Module 2

Module 2 Framing Document

Do make time to read this Framing Document for Module 2 ahead of the start of our week together! Doing so will give you a perspective on the week that should allow your daily grappling, reflecting and learning to make more sense and find coherence more swiftly.

 A reading list is included as the last section of this document. You will receive these readings electronically and as a printed pack. This is for your further and deeper reading on angles that we cover or cannot include because of time. Do a scan of them during this week, so that you have a sense of which you can use in your evolving Social Change Initiative (SCIs) framing. 


This Framing Document sets out the core ideas shaping Module 2 and is designed to spark critical reflection, analysis, questions, points for debate, and is for use as a reference point for the whole of the module. It sets out the module theme, rationale, objectives, learning journey you can anticipate, and expected roles and responsibilities for this module’s learning process. 

In introducing Module 2 we want to pose a similar set of questions to those posed in Module 1. What is Module 2 about? What does Tekano want to achieve with Module 2? What is planned? What will we learn? How will it be done? What is our role as Fellows? 

While Module 1 provided a foundational understanding of how the prevailing context matters for health equity and what is required as leaders for social change, Module 2 expands on this but explores the ways in which politics, power, and ideology all underpin and influence people’s health. Given that the world we live in is so complex, the world of health provision, access and what determines health outcomes, must inevitably reflect this complexity. As we learnt in Module One, health is not just about the well-being of an individual. Health is shaped by complex social, economic, political and ecological dynamics and factors. Political and ideological opinions and choices matter!

We shape and extend our understanding of health inequity by using a political economy approach.  Using a political economy approach allows us to introduce tools for deeper analysis. When we use political economy as an analytical tool, we are able to develop complex and critical knowledge of the interconnections between the political and economic factors that shape our lived realities.  We are able to develop a critical understanding between the theory of ‘free’ markets and how markets actually work depending on where we are positioned in societies. We are able to develop a critical understanding on how and why political choices are made and how they impact on public policies. We are able to challenge the neoliberal rhetoric of ‘There Is No Alternative’ (TINA). We are able to consider and evaluate critical perspectives of radical political economy conceptual tools, and what these African, decolonial and feminist lenses offer our deepening analysis.

We are intentional about this, but we are also open to hearing and learning from Fellows on alternative ways of reaching an understanding of health inequity. A political economy approach sees economics not simply as technical science of demand and supply, instead it is a way of seeing the broader political context and the relations of power as they influence the production, distribution and consumption of goods and services, as well as the (political) ‘management’ of these economic variables, relationships and functions. We need to understand how power relations in society influence and determine health services and delivery, and the distribution and redistribution of these. So while traditional economics treats people and societies as functions of economics, political economy treats economics as a function of people and their societies, influenced by the particulars of social and political relationships and structures of power.

A radical political economy framework provides the tools for exposing, understanding and making sense of how, amongst others, race, class and gender determines or influences the social and political relationships and structures of power, and the differential economic effects and health outcomes that flow from these relationships and structures. This requires deconstructing and reframing basic economic constructs and assumptions.

Module theme

While the evidence on the structural and social determinants of health is widely known and extensively researched and written about, and to a large extent is acknowledged by those in power, inequalities in health continue and are tending to deepen. These are pronounced, depending on your class, race, gender, sexual orientation and geographical location. Module 2 attempts to address the simple yet highly complex question, why? Are health inequalities inevitable? Or are there social, political and economic factors at play? We grapple with how the decisions, actions, manifestations and general approaches by society around health inequity is highly political. Health or ill-health are inextricably linked to the social and economic context. And we begin to explore what is needed from us, as activists for social change to build the power needed for social change. This is underpinned by the belief that the power and influence of activists in left formations can determine health equity. 

The theme for this module is The Political Economy of Health and the Challenge for Social Change. Based on the module’s theme, objectives and our conceptualisation of this being a continuous learning journey and narrative, the module’s daily programme will cover the following pillars: 

  • Day 1: Health as a human right
  • Day 2: The political economy of health 
  • Day 3: Health as a public good 
  • Day 4: Movements, leadership and social change 
  • Day 5: Social change initiatives 

Building from the theme and the specific objectives for the module, Fellows will be challenged to deepen their critical thinking and reflection on the politics of health and the challenge for advancing health equity. Fellows are supported in understanding the political economy as a tool for deeper analysis.

