This thesis focuses on the transformation of healthcare services for the blacks in the former Transvaal during the period from the 1930s to 1990s. The thesis argues that over this period the healthcare of rural blacks from Union to Republican governments had incipient features of primary health care – haphazardly driven by progressive-minded individuals within the state, by missionaries, as well as other stakeholders, motivated by concerns over the socio-economic conditions of the blacks. Although the concept of primary health care did not exist in popular public health parlance during the Union era, prototypical concepts such as ‘native health’, ‘preventative health’ or ‘community health’ were used interchangeably to describe and formulate a variety of initiatives meant to deal with health challenges caused by diseases such tuberculosis, malaria, syphilis, HIV/AIDS and other poverty-related diseases. A brand of ‘Community-Orientated Primary Care’ was popularised by Sidney Kark to refer to his initiatives at the Pholela Health Centre, a model primary health care project of the early 1940s. The model inspired the establishment of similar health centres in the rural areas of the Transvaal and other provinces, as part of the broad sweep of social medicine from the 1940s.
This thesis also argues that the road to the full embrace and implementation of primary health care was characterised by many challenges emanating from the state’s reluctance to support its implementation, as that had the potential of upsetting the policy of racial discrimination. Opposition to the state’s reluctance to implement a national healthcare system based on the precepts of primary health care emerged and intensified from the time the National Party came into power in 1948. Aspects of the healthcare system of the former Transvaal were also uniquely influenced by some former medical students of the University of Natal Medical School who, from the late 1960s to the early 1970s started to use their newly acquired skills and experience to deliver community health care services in parts of the Transvaal. Although the historic Alma Ata Conference of 1978 added impetus to the popularity of the concept of primary health care, its full implementation in South Africa was wobbled by the reluctant apartheid state. As expected, primary health care became a battleground of political wrestling between the state and liberation movements and other stakeholders. It was only after the 1994 general elections that the concept was declared a national policy, to be prioritised by all government departments.
Although several scholars have dealt with progressive healthcare initiatives during South Africa’s twentieth century, a focus on the rural Transvaal offers a new opportunity to revisit key developments in the country’s public health history, and to reflect on the layered and indeterminate nature of the emergence of primary health care, with particular emphasis on the contribution of educated African healthcare professionals and grassroots movements. Like the Pholela and the National Health Service Commission initiatives which have been covered extensively in the literature, a history of the development of the public health system in the Transvaal offers a vista to understand the colonial origins and changing fortunes of rural primary healthcare over the course of an eventful seven decades in South Africa.