, nurses, who are committed and skilled, but demoralised. Melvyn of the Department of Health made the point most strongly that things aren’t as ‘doom and gloom’ as those in the room were suggesting. The Department of Health has the best Minister in the Cabinet. There is good leadership. Important things are happening. Perhaps there could be less battering going on? It is demoralising for those who are responsible for improving public health. Melvyn also brought one of the other threads of the debate out in the spotlight again. How to prioritise? In an ordinary day he has to deal with diverse sets of needs – a mother with an autistic child, an institution for the mentally ill, a conference on kidney transplants and dialysis – none of them prioritised by the government but all important. There is a contradiction between the need to prioritise certain things, and the need to deliver healthcare to all people. Neo’s triage analogy works here too.
More than any other topic we’ve had in the Public Positions Seminar Series, healthcare is the only one which is genuinely, as Shireen Hassim remarked, a question of life and death. Government needs to find a solution. But there was a subtext running through the seminar which I think is important to highlight – good ideas have unintended and sometimes contradictory consequences. To try to ensure we don’t keep falling into traps, policymakers have to open their eyes to the realities of South African health care and not wish some of them away, pretend they don’t exist, and base planning on idealism. ‘Cookie cutter’ models don’t work. Monitoring and evaluation needs to be taken seriously. It is critical to gather more information about the healthcare system, how it works, who is using it and who works in it. I think there is a case to be made for pragmatic, evidence based, context specific, policy making.