| Upon coming to power in 1994, South Africa's postapartheid government launched its ambitious Reconstruction and Development Programme with several major primary health care initiatives. Two years later, it adopted a macroeconomic policy that put neoliberal reforms ahead of redistributive goals. Based on one year of ethnographic research in an urban health district, this dissertation examines the relationship between this discordant national policy configuration and the micropolitics of government primary health care in the late 1990's.;Seeking legitimacy in the eyes of formerly disenfranchised citizens and potential foreign investors, state health officials sought to promote both democratic inclusion and fiscal constraint in health services. In pursuing these goals, national policies called upon primary health care actors in ways that exacerbated existing inequalities and tensions among them. For example, state policies required White patients, and nurses to accept the desegregation of public health facilities but allowed those with greater economic resources to resegregate themselves into the private sector. Public service campaigns encouraged patients to demand high quality services while requiring nurses to tolerate severe understaffing and resource shortages.;Through interviews and observations in primary care settings, I found that, whether Black or White, the ability of primary health care actors to contest the state's demands depended largely on their sense of economic dependence on state resources. Similarly, conflicts between nurses and patients over status and respect played out differently depending on the character of professional power relations in a particular clinic and of social power relations in the surrounding community.;Overall, certain patients and professionals did gain new institutional status and rights, but these gains were largely confined to the second tier of a two-tiered health system. Similarly, access to primary health care did broaden, but only at the cost of reduced access to hospital services. Finally, responsibility for service delivery became increasingly identified with local officials, while the bulk of funding remained in provincial hands. This disarticulation of democratic and fiscal accountability tended to locate state failure at the local level, while protecting the legitimacy of provincial technocrats and national politicians. |
