POLICY-MAKING FOR REAL : POLITICS AND PROGRESS IN SOUTH AFRICAN HEALTH CARE

In this article, the problematic nature of health reform and health poUcy-making in a changing South Africa comes under critical review, its aim being to argue the case for progressive reform alternatives as solutions to South Africa’s health care problem s. In answer to Coovadia’s (1991, 23) belief th a t"... choices have to be made on basis of reason and not outdated ideology", this exercise may be regarded as an endeavour to present a systematic and impartial exposition of principles and requirements needed for health reform and health policy-m^lking in South Africa. The main problems in South African health care will be stated with the purpose of illustrating and emphasising the need for reform in the health sector. This leads to an exposition of the requirem ents, principles and strategies to be incorporated in a health policy according to which South Africa’s h e a lth c a re p ro b lem s can be appropriately addressed and the health care system reformed. The final section of the article comprises a reflection on the p ro sp e c ts an d fea s ib ility of fundamental, progressive reform against the background of existing power relations in the South African health sector.


INTRODUCTION
Problems have been accumulating in South African health care for well over three centuries yet when it comes to r e s o lv in g th e c ris is by m ea n s of a p p ro p r ia te po licy m ea su res, one becomes aware of the powers at play and the interests at stake in maintaining the status quo, th u s o b s tru c tin g m uch initiative in the process of reform.
In this article, the problematic nature of health reform and health poUcy-making in a changing South Africa comes under critical review, its aim being to argue the case for progressive reform alternatives as solutions to South Africa's health care problem s.In answer to Coovadia's (1991, 23) belief th a t"... choices have to be m ade on basis of reason and not outdated ideology", this exercise may be regarded as an endeavour to present a systematic and impartial exposition of principles and requirements needed for health reform and health policy-m^lking in South Africa.The main problems in South African health care will be stated with the purpose of illustrating and emphasising the need for reform in the health sector.This leads to an exposition of the requirem ents, principles and strategies to be incorporated in a health policy according to which South Africa's h e a lth c a re p ro b le m s can be appropriately addressed and the health care system reformed.The final section of the article comprises a reflection on th e p r o s p e c ts a n d fe a s ib ility of fundamental, progressive reform against th e b a c k g ro u n d of existing pow er relations in the South African health sector.

THE NEED FOR PROGRESSIVE HEALTH REFORM: PROBLEMS TO BE ADDRESSED
Shortages in South African health care Perhaps most manifest problems in South A frican health care today concern resources.Specifically, shortages of manpower, physical facilities and finance (i.e ., p rim a ry sh o rta g e s), and the m aldistribution, m is-allocation and m a l-u tilis a tio n of re s o u rc e s (i.e., secondary shortages) are all apparent.
W ith regard to labour power.South A frica has to contend with primary shortages in almost all categories of professional and non-professional health workers.In many cases, personnel: p o p u la tio n ra tio s in d ic a tin g th e availability of labour power in various categories of health workers in South A frica co m p are unfavourably with minimum-criteria set by the WHO and fall far short of comparable ratios in other middle-income, industrialised countries.The exception is nurses -South Africa boasts one of the highest total nurse: population ratios in the world, namely 49:10000 (Cf. Cooper et al. 1988a, 78;D epartm ent of National H ealth and Population Development 1988 35 & 37;Dewar 1990, 4-5;Republic of South Africa 1988/89, 514;1990/91, 155).As regards doctors, dentists, pharmacists and supplementary health workers, quite the opposite prevails.Bear in mind, however, that already scarce labour power is divided unevenly between the private and public sectors of health care -the former providing occupation for an increasing number of health workers as working conditions in the overburdened public sector become difficult.The ensuing m aldistribution of personnel between the respective sectors eventually finds reflection in discrepancies in the lab o u r pow er available to various socio-economic and racial groups and in different geographical areas; it is clear that in this respect the private sector, catering for the needs of a privileged urbanised cUentele, comes off best.This particular discrepancy, which permeates all aspects and spheres of health care in South Africa, may be attributed to the fact that whites have by far the largest share of health insurance in this country.The health insurance industry was in fact established by De Beers Consolidated Mines in 1889 to ensure that its white employees and their dependents could avail themselves easily of private health services which were abundant in South A fric a 's m ain c e n tre of in d u stria l development at the time (Van Rensburg et al. 1992, 218).In 1989, almost 70% of w hites in S outh A frica had health insurance, as against approximately 30% of each of the coloured and Asian populations and 6,5% of all Africans (Van Rensburg et al. 1992, 228).The problem of primary personnel shortages in the South African health care system thereby acquires a secondary dimension within which race and privilege feature promiiiently.