A political economy lens opens our analysis to how political and economic systems privilege or disadvantage. It provides the tools to help us consider and argue for the shaping things differently. And integrating an overt gender lens will help us see that the economy produces more than just goods and services, but also how it produces gender inequality by not recognising the social reproduction role borne by women. This reproduction of inequality for women includes the existence and costs of unpaid (domestic and care) work, its effects on labour force participation, and the role of policy and social norm change in redistributing unpaid work and creating fairer and more just economies, based on societies and people’s needs rather than greed.

If we privilege an apolitical analysis, we will simply be contributing to shifting seats at the same tables or facilitating the wheels turning within existing systems – we will perpetuate the status quo of health inequity. We want our political economy tools of analysis to support Fellows in understanding and critiquing unjust systems. We want to ensure that our political economy analysis does not ignore the most pervasive systems of power in society, that of class, race and gender relations. We want Fellows to leave this module with an ability not only to understand the political economy of health, but also to be able to use these a tool of analysis for thinking, working and in advancing solutions to health inequity and social justice more generally. 

This kind of grappling can shift our overall worldview, and can shake the very foundations of how we have come to understand the world through the institutions that socialise us – our families, communities, schools, colleges, religious institutions, etcetera. It can be liberating but it can also leave us feeling vulnerable and confused when it challenges so many dimensions of our lives. Do speak out about these worries, either within the learning space, or with individual facilitators, as we have specific mentors to support Fellows in this grappling. 

The implications of Module 2 objectives

The core logic and pillars underlying the module’s objectives are the following: 


Health as a human right. According to the WHO, “A human rights-based approach to health provides a set of clear principles for setting and evaluating health policy and service delivery, targeting discriminatory practices and unjust power relations that are at the heart of inequitable health outcomes.” We will also grapple with the complexity of the notion of human rights, how rights are granted through legislation, the responsibilities of ‘duty bearers’ and of ‘rights holders’ in this paradigm, and this supply and demand system of addressing inequality and injustice in the western world. We argue that a rights-based approach is an important angle in understanding and addressing health inequalities. We will observe how this right is either being upheld or advanced or undermined or dismantled, and we will try to understand why this dichotomy persists.


The political economy. Understanding the political economy of health is critical in developing a foundational analysis for advancing social change towards health equity. It helps us to understand how power and resources are distributed in society. It helps illuminate the economic hierarchies through socioeconomic divisions (race, class, SOGI, etc.), power and inequalities. It is important for ensuring that our social change endeavour is designed for maximum impact.


Neoliberalism and its impacts. We started grappling with neoliberalism in Module 1, and here we go deeper. This time Fellows are supported to grapple with the impacts of neoliberalism as a key underlying and driving feature of the current health context and crisis. We will look at country case studies and how neoliberalism has impacted on health in select countries, and what we can learn for South Africa’s highly inequitable health care system.


Exploring alternatives. TINA – the acronym for ‘There Is No Alternative’ is a key feature of the neoliberal mantra or narrative. It is the central political rule applied by neoliberal states and individuals. The claim is that the free market economy is the best, that it is right and the only system that works, that ‘the poor will always be with us’ and that debate about this is over. We argue that the overwhelming anti-neoliberal political effort must involve dismantling the TINA argument. We offer some examples of countries that are grappling with alternatives, as part of exploring ‘health as a public good’.


Relational leadership. The meaning, theory and practice of Fellows as relational leaders consciously cultivating collaboration, leadership in community and in context, and working collectively with other Fellows and others in wider networks of catalytic communities. We do this primarily through critical self-reflection, but also in careful listening and learning from others.


Critical skills for critical, committed and engaged agency for social change – are a crucial part of the learning process. Fellows are challenged to grapple and engage in the fellowship as critical, involved, active and dynamic participants. Our pedagogy is very different from passive, receptive learning. Our learning approach supports Fellows to acquire new or refreshed critical skills for the envisaged learning – skills such as self-care for learning and social agency, listening to hear and understand as different from defensive listening normally aimed at responding, critical reading, critical analysis, critical reflection, journaling, etc. 

