Day 2: The Political Economy of Health

Activity 7: Inside the South African political economy: a panel with case studies

2 hours 30 minutes


To help us to:

  • Deepen our political economy tools of analysis through exploring social stratifications that compound and intersect, exacerbating marginalisation 
  • Challenge dominant and normative perspective in political economy analysis

Task 1
Journal reflections within small groups: Exploring one angle into how social stratification is a political economy issue

(45 minutes)

We will have four groups and each group will be assigned one social stratification area, with a conversation facilitator (and a critical respondent indicated in brackets): 

  • Race and class with Haseena Majid (Dinga)
  • Gender with Ntombohlanga Mqushulu (Funzani)
  • Sexual Orientation and Gender Identity (SOGI) with Bayanda Ndumiso (Masana)
  • Rurality and land with Thamsanqa Hukwe (Phethani)
  1. Start with 10-15 minutes of individual silent reading, reflection and journaling time. Read the mini social stratification brief allocated to your group. While you read, use your journals to note down your questions, concerns, issues that you want clarity on, etcetera. Be ready to offer your reflections in your group. If you finish your journal work ahead of others, take the quiet time to read some of the other briefs, so that others do not feel rushed. 
  2. Conversation facilitators (Haseena, Hlanga. Bayanda and Thami) and critical respondents (Dinga, Funzani, Masana and Phethani) will hear your questions, concerns and issues but will not give immediate responses. They will take notes towards weaving their responses to your inputs into the plenary conversation that offers their own perspectives on the political economy of the social stratification that you have worked on. 

Task 2
Plenary: A tapestry picture of grappling with social stratification as key to political economy analysis

(1 hour 45 mins)

In plenary, the conversation facilitators and critical respondents will be seated together in a conversation space. 

We will first hear from the conversation facilitators as they we weave a tapestry of how social stratification manifests. They will share their own perspectives on the political economy of the social stratification that their group has grappled with, while also weaving in their responses to their group’s questions, concerns and issues. The structure of their presentations in plenary will be to share and each facilitator will have a maximum of 15 minutes (15 mins x 4 = 60 mins): 

  • Key facts and figures
  • A political economy analysis of their stratification
  • Implications for political economy as a tool of critical analysis
  • What a political economy approach to their stratification would mean for improving health systems and for health equity

After we hear from all four conversation Facilitators, it will be the turn of the critical respondents to engage in two ways (max. 10 mins x 4 = 40 mins). They will first engage on the particular social stratification that their group grappled with. They will then also be free to step back on the overall picture emerging across all four, and the patterns that we should notice and reflect further on from a bird’s-eye view of the tapestry. The facilitators and respondents will also reflect on how the approach that we have taken, challenges dominant and normative perspectives in political economy analysis. 

We’ll close the plenary with a question to the floor, to Fellows, to hear the extent to which this exploration of social stratification assists as a further tool of political economy analysis (5 mins).

The Political Economy of Race

Adapted from Niemah Davids story, Racism in medicine is ‘a horrible injustice’ (2021)

Full story @

Racism in healthcare manifests in a range of ways. But the common themes include neglecting, disbelieving and actively discriminating against patients.

Professor Ntobeko Ntusi, the chair and head of the Department of Medicine at the University of Cape Town (UCT) and Groote Schuur Hospital (GSH) provides examples of how the scourge of structural racism affects the medical fraternity, patients, and academic hospitals. “Martin Luther King Jr. stated that ‘of all the forms of inequality, injustice in health is the most shocking and the most inhumane’. That observation rings [as] true today as it did 60 years ago,” says Professor Ntusi.

Profound impact

Structural racism, Ntusi argued, goes beyond individual prejudice. He described it as a perpetual inequity, deeply ingrained in social policy, legislation, law enforcement, the economic system, and the healthcare system. “It results from the pervasive, misaligned thought process that places one racial [and] ethnic group above another. [Racism] is often driven by white supremacist beliefs, and the failure to understand that all humans share homology [in] 99.9% of their DNA,” he said.

He said within the healthcare sector, structural racism has “profoundly impacted” the mental and physical health of historically marginalised groups. Research indicates that in all corners of the world, black people have lower life expectancies when compared with white people; and predominantly black communities are more likely to experience a shortage of primary healthcare physicians. In addition, black patients globally experience some of the worst health outcomes when compared with any other racial group.

“On a deeper level, the medical community has also promoted structural racism through biased research and papers published in scientific journals,” Ntusi said. “Racial discrimination in the healthcare system [in] many countries – including ours – has negative consequences for both patients and healthcare workers; and it leads to a higher illness risk, and in some cases a lower standard of care for black patients.”

The Covid-19 pandemic has highlighted this. A study published in The Lancet indicated that black Americans are four times more likely to succumb to Covid-19 when compared with white Americans, and data from other countries revealed a similar pattern. In South Africa, Ntusi led a study of healthcare workers at Groote Schuur Hospital which showed that black healthcare workers are also more at risk of contracting Covid-19. A sister study, which surveyed healthcare workers in London, corroborated these findings. The results of both studies have not yet been published.

Racism in healthcare

According to Ntusi, racism in healthcare manifests in many ways but the common themes, include neglecting, disbelieving and actively discriminating against patients. A 2016 study found that 73% of white medical students surveyed hold at least one ‘false belief’ regarding biological differences between races. The following beliefs from white medical students were recorded in this study: black people have thicker skin, less sensitive nerve endings, stronger immune systems, and higher pain-tolerance levels.

“Researchers noted that these beliefs are centuries old, and some 19th-century doctors used them to justify the inhumane treatment of slaves,” said Ntusi.

These ageold beliefs, he added, continue to have an impact on modernday medicine. In another study, it emerged that black children with appendicitis are less likely than white children to receive appropriate pain medication. A report published in Frontiers in Paediatrics, a leading medical journal, also revealed that doctors are less likely to admit black children to hospital after a visit to the emergency department, and less likely to request blood tests, computed tomography scans or Xrays for young black children compared with white children.

But patients are not the only ones subjected to racism and discrimination. Black medical students and faculty members are also directly affected.

“Academic medical centres are where medical students learn to become physicians and [where] faculty members engage in cuttingedge research education and clinical care. But these academic centres of excellence fail to uphold their commitment to maintaining diverse, equitable and inclusive environments for black students and faculty,” he said.

Ntusi said black faculty members have cited lack of mentorship, lack of sponsorship, promotion and career advancement opportunities, and an overall lack of support as some of challenges they face daily and account for the reason for the high attrition rate among doctors from academic medical centres.

In disbelief

In recent years, Ntusi has travelled the length and breadth of the country to recruit young black UCT medical graduates to return to the university to specialise in a medical discipline. But their feedback has seldom been favourable.

“I am in constant disbelief – and embarrassed – at the amount of psychological trauma that black medical students and black registrars suffer in institutions like ours. This phenomenon is not unique to UCT, and is reported globally,” he said.

In several studies, black medical students reported social isolation, and experiences of racism and tokenism perpetuated by fellow students and faculty members. Racial bias, Ntusi added, even manifests in the way medical school faculty members describe black students in evaluations.

Closer to home, in apartheid South Africa, medical research was carried out on the physical differences between black and white patients, and new theories were subsequently developed to explain perceived differences and to justify the superiority of the white ethnic minority.

“In the hospital where I work [Groote Schuur Hospital], it was not until about 40 years ago that black registrars were allowed to look after white patients; and even more recently when black and white patients could be treated in the same ward,” Ntusi said. “We all need to recognise, name and understand our attitudes and actions, including [our] unconscious bias. We must be open to identifying and controlling our implicit biases. We need to model tolerance, and practise respect, openmindedness and peace in our engagements. These things need to be part of medical education, as well as part of institutional policies.” 

“We, as scientists and clinicians, and society more generally, must realise the struggles of one marginalised community are the struggles of all of us. My fight as a black doctor to serve my patients without fear of racism, and the fight of a black patient to be treated with dignity and respect, should also be your fight.”

2. The Political Economy of Gender

Adapted from Mandisa Mbali and Sethembiso Mthembu’s article, The Politics of Women’s Health in SA (2012)

Full story @

There are several interrelated crises in women’s health in South Africa. Since the 1990s, HIV/AIDS has been considered foremost among these and it has posed a demographic, health, social and cultural catastrophe for South African women. HIV has become the leading cause of maternal mortality in South Africa, according to the government’s own statistics. Women’s social and health statuses are also being blighted by the high rates of intimate partner violence and sexual assault in the country. A recent global perception poll of the ‘best and worst’ group of 20 countries for women canvassed the views of 370 gender experts from five continents. South Africa was ranked 16th out of the group of 20 countries, right above Indonesia, Saudi Arabia and India, because it has “Some of the highest rates of sexual and gender-based violence in the world. 

