Ways of Doing: Restorative Practices, Governmentality, and Provider Conduct in Post-Apartheid Health Care

ABSTRACT

In this article, we consider the conduct of post-apartheid health care in a policy context directed toward entrenching democracy, ensuring treatment-adherent patients, and creating a healthy populace actively responsible for their own health. We ask how tuberculosis treatment, antiretroviral therapy, and maternal services are delivered within South Africa’s health system, an institutional site of colonial and apartheid injustice, and democratic reform. Using Foucauldian and post-Foucauldian notions of governmentality, we explore provider ways of doing to, for, and with patients in three health subdistricts. Although restorative provider engagements are expected in policy, older authoritarian and paternalistic norms persist in practice. These challenge and reshape, even ‘undo’ democratic assertions of citizenship, while producing compliant, self-responsible patients. Alongside the need to address pervasive structural barriers to health care, a restorative approach requires community participation, provider accountability, and a health system that does with providers as much as providers who do with patients.

KEYWORDS:

• Governmentality
• narratives
• patient experiences
• post-apartheid health care
• provider conduct

Acknowledgments

We thank our REACH colleagues who contributed in so many ways to the project and express our sincere gratitude to all who took part in the study and generously shared their stories. We are indebted to the three peer reviewers and Lenore Manderson for the insightful, constructive comments that have helped to shape this article. Ethical clearance was granted by the South African Universities of Cape Town (460/2006) and Witwatersrand (R14/49), and permissions were also obtained from relevant provincial and local health research committees and district- and facility-managers. Informed, written consent was obtained from all individuals interviewed.

Funding

This work was carried out with support from the Global Health Research Initiative, a collaborative research funding partnership of the Canadian Institutes of Health Research, the Canadian International Development Agency, Health Canada, the International Development Research Centre, and the Public Health Agency of Canada (103460-054). This article was facilitated by attending the Wits School of Public Health Thanda Ukubhala writing retreat, which received financial support from the Faculty of Health Sciences Research Office. The first author’s research is also supported in part by the National Research Foundation of South Africa (86472) and Carnegie Corporation of New York. As the South African Chair for Health Policy and Systems Research, the second author acknowledges the support of the South African Research Chairs Initiative program of the Department of Science and Technology, administered by the NRF (87369). We acknowledge that the views expressed, findings and conclusions are solely the responsibility of the authors and that the funders accept no liability whatsoever in this regard.

Additional information

Funding

This work was carried out with support from the Global Health Research Initiative, a collaborative research funding partnership of the Canadian Institutes of Health Research, the Canadian International Development Agency, Health Canada, the International Development Research Centre, and the Public Health Agency of Canada (103460-054). This article was facilitated by attending the Wits School of Public Health Thanda Ukubhala writing retreat, which received financial support from the Faculty of Health Sciences Research Office. The first author’s research is also supported in part by the National Research Foundation of South Africa (86472) and Carnegie Corporation of New York. As the South African Chair for Health Policy and Systems Research, the second author acknowledges the support of the South African Research Chairs Initiative program of the Department of Science and Technology, administered by the NRF (87369). We acknowledge that the views expressed, findings and conclusions are solely the responsibility of the authors and that the funders accept no liability whatsoever in this regard.

Notes on contributors

Bronwyn Harris

Bronwyn Harris is a health systems and policy researcher at the Centre for Health Policy in the School of Public Health, Faculty of Health Sciences, at the University of the Witwatersrand, South Africa. Her work focuses on access, justice and equity in health systems.

John Eyles

John Eyles is professor and South African Chair for Health Policy and Systems Research at the Centre for Health Policy in the School of Public Health, Faculty of Health Sciences, at the University of the Witwatersrand, South Africa. His research interests include qualitative methods, health care resource allocation, and public involvement in health care decision making.

Jane Goudge

Jane Goudge is associate professor and director at the Centre for Health Policy in the School of Public Health, Faculty of Health Sciences, at the University of the Witwatersrand, South Africa. Her recent focus has been on health sector reforms and their implementation.