Primary shortages also occur with regard to institutional resources of health care in South Africa, i.e. hospital a n d clinic facilities.As clinic services are provided by local authorities and are only partially subsidised from the national public health budget, the nature, extent and quality of these services vary according to th e siz e a n d w e a lth o f th e local p o p u la tio n s c o n c e rn e d .
L ocal authorities serving densely populated, relatively affluent communities are in a b e tte r p o s itio n to p ro v id e m ore com prehensive services of a higher s ta n d a r d th a n th o se serving underprivileged communities and it is consequently difficult to come to any single, decisive conclusion regarding the standard of clinic services in South africa.Savage & Benatar (1990, 154) consider the whole range of primary, preventive and community-based health services in South Africa to be generally inadequate and counter-productive: "There is a m arked dom inance o f spending on cu ra tive m e d ic in e over p reven tive m edicine.This m eans insufficient resources are being injected into a badly p la n n e d [a n d already fin a n c ia lly impaired] health care system that places little emphasis on primary and community health services.One consequence is that the resources and facilities in even the best hospitals are under pressure when, with better planning, demands for health care at the tertiary level could have been met more effectively and less expensively at primary and secondary health care levels."The non-white population of South Africa, whose epidemiological profiles reveal a prevalence of acute, infectious diseases and who could, by implication, benefit most from primary hedth care services, eventually su ffers th e d e trim e n ta l c o n s e q u e n c e s o f th e s e d is to r te d priorities.
As re g a rd s h o sp ita l fac ilitie s, the provision of hospital beds in South Africa has deteriorated in recent years.In 1989 the total hospital bed: population ratio was 3,7:10000, as against 4,4:1000 in the m id-1970s ( B e n a ta r 1988, 23-24; D epartm ent of National H ealth and Population Development 1988, 25;1991, 77;Naylor 1988Naylor ,1157;;Republic of South Africa 1990/91, 156).Considering the general inadequacy of primary health services in South Africa, this indicates a s h o rta g e of h o s p ita l b e d s if th e in te rn a tio n a l c rite rio n req u irin g a m inim um of 4 b e d s p e r 10000 of p o p u la tio n s d e p riv e d of a d e q u a te primary care is applied.This shortage of hospital beds manifests itself to varying degrees in the respective sectors of health care and consequently also in the d iff e re n t p o p u la tio n g ro u p s. Considering the fact that only about 20% of the South African population has access to private hospital services by virtue of medical scheme membership, the provision of hospital beds in the p riv ate se cto r can be re g a rd e d as superfluous.The international norm requiring at least 2 hospital beds per 1000 of populations which are adequately provided with primary health services is by far exceeded in this sector -in fact, the hospital bed:population ratio concerned was 4:10000 in 1990.Meanwhile, the vast m a jo rity o f S o u th A fric a n s are dependent on public hospital servicesthe inadequacy and insufficiency of w hich a re c le a rly show n by b ed occupancy rates of up to 151,4% in some public hospitals^.Particularly significant is the fact that severe over-occupancy and over-utilisation of hospital beds occur mainly in public hospitals serving non-white communities (Van Rensburg et al. 1992, 244-245).

Financial aflairs in the health sector
With regard to financial resources, both s ta te a n d h o u s e h o ld b u d g e ts are stretched in the attempt to keep up with the increasing demand for more and better health services from a rapidly expanding consumer population on the one hand and high-tech, specialised medicine on the other hand.
A review of expenditure figures reveds that the real increase in per capita-health expenditure in the private sector has cost the consumer severely.Significant real increases in an already relatively high per capita-expenditure rate in the private health sector and the marked escalation of the cost of health insurance clearly are related.In 1987, per capita-health e x p e n d itu re in th e p riv a te se c to r amounted to R555.It has increased in re a l te rm s (a s m e a s u re d a g a in s t 1985-price indices) with 5,9% from 1987/^ to 1988/89 and with a further 10,7% in the following year (Department of N ational H ealth and Population Development 1991, 76).Meanwhile, the cost of h e a lth in su ran ce has b een increasing at more than twice the rate of inflation since the beginning of the 1980s (B room berg 1980s et al. 1990, 139;Benatar 1991, 33;Centre for Health Policy 1990b, 2;Naylor 1988Naylor , 1160;;Van Rensburg et al. 1992,231).The problem concerning financial resources in the p riv a te s e c to r th u s r e la te s to uncontrollable cost escalations and the increasing unaffordability of health care, which seem to be endem ic to the combination of free-market mechanisms of financing and the private provision of care.To be more specific, the following factors lead, in mutually reinforcing relation, to increases in the cost of health care in the private sector: • a com m ercialised and essentially utilitarian approach towards health care; • third-party financing arrangements and the guaranteed remuneration of providers on a fee-for-service basis; • consumer ignorance; • s u p p lie r-in d u c e d d e m a n d , i.e. physicians' ability to generate and regulate the need and demand for their own services (Cf. Maynard 1986, 1163;Rosen 1989,457); • p ro fe s s io n a l a u to n o m y in an unregulated market and; • the universal, though unpredictable and uncertain nature of the need for care.
Despite increase in the cost of health insurance and private health care, the private sector continues to cater for the needs of consumers (mainly whites) who still can afford claim to the standard of care offered by private providers and private health care institutions.
The public sector is experiencing severe financial shortages.Although public health expenditure has increased in real terms in recent years, the effect of these increases is neutralised by: • the high inflation rate; • the rapidly increasing size, due to a high n a tu r a l r a te o f in c re a s e (birthrate), among the public sectors's clientele; • the growing number of patients who find the private sector inaccessible as h e a lth in s u r a n c e b e c o m e s increasingly unaffordable and who are consequently throw n upon public health services.
At the same time, however, considerable amounts of money still are being spent on the administration of a cumbersome and wasteful public health bureaucracy.In contrast with the per capita-expenditure rate of R555 in the private sector in 1987, the comparable rate in the public sector amounted to only R159 -increasing in real terms by a limited 3,6% per annum ever since (D epartm ent of N ational Health and Population Development 1991, 76).
It a p p e a r s th a t th e administration of the public health care system absorbs a disproportionately large amount of resources and that political decision-making may contribute to a high r a te o f p u b lic h e a lth e x p e n d itu re .
K elly (1988,117) calculated that the costs incurred by the duplication of services and facilities re su ltin g from th e d iffe re n tia tio n betw een "own" and "general" affairs amounts to approximately R800 million per annum.It has been estimated that of every rand spent in the public health sector, twelve cents go tow ards the "administration of apartheid" (C f De Beer 1988, 9; Savage 1986).The bottom line is th a t"... the duplication o f everything fro m a d m in istr a tiv e stru c tu re s to sta tio n a ry , th e m u ltip lic a tio n o f ministerial motor cars, the need for extra staff and the existence o f three separate structures to co-ordinate between all the fragments o f the health services must cost the tax payer several million rand per year, with no benefits in terms o f additional services" (Centre for the Study of Health Policy 1988,9;cf. Cooper et al. 1989,2-3).
While problem s concerning financial resources in the private sector stem from the inherent nature of private health care provision in a free market, the problems concerning financial resources in the public sector seem rather to be the result of inefficient organisation and lack of c o -o r d in a tio n .
A lth o u g h th e s e inadequacies are surm ountable, the cUentele of the public sector (mainly non-whites) have to contend with the detrim ental effects they have on the quality and quantity of services and faciUties available to them.

The latent problems in South African health care
To appreciate the complexity of South Africa's health care problems, one has to bear in mind that the aforementioned problems are manifest in nature; they are the symptoms of underlying problems a n d d e f ic ie n c ie s w h ich m ust be addressed if the health care crisis is to be resolved.In the final analysis, many of th e m an ifest p ro b lem s co n cerning shortages of resources and inequalities in the d istrib u tio n of reso u rc es, with c o n s e q u e n t d is c r e p a n c ie s in th e availability, accessibility, acceptability and affordability of services and facihties for the various groups comprising the South African population, seem to be the result of: • the structural fragmentation of the health c£ire system itself (This refers to the first-order pluralisation between the private and pubUc sectors and the second-order fragmentation among various independent organisations, bodies and institutions of health care p ro v isio n w ith in th e re sp e c tiv e sectors); • the inevitable lack of co-ordination and co-operation among the various c o m p o sin g p a rts o f th is highly fragmented system; • the leaving, to a large extent, of the provision of health care to market forces and private providers whose main objective is profit making; • the strong impression which the legacy of apartheid has left on South African health care and; • th e d is to r tio n s c a u se d by th e domination of the health care system by the medical profession.
Yet, standing above all these problems and contributing to their existence is perhaps the most distinct characteristic of the South African health care system, namely the absence of a binding and enforceable national health poUcy.As such, th e system rightfully can be regarded as a ship adrift in a sea of needs, demands and requirements.In this view, progressive reform clearly requires the issues of stru ctu ral integration and national health policy-making to be addressed if we are to find solutions for its health care problems.There is a need for an integrated system of health care in South Africa, which could, within the framework of a national health policy, provide effective, appropriate health care of an acceptable nature, standard and quality at the lowest possible cost and price according to the real health needs a n d demands of th e entire population in its full diversity.In short, this country is in need of a new, socially accountable health care system that would be attuned to the re d demands, needs amd abilities of its total cUentele on the one hand and which, on the other hand, would find its legitimacy in the approval/acceptance of this clientele (Van Rensburg et al. 1992,365).

THE PRINCIPLES AND REQUIREMENTS OF PROGRESSIVE REFORM IN SOUTH AFRICAN HEALTH CARE:
Socially accountable health care is based on acknowledgement of health care as a basic human right, a social good and a public (collective) affair.Egalitarian values such as altruism, equality, equity and justice would consequently feature prominently in a poUcy that will have to embody these principles in a socially accountable health care dispensation in South A frica.Socially accountable h ealth care ultim ately rests on the following basic principles.•Availability: G e o g ra p h ic a lly , strategically and logistically the full spectrum of services and faciUtiespreventive, curative and rehabiUtative should be so distributed as to enable people to avail themselves of them as the need arises.• Acceptability: T he serv ices and facilities being supplied should be p e rs o n a lly an d so c io -c u ltu ra lly acceptable for the m em bers of a particular community.Variables such as th e lev el of u rb a n is a tio n , in d u stria lisa tio n , m odernisation, westernisation and education of the cUentele, as well as diverse views and beUefs regarding health, disease and health care should be acknowledged and taken into account in the planning and provision of care.
• Adaptability a n d flexibility: Constantly changing health needs of v arious com m unities necessitate r e g u la r re -a s s e s s m e n t o f th e appropriateness of the care supply in those communities.The care supply should be re -a ttu n e d and newly s y n c h ro n is e d a c c o rd in g to the evolving n e e d s and dem ands of communities.
• Accessibility: G e o g ra p h ic a l, fin a n c ia l, r a c ia l, p o litic a l, infrastructural and other barriers should not be allowed to obstruct the need-related access to health care.
• Affordability: No individual should be denied or deprived of basic health care because of inabiUty to pay for it.
Neither should the subsidisation and financing of health care consume disproportionately large amounts of the state's welfare expenditure.
Since private sector seems unable to p ro v id e fo r c o s t-e ff e c tiv e and comprehensive health needs of the total population, and the government seems unable to do so in an effective and equitable manner, health reform requires visionary thinking with regard to the introduction of alternative arrangements.
The existing health care system will have to be restructured if the requirements of socially accountable health care are to be met.The focus and emphasis in this process of structural reform should be on the following: • f i r s t o f all, th e ex foliation and elimination of fragmentation in the health care system; • secondly, th e in tr o d u c tio n and e n c o u ra g e m e n t o f a p p r o p r ia te orientations towards health care in order to ensure that the real health needs of the total population are e q u a lly , c o m p re h e n s iv e ly and appropriately addressed;  1989, 5;De Beer 1988, 4).
T hese objectives re q u ire d ifferen t principles and practices of planning, control, organisation and financing than those currently in operation.Amongst others, they require: • a fimdamental reconsideration of the ra tio n a le o f h e a lth care and its provision; • a re-orientation in the training of health workers; • c o m m u n ity in v o lv e m e n t and deliberation in the planning of health care so that the care supply may be synchronised with actual needs and demands of various communities; • organisation of the care supply on a re g io n a l b a s is , yet w ith in the framework of an enforceable, national health poUcy; • co n so lid atio n of resp o n sib ilities reg ard in g the planning, control, financing and provision of health care into a single, representative and capable authority with no primary financial in te re st o r com m ercial motive in the provision of care.
Against this background a blueprint -for socially accountable health care entails the following: Planning and organising for socially accountable health care As r e g a r d s planning, so c ia lly accountable h ealth care requires a c o m m u n ity -b a s e d , d e m o c ra tis e d approach and establishment of basic p la n n in g u n its (" h e a lth c a re communities") is crucial in this regard.For planning purposes, communities should constitute groups of people who are in comparable political-economic, social and geographiccd circumstances and w ho d is p la y fa irly sim ila r d e m o g ra p h ic and e p id e m io lo g ic a l profiles.The basic contention is that such factors have bearing on the need and demand for c^u-e, and by planning health care accordingly, an appropriate care supply can be e n su re d .The rationale for community-based planning lies in its p o te n tia l to pro v id e an appropriate combination of services and facilities according to the real needs and demands for health care as displayed by smaller "health care communities" -thus in economising by eliminating excessive or unnecessary provision (Cf.Allan & Hall 1988,31;Tannen 1980,128-129).
While the need for health care can be derived from various measurable and stan d ard ised health in d icato rs, the demand for health care can be only established by consulting communities to e sta b lish th e ir view s, b e lie fs and expectations regarding health and health care.Such consultation could reveal valuable information about what various c o m m u n ities c o n s id e r n e c e s s a ry , affordable, appropriate and acceptable in terms of health care; it should give, too, an indication of which services various com m unities would actually utilise.Since community-based planning leads to equal provision of care to communities with relatively comparable needs and th ere fo re also enhances th e equal p ro v isio n of c a re to d iff e re n t communities which are equally exposed to similar health risks, the underlying principles of equity and equality in health care are honoured (Cf De Beer 1988, 5;Klopper et al. 1989,209;Price 1987,51 & 62).W ith p a rtic u la r re fe re n c e to planning of health care in South Africa, Klopper et al. (1989:210) are of the opinion that "... [a] number o f regions determined by administrative efficiency will have to be created to implement resource allocation policy.Appropriate administrative structures are therefore sine qua non for the distribution o f resources to ensure equity.Regionalisation is the method by which it is best achieved."Note, however, that this requires the health planning process in South Africa to be reversed from the prevailing authoritarian process of imposition from above to a dem ocratised process of consultation from the bottom up (Centre for H ealth Policy 1990, 2).It also requires the boundaries of "health care communities" to remain flexible -in other w ords to be expanded or se ce d e d according to varying and continuously ch an g in g n e e d s an d d e m a n d s of clientele.
Existing control mechanisms in South African health care are unsuitable and in a p p ro p ria te for the provision of socially accountable health care.In stark contrast to the fragmented, responsibility c u rrently c h a ra c te risin g the South African health care system, stands the need for a central controlling body in v este d w ith re s p o n s ib ility of formulating an appropriate national health policy in accordance with the criteria of socially accountable health care; such a body would control the implementation of policy.Klopper et al. (1989, 209) clarify the apparent anomaly betw een regionalised planning and centralised control as follows: "The contention is that a central co-ordinating health authority is essential to formulate p o lic y a n d en su re u n ifo rm implementation in regional authorities within the national framework.Without an e ffe c tiv e ce n tra l p la n n in g a n d monitoring authority, autonomous regions could pursue laissez-faire and sectorially m otivated policies, thereby creating interregional disparities and defeating the purpose o f ensuring equity o f health care in S o u th A f r ic a ." A r e s p o n s ib le , representative authority with mandate to accomplish fundamental reform through critical reconsideration of prevailing practices in health care therefore should orchestrate and control the entire reform process.Its basic premise and main objective should be to transform the c u rre n t h e a lth care p o lic y , in to a pro-active health policy in the true sense of the word, implying that the reed needs and demands of the total clientele should apply as the overriding principle in deployment and allocation of resources.

The flnancing of socially accountable health care
The financing of socially accountable health care is crucial in the sense that the mandate for progressive, fundamental health reform lies in the control over financial resources in the health sector.Wohnsky (1988, 67) remarks: "It should become clear that the way to control the health care delivery system is to regulate the flow of money into and within the system... T herefore, if you want to control the system, you have to control the purse strings".With finer nuance as to th e r e q u ir e m e n ts of so c ia lly accountable health care in South Africa, De Beer (1988, 12) essentially holds the same opinion: "Firstly, there must be a single national structure responsible for the p la n n in g , c o -o r d in a tio n a n d implementation o f health care.This structure and all its facilities m ust be integrated racially and ethnically and must eschew the artificia l separation o f preventive and curative services.Many o f the activities currently carried out in the private sector will also need to be integrated into a nationally co-ordinate strategy.Secondly, the money used to finance health care should be collected and administered by the same central authority which is responsible for the planning and provision o f health care..." Structural in te g r a tio n a n d o r g a n is a tio n a l rationalisation of this n a tu re could enhance social accountability in the sense o f a ffo rd a b ility in se v e ra l waysprovided, of course, that this central authority has no financial interest or commercial motives in the provision of health care.It should remain impartial and accountable only to the communities whose health needs and demands it has to provide.In this sense, Dodds ' (1992, 14) remark on development in general a lso a p p lie s to h e a lth re fo rm in particular: "We need a process that focuses on what people want and not on eliminating what they don't want...Such a process is one o f interactive, participating national developm ent planning, and should be conducted with the aid o f facilitators who don't have a stake in the system short o f seeing it succeed."The key to affordable health care ties in effective, efficient organisation and planning by a socially accountable financing agent -on condition, of course, that the profit motive and the idea of free-market health care are abolished.

PROSPECTS FOR A SOCIALLY ACCOUNTABLE HEALTH CARE SYSTEM IN SOUTH AFRICA
The aforementioned structural changes and rearrangements in the South African health care system should settle much of the present organisational confusion and financial waste and should render the system capable of providing socially accountable heahh care.Yet, regardless how clear the rationale and motivation for socially accountable health care may seem, the implementation of progressive refo rm tow ard s its end may prove extremely difficult and problematic.This can be explained by the fact that the structural reform of the South African health care system according to the principles and requirem ents of social a c c o u n ta b ility im p lie s d iffe re n t priorities, in health care than those currently prevailing.
Socially accountable health care indeed sees the various in terests vested in current health care arrangem ents at stake.As regards medical practitioners, socially accountable health care requires re-orientation and reconsideration in th e ir e s ta b lis h e d w ork e th ic , ro le definition and traditional professional values.For medical practitioners, the id e a an d re q u ire m e n ts of socially accountable health care may constitute a challenge to established views regarding the nature of health care.Such views are cultivated by a free-m arket ideology, a c c o rd in g to w hich th e v alu es of lib e ra lis m , in d iv id u a lism , p riv a te ownership, free enterprise, freedom of choice and contract, market entitlement, regulation through competition, profit m ak in g a n d m a te ria l re w a rd s for individual input are highly regarded (Fourie 1989, 137-142).
The view is fostered that health care is a commodity to be traded at a profit in the free market, and can therefore be regarded as the privilege of those who can afford it and have earned their claim on health care.This ideological orientation benefits the medical profession in the sense that it allows them the privileges of health care provision in a free market -a high income level, so c ia l e steem and p restig e , unhampered professional and clinical a u to n o m y an d a la rg e d e g re e of involvem ent in the d e lib e ra tio n of m a tte rs p e rta in in g to health care.However, this orientation and approach towards health care runs counter to the notion of socially accountable health care based on a hum anitarian approach, embracing values of altruism, equity, equality and justice and culminates in the recognition of health care as a basic h u m an rig h t.P ro s p e c ts of an enforceable national health policy, the a b o litio n of fe e -fo r-s e rv ic e remuneration, centralised control and collective financing therefore may be expected to meet with opposition from professional ranks.Ugalde (1979, 109) explains: "In some societies in which a fee fo r service is the prevalent form o f obtaining medical services, the medical p r o fe s s io n has b eco m e a m o n ey aristocracy and has built pow erful associations to retain its privileges when threatened by populations who consider access to medical services to be more a right than a privilege" (cf.Segall 1983Segall , 1954)).
For state and health authorities, social accountability requires acknowledgment and a c ce p tan c e of an unavoidable responsibility for providing health care to the whole South African population.To understand their failure to do so, one has to reaUse that, in its role as facilitator of opposing interests, the state continuously a tte m p ts to m aintain a p recario u s balance between the conflicting demands with which it is confronted.Opposing demands however, are considered and weighed within a power matrix eschewed by the state's interest in maintaining a socio-po litical o rd er based upon a capitalist economy.For the state, the very issues of its legitimacy and power are at stake in the sense that the rationale for its existence and the basis of its power depend on a capitalist social order.In addition to protecting its legitimacy and power, the state also benefits from prom oting m easures and strategies conducive to the preservation of the status quo in the sense that it is exempted from a considerable financial and moral responsibiUty regarding the provision of health care, as well as from the blame should affairs in the health sector come under criticism.
B ecause the state and the m edical profession constitute no mutual threat to each other, they form a close coalition when their interests are threatened or questioned.Those who threaten to overturn the political-econom ic and ideological order are denied access to the corridors of power and are reminded that the right of admission to positions of power is reserved for the guardians of capitalism .T he state and medical profession have been lulling their sense of social resp o n sib ility by superficial changes in arrangements in the health sector and by ad hoc adjustments to problematic practices and priorities in South African health care.Continuous amendments to the Medical Schemes Act (72 of 1967) and numerous changes in the m ethod of ta riff d eterm in atio n for private health services substantiate the argument (Van Rensburg et al. 1992, 218-224).These are typical examples of what Waitzkin (1983, p.42) regards as "reform istic reform" -a concept he explains as follows: "'Reformist reforms' provide sm all material improvements while leaving intact current political and economic structures.These reforms may reduce discontent for periods o f time, while helping to preserve the system in its present form: ' A reformist reform is one which subordinates objectives to the criteria of rationality and practicability o f a given system and policy... [I]t rejects those objectives and demands -however deep the need for them -which are incompatible with the preservation o f the system'" (cf Lindblom 1979, 522).The effect of a reform process confined within the boundaries of a free-market capitalistic system is clearly observable in South African health care.(1986) Commissions largely faded into obscurity (Van Rensburg et al. 1992, 60-64;74-76).This observation is further substantiated by the persistent pursuit of a policy of privatisation am idst the curtailment of public health expenditure -contradictory to the clear need for different m easures and strategies to address our health care problems.

CONCLUSION
Self-righteous professional, political and financial interests rem ain the sacred cows in the reform of South African health care.In fact, the South African health care system serves as reminder that social policy is much rather the outcome of prevailing wills, wishes and wants of the political and economic powers than it is a process conducive to and protective of the social interest.Health policy-making and health reform are political processes and therefore prospects for progressive health reform and socially accountable health care in South Africa are deemed unfavourable.Perhaps we are too pessimistic in our prospects for a socially accountable health care dispensation in South Africa and maybe our judgment of the various players in the field is too harsh.Yet, we tend to agree that Tannen's (1980, 118) verdict of the m atter in the USA is equally applicable to South Africa: "Surely medical ideology is shaped and determined by many different forces and is not dictated by any one class, but o f the m a n y v a ria tio n s a n d d iffere n t organizational form s possible, it is no accident that the prevailing form o f m e d ic a l p ra c tic e to d a y is largely compatible with the capitalist mode o f production and its social relations, It would be highly unlikely for the medical system in this country to foster ideas relating to the social origins o f disease, collective responsibility fo r health, democratization o f m edical skills, or community control o f medical facilities, These concepts run counter to the prevailing values o f the rest o f society."(Cf. Battistella & Smith 1974, 707;Lindblom 1979, 520-521;N av arro 1989, 889;Roemer & Roemer 1982,112).

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Appropriateness and relevance: The kind of services and facilities suppUed should bear a clear relation to and should co-ordinate with the real h e a lth n e e d s o f c o m m u n itie s dependent upon these services and faciUties as sources of health care.
T h e se a re derived from principles stipulated by, am o n g st o th er, C o e 1978,413-415; Elling 1974; Prescot & D e F erranti, 1985; TVaddle 1982: 355.A lso cf.V an R e n sb u rg e t al., 1992 : 364-365 in this regard.Curationis, Vol. 16, No. 3,1993 • thirdly, th e a c c o m p lis h m e n t of m a n a g e ria l a n d o rg a n is a tio n a l efficiency to ensure optimal utilisation of available resources and personnel in the best interest of the clientele (Cf.Centre for the Study of Health PoUcy An inability and reluctance to question and oppose vested interests have trapped health reform in a v icio u s cy cle of re fo rm ism .The prejudice and overt antipathy against, the d is c r e d ita tio n a n d id e o lo g ic a l impeachment of, and even the sabotage of progressive reform initiatives are cases in point.One needs only ask what has becom e of the recom m endations of various commissions of inquiry which have meticulously investigated several problematic aspects of South African health care.It appears that the politics of the fre e -m a rk e t and th e capitalist hegemony in health care have ensured th a t th e re c o m m e n d a tio n s of the National Health Services Commission of 1944 ( o r s o -c a lle d G lu ck m an Commission), the Vos-(1925), Loram-(1928( ), Collie-(1936) )  and Browne- REFERENCES ALLAN, J.D. & B.A. HALL.(1988)."Challenging the focus on technology: A critique of the medical model in a c h a n g in g h e a lth c a re system ."A d v a n c e s in N u rs in g S c ien ce 10(3):22-34.BATTISTELLA, R.M. & D.B. SMITH.(1974)."Towards a definition of health service m anagem ent: A hum anist orientation."International Journal of Heahh Services 4(4):701-720.

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