  • As a consequence of feminist advocacy, South Africa’s Constitution refers to sexual and reproductive rights in three places:
  • The equality clause (s.9.3), which forbids discrimination on grounds of sex, gender and sexual orientation
  • Section 27. 1. A, which states that “Everyone has the right to have access to health care services, including reproductive health care”
  • Section 12 dealing with “freedom and security of the person”

Mandisa and Sethembiso comprehensively outline key issues in women’s health covered in greater detail in other aspects of their publication. A gender lens opens our analysis to how political and economic systems privilege or disadvantage different groups based on their identities or other characteristics, including sex, gender, age, class, ethnicity, religion, sexual orientation, disability, marital or citizenship status and geographical location. These systems shape the opportunities, choices and well-being of different people differently, and they also affect the effectiveness of any intervention or reform for different groups.

These include (in summary here):

  • Rights in relation to sexual and reproductive health including the rights to access to information (frequently manifest in health professionals obtaining informed consent for medical procedures following adequate counselling), education, dignity, and for our bodily integrity to be respected
  • The politics of women’s health and the public contestations for control of the state, or policy making, or budgetary allocation. For instance, multiple reports have come to the fore indicating that women living with HIV have been coerced and in post-apartheid South Africa Involuntary sterilisations have continued
  • The adverse social and emotional impacts of forced sterilisations on women living with HIV – an already marginalised social group. 
  • Accountability for abuses at public-sector health facilities, including anti-poor and sexist verbal abuse and assault
  • Perspectives and experiences of accessing contraceptive devices and drugs at public sector health facilities highlights patients’ perceptions that some providers are rude and impatient as a ‘major deterrent’ to their use. 
  • Further research on the global debate over how to respond to a recent study which shows that injectable, hormonal contraceptives such as Depo Provera may double the risk of HIV transmission among women who use it and their partners. 
  • The need for more training for health care professionals on HPV and cervical cancer in women living with HIV and a greater provision of Pap smears as part of a continuum of prevention, treatment and care for all women, with an additional, initial emphasis upon women living with HIV.
  • The issue of women not receiving adequate counselling before and after hysterectomies
  • South Africa’s high rate of maternal mortality is a major women’s health policy challenge
  • Ensuring that the National Health Insurance (NHI) scheme receives considerable engagement by feminist civil society and women’s organisation in particular
  • Specific planning and costing to be conducted to address the high rates of cervical and breast cancers, trauma from gender-based violence, and the sex-specific manifestations of HIV disease in women and men. 
  • Improving maternal and child health services is both popular and necessary and should certainly be a focus for NHI-financing. 

All of this points to a wide chasm between many women’s experiences of public sector health services which are of poor quality, inaccessible, provided in an unprofessional manner and the rights enshrined in our country’s constitution. HIV/AIDS and concomitant rises in maternal mortality are also at the centre of the crises in women’s health in South Africa. 

South African women’s rights activists have successfully pressed for gender-related law reform in the past, most notably that legalising abortion. Alliances between men and women in government and civil society who were in favour of this reform were key to its success.

This suggests that whether future health-related legislation will be gender progressive may critically depend upon whether feminist health activists in civil society can forge a joint agenda with feminists in government, in the manner of the legalisation of abortion. Such strategic alliances may prove critical in the decriminalisation of sex work and the forging of an NHI which will improve women’s health.

It is unclear where promising advocacy initiatives such as SHARISA might lead, but the status quo of multiple advocacy organisations lacking a common sexual and reproductive health and rights policy agenda means that they are still largely politically ineffectual. A strong civil society coalition on sexual and reproductive health and rights with a list of common demands could certainly assist in ensuring that the South African government is held accountable in terms of the progressive realisation of health services which uphold women’s dignity and rights. This is all the more important at a time when the government is fundamentally reconfiguring our health system.

3. The Political Economy of Sexual Orientation and Gender Identity (SOGI)

Full Text from an IOL article, Health Care for SA’s LGBT+ Community Needs Boost (2020)

Story @

South Africa’s LGBTI community continues to face extreme discrimination and inadequate health care. Every day, lesbian, gay, bisexual, transgender and intersex (LGBTI) people face violence, exclusion and discrimination in South Africa. 

Seoketsi, from Limpopo, was physically assaulted by a nurse. After laying a charge against the nurse, a doctor refused to examine Seoketsi or to sign a report about the assault. 

Getty Myeni, from Ermelo, knew the men who stabbed her to “fix her to become a real man”. She reported the attack at the local police station where she was ridiculed and mocked. Despite knowing her attackers, the police did not investigate the case.

Thabo, from Bloemfontein, is mistreated by his stepfather who wants him to “toughen up and be a man”. Augustine, from Mpumalanga, said: “My life is a hell – the name-calling, staring, insults and harassment is my daily reality.”

