Integration in South Africa : a study of changes in the community health system
In the thesis, I analyse a facilitated pilot project of integration of health care services at the community-level. The importance of the thesis is justified by three reasons: firstly integration and the creation of a district health system, as envisaged under Primary Health Care, is promoted as the solution to the health inequalities inherited from Apartheid in South Africa. However, many pilot integration projects have failed and analysing a failed project from an anthropological perspective provides valuable insight. Secondly a renewed interest in Primary Health Care, as the World Health Report of 2008 sets out, also makes this a pertinent pursuit from an international viewpoint. Thirdly the human experience is often ignored in health reform literature. I argue that anthropology can provide valuable insight into integration processes in a health system. Because anthropology explores the human experience, it provides a detailed understanding of the changes in a community health system and their impact on all role players. The data presented in the thesis were collected in an ethnographic communitylevel study in one township urban South Africa between October 1999 and October 2002. This makes this it a historical piece of work to a degree. I describe and critically analyse the facilitated process from the start of the project in October 1999 till its disintegration in failure in June 2001. I also describe and analyse the findings from community research conducted in 2002. For the analysis, firstly I build upon Scott’s concepts of dominance and resistance from his book Dominance and the Arts of Resistance to construct a framework. I argue that to understand a change process fully requires considering the historical context, the international arena, the present context and the facilitator.