Collaboration between the state and civil society: An uneasy coalition
In the previous chapter, a mapping of the mental health system was undertaken, by illustrating mental health service networks in a South African district. However, in reality the borders between state and non-state actors are far from clear. In this chapter, we focus on a particularly important, if neglected, dimension of mental health services: the complex and highly politicised relationship between the State and CSOs. Though the focus is on CSOs that are involved in mental health care, it is important to understand this loose subspecialty in terms of the broader nature of State-CSO relations in the post-apartheid period. Using a single term to describe organisations that are inherently varied, can hide the plurality that has become a central feature of CSOs. However, this plurality should be taken as a key indicator of democratic growth:
[We adopt] a definition of civil society that celebrates its plurality. It recognizes that the set of institutions within this entity will reflect diverse and even contradictory political and social agendas. As a result state-civil society relations will reflect this plurality. Some relationships between civil society actors and state institutions will be adversarial and con- flictual, while others will be more collaborative and collegiate. This state of affairs should not be bemoaned. Instead, it should be celebrated since it represents the political maturing of South African society.
(Habib 2005, p. 672)
Post-apartheid policy contexts shaping CSO activities
The roles, responsibilities, identities and activities of CSOs were substantially altered during South Africa’s democratising period, where a host of structural, legislative and policy changes took effect. The civil society domain was very much enabled and constrained by the “brave new world” constructed by business and the state (Heinrich 2001). The apparent wave of neoliberal-inspired social policy in many young democracies can very much be conceptualised in terms of Bourdieu’s “bureaucratic field”, a mechanism that acts like a sphere that influences the motivations and practices of CSOs (Janse van Rensburg et al. 2018), who “attach themselves to new procedures designed to meet the disciplinary demands of the neoliberalizing bureaucratic field” (Woolford & Curran 2012, 48).
The bureaucratic field acts as a prism that refracts economic neoliberal policy, affecting almost all aspects of society (Wacquant 2009a); “the working of the economic system here not only “influences” the rest of society but actually determines it - as in a triangle the sides not merely influence but determine the angles (Polanyi 1977, 14). The neoliberal market-driven ideology of ‘lower costs, higher efficiency’ that pervaded state power (Zizek 2010), infused South Africa’s post-apartheid bureaucratic field and inevitably permeated the ways in which CSOs were structured (Habib 2005). Furthermore, the global hegemony of “poverty reduction” within international development (Ferguson 2015), with significant resource support from international agencies to CSOs, created a system that insisted on measurement and indicators - reigning in and depoliticising CSOs’ strategizing capabilities (Mitlin et al. 2007). Market- led relations and increasing commercialisation threatened the core values of the CSO sector: corporate human resourcing rather than volunteerism; financial accountability rather than community accountability; and dependence rather that autonomy. This unfolded against the backdrop of key policy and legislative shifts.
The Constitution of the Republic of South Africa (South African Government 1996) has been, in many ways, the lynchpin of post-apartheid re-building and development. Importantly, it presented the new African National Congress (ANC) government with a substantial amount of symbolic capital, rendering the state into “hope generating machine” (Muller 2014,41). While the human rights ethos of the Constitution acted as a blueprint for succeeding legislation and policy, the ANC had to balance socio-economic transformation in step with the global milieu during the 1990s, on the one hand, and social justice and the restoration of entitlements, on the other (Sitas 2010). In this vein, the Reconstruction and Development Programme (RDP) was particularly significant, aiming to address colonial and apartheid- era injustices by targeting poverty and unequal social service distribution with a social-democratic approach (Karriem & Hoskins, 2016). The expansion of health and social services during this period is significant - health care is a strategic public good, and a key source of contestation: “Health systems frame and either legitimate or de-legitimate the very nature and competence of the state. States that cannot ensure health care, lose their legitimacy” (Mackintosh 2013).
Health and social development were especially prominent in R DP-led gains during the first years of democracy. This included the provision of free PHC to vulnerable groups; the implementation of an essential drugs programme; greater parity in district-level health expenditure; a clinic building and upgrading programme; expanding welfare benefits to those in need; and a revitalisation and construction of public hospitals (Harrison 2009; Van Rensburg and Engelbrecht 2012). Yet, it quickly became apparent that the RDP was in trouble; this became evident in the missing of targets of the first few years of implementation, as well as underspending and allegations of corruption. The RDP also suffered from ambiguity, some perceiving it as a radical socialist transformation, while others seeing it as an anti-poverty programme (Blumenfeld 1997). Weak power and bureaucratic obstructions in implementing the RDP across various national departments further hamstrung its outcomes (Karriem & Hoskins 2016). Ultimately, apart from selected quantitative progress, the RDP did not qualitatively improve the plight of vulnerable populations such as PLWMI. Van Zyl Slabbert (2006, 102) spoke to the core of the RDP’s legacy: “In whichever way we look at it, we will measure the success of our transition by the demonstrable improvement in the quality of life at the local level. That is where we live every day”.
Following the RDP, the Growth, Employment, and Redistribution (GEAR) policy was introduced in 1996. The apparent dramatic shift from a somewhat Keynesian RDP to a neoliberal GEAR has been well described (Bond 2005; Karriem & Hoskins 2016; Nattrass 1996; Peet 2002; Terreblanche 1999; Visser 2005). In many respects, GEAR reflected global neoliberal forces at work during the time (International Monetary Fund and World Bank influences in many developing states), prioritising deregulation, privatisation and market dynamics above redistribution and social justice (Harvey 2005). Importantly, GEAR provided a fertile environment for the proliferation of private hospital groups and privatisation of mental health services, adding impetus to an already fractured, unequal and dualistic health system. Perhaps the most striking indication of the ideological shift from the RDP to GEAR was the transfer of oversight power from the presidency to the Ministry of Finance, cementing the transformation from “growth through redistribution” to “redistribution through growth” (Karriem & Hoskins 2016). Adding to calls for increased state-civil society collaboration in the ANC Health Plan and White Paper for the Transformation of the Health System in South Africa, the Non- Profit Organisations Act 71 of 1997 created a formal, legal structure for such relations. Specifically, the Act allows for CSOs to register as public benefit organisations, and set standards of governance, transparency and accountability by offering inducement rather than penalty in creating structure for voluntary registration (South African Government 1997.
As discussed in the previous chapter, the narrative of collaborations across state and non-state divides, as well as across sectors, has been firmly put in centre stage by the introduction of the ambitious, state-driven National Health Insurance (NHI) scheme. A notable feature of this project has been a combative tone between state and private care sectors. Throughout his tenure, the Minister of Health spearheading the NHI Dr Aaron Motsoaledi, took a firm public stance against a perceived frivolous and unjust private sector, adopting war language and casting the stand-off as an ideological battle rather than a pragmatic economic one. Probably due to coinciding with Barack Obama’s introduction of the Affordable Health care Act in the United States at the same time, a similar discourse of socialist versus free market medicine was deployed. Alex van den Heever, a prominent voice of critique against the NHI proposals, noted that the Green Paper on a Policy on National Health Insurance contains factually incorrect information that deliberately inflate the public-private health care system discrepancies in South Africa (van den Heever 2011). Indeed, the public-private divide in rhetoric regarding the reasons for and need to curb private sector labour costs and decrease social inequality persists, and will likely continue to haunt the broader discourse of universal coverage.