Family rejection when a person ‘comes out’ often results in violence, abuse and adverse health outcomes. LGBTI youth who experience family rejection are eight times more likely to attempt suicide, almost six times more likely to experience elevated levels of depression, and three times more likely to use illegal drugs than those LGBTI youth who were accepted by family members, according to UN Women.

Beyond Zero’s Me1st campaign – which targets men who have sex with men – and the #UnMuteMe campaign – which supports transgender people – indicate that harassment by family and society is a contributing factor to the mental health issues of many LGBTI people.

Bulumko Futshane, Beyond Zero’s programme director for HIV prevention under the Global Fund, said: “Family rejection is high and leads youth to either run away from or be kicked out of their homes. Once they find themselves homeless, they are at risk of HIV and other sexually transmitted infections and engaging in risky sexual behaviour including sex work. Intimate partner violence is also prevalent.”

The LGBTI community is often reluctant to seek medical care because of discrimination or a lack of experience with LGBTI health. This stigma results in increased HIV and TB transmission because patients do not adhere to their treatment routines.

Beyond Zero is training health-care workers and engaging with law enforcement and community members to provide an accepting environment for transgender people to seek treatment and support.

Me1st is targeted at helping men who have sex with men because they are a key at-risk population for HIV/Aids. It provides access to information and free health care that is discreet, confidential, free of discrimination and administered by qualified professionals. For more information, see

4. The Political Economy of Land and Rurality

Adapted from research by Bernhard Gaede and Marije Versteegi, The State of the Right to Health in Rural South Africa (2011)

Full paper @

South Africa has poor health outcomes in both rural and urban areas, despite spending significantly more on health than other middle-income and developing countries which produce better outcomes. A review of the state of health in South Africa found insufficient progress in combating HIV and AIDS and malaria, no progress in improving maternal health, and a deterioration in the mortality rate of children under five years of age.

A recent study found that the provinces with the greatest health burdens, least economic resources and largest populations received the smallest share of national public healthcare funds. The racial and geographical inequities of the apartheid past have not been adequately addressed in current healthcare spending processes, and provinces with greater existing capacity in terms of hospitals and number of doctors benefited from higher funding allocations. The continued inequities are explained by the “infrastructure inequality trap”, where better-resourced health infrastructure requires higher levels of funding to maintain current levels of care, and also has greater capacity to spend the funds allocated and leverage additional funds. As a result, the inequitable distribution of healthcare infrastructure continues to perpetuate inequalities between urban and rural areas, such as per capita spending on PHC.

The experience of Sarah outlined below is not an exception. In rural South Africa (SA) accessing affordable, good quality and comprehensive health care remains a real challenge for many. There have been significant improvements in the healthcare system since 1994, such as introduction of free primary health care (PHC) for all, the establishment of a district-based health system, introduction of the essential drugs programme and the hospital revitalisation programme 

Sarah (48 years old) lived in Gauteng and had been treated for hypertension. She had a stroke, for which she was treated at a local hospital, and was left with weakness of the right side. She was unable to continue to work and returned to the rural area where she grew up. She had referral letters from hospital to receive occupational therapy and medication.

Sarah moved into her family homestead where her sister and her children lived, as well as some of her own children and grandchildren. The homestead was situated on a hill about four km from the tarred road, with no piped water and a pit latrine. Sarah had previously provided most of the family’s income.

The community caregiver paid her a visit and advised her to go to the local clinic with the referral letters. She explained that Sarah should apply for a disability grant but said that this would not be easy.

It was difficult for Sarah to get to the clinic because of her one-sided weakness, but when she did manage to get there the rehabilitation team was not available, and she was given an appointment to return in five weeks’ time. A nurse took the letter but due to unavailability of the prescribed treatment at the clinic, she was prescribed a first-line agent according to the standard treatment guidelines. She indicated that she was not able to refer Sarah for a disability grant as the forms needed to be completed by the doctor – who would come the following week.

The effort involved in getting to the clinic was too great. The family discussed what to do next. They considered traditional medication or a visit to a general practitioner (GP), but to see the doctor at the clinic would have meant at least two more trips. They decided to spend the money on going to a GP, who said Sarah needed to go to the local district hospital with a referral letter stating that she needs occupational therapy and a grant. When they got to the hospital a sister shouted at them for not going to the clinic. Sarah was told to go back to the clinic – and still had no referral for occupational therapy nor a disability grant.

To realise the right to health, the specific conditions and realities of rural areas need to be taken into account. This in turn requires sufficient insight by policy makers into rural health systems, so that implementable policies are designed that can achieve their intended goals equally among citizens. The focus on inequities related to race and socioeconomic status needs to be broadened to include the explicit link to geographical location.