These underlying logics mean that each Fellow must be fully present, active and engaged in the learning process throughout the module. Here is a reminder of some useful tips to achieve this, as shared in Module 1: 


Please consistently bring and involve your full body, mind and heart throughout the module, be aware of where we are and what we are doing, wake up to the inner workings of our mental, emotional, and physical processes, work out ways to control our reactions to what is going on around us, work out with manage and respond affirmatively what is going on around us and how not to be overwhelmed by what is going on around us. Whenever you bring awareness to what you’re directly experiencing via your senses, or to your state of mind via your thoughts and emotions, you’re being mindful.

The head, the heart and the hands

Health equity, social change and human transformation are not just about what we think or do practically or what happens in the real world. They are also about how we feel and understand how we feel. In other words, as emerging leaders for health equity and social change, we need to consciously find a way to ensure that we continuously connect the head (thought and logic), the heart (feelings, emotions) and the hands (doing, action, praxis). This approach consciously relates the cognitive domain (the head) to critical reflection, the affective domain (the heart) to relational knowing and the psychomotor domain (the hands) to engagement, action and practice. Over time, this conscious and continuous linking of the head, the heart and the hands can result in a rich synthesis of experience and reflection along with awareness and caring. Experiencing reflection, awareness and caring are an essential ingredient in shifting and transforming ourselves into being the new, more empowered leaders and agents needed for health equity and social change. 

Expectations vs. objectives

Work out what each of the set objectives of the module means to you. Go beyond the given text or words, use your own words or other creative ways to give your own meaning and interpretation of the set objectives. Also work out your own expectations from this module (what you expect to learn and contribute) and weigh them up against the set objectives, work out the similarities, the connections, the differences and the disconnections between the set objectives and your expectations – use these to assess your own learning journey throughout the module. 

Your existing knowledge

Whilst you will definitely learn new things in the Fellowship, the learning approach seeks to recognise, affirm and build from your existing knowledge, experiences and contexts. Creatively tap into your experience and existing knowledge that you enter the module with. Connect it with the Fellowship learning experience. Work out what to unlearn, what to relearn, what to learn anew, and keep a door open to ongoing uncertainty about knowledge and the future as we cannot ever determine our life’s pathways in advance, even more so our journeys as agents for social change. 

Questions you have

Work out the questions you have and also the areas of curiosity and learning you have an interest in, share these with others, and bring them in an organic way into the learning process. 

Listening to others (putting our ear to the ground) and engaging in genuine dialogue

Much of the learning in the Fellowship happens through conversation and collaboration among Fellows and the envisaged broader catalytic community. Listening happens in our brains. People often hear what they are ‘listening for’; then, they change what they hear depending on what they know and how they feel about the information shared. They even subconsciously change it to fit their own interpretations and interests, which is why it is so widely said that we misunderstand, misinterpret or change most of what we hear. Thus, the importance of listening to learn and understand. When you truly listen, what you hear can change you. You might change your perspective, your position or your mind, because the information you receive is not altered by your filters or biases — both of which can be deterrents in our listening and our learning. In the section dealing with the learning approach, we extend this discussion on listening by suggesting four elements of the required action listening – connective listening, reflective listening, analytical listening and conceptual listening. These are crucial to enhance and optimise learning effectiveness and to lay the foundation for healthier cultures for collaborative, relational leadership. As author Mary Mayesky so aptly stated, “learning to listen’ is a prerequisite of ‘listening to learn’ – i.e., best to listen to learn and understand which is different from listening in order to reply as is often the case in our excitable and heated social and political contests. 

Your voice

Speak!!!! Express how you feel, what you think and what you would like to do. Speak respectfully and not for long. As you express your voice, hear other voices too. 

Applying a critical thinking approach

Use the critical thinking approach that we worked through in the Orientation. Critical thinking seeks to go deep, beyond the obvious surface of dynamics and phenomena in society. The critical thinking approach does not take things as they appear on the surface. It deliberately digs deