6 - On Accompanying the Ill

Summary

In 1994, following the first democratic elections, the new South African state sought to create a unitary public healthcare system. It was to be a particularly daunting task, given the uneven, discriminatory and inequitable structures that had been inherited from the apartheid state. Out of a number of parallel and racialized health services, the new state planned to bring together and yet to decentralize health delivery across national, provincial, district and community levels of organization. Resources and services were to be distributed between the different organizational levels in order to provide a ‘continuum of care’ for patients through various forms of referral that, in addition to hospital and clinic care, encompassed community and home-based care (Marais 2005: 64).

Great emphasis was placed on supporting communities in carrying out their own immediate care functions. Promulgating ‘the community’ as a potential resource for care followed on from primary healthcare models in which people on the ground necessarily formed an integral part. The notion of community-based care, aligned as it was with the ideas of self-reliance circulating globally within neo-liberal discourse, had particular local appeal for an emerging nation, in which each person was ‘called upon’ to play their part, and in which ‘local solutions’ were high on an Africanist agenda. Indeed, relying on community-based care was not only envisaged as an activity that would solve issues of scale, quality and sustainability, but also as one that would contribute to community solidarity and mutual assistance. In the terminology of the 2001 National Guidelines for Home-Based Care/Community-Based Care (DOH 2001a: 3), a bed-rock of community-based care was envisaged as something that would encourage ‘traditional community life’ and create ‘responsibility’ within particular localities (Mills 2004: 3, DOH 2001a: 3). The latter idea demonstrated a surprising confluence between local systems of solidarity – on which poor people undoubtedly depend – and the ideal of ubuntu, a history of cooperative struggle in confronting the apartheid state and neo-liberal ideas of self-reliance (Marais 2005: 66).

In the guidelines, written before the availability of antiretroviral medication through the public health system, care was defined as ‘the provision of health services by formal and informal caregivers in the home, in order to promote, restore and maintain a person's maximum level of comfort, function and health including care towards a dignified death’ (DOH 2001a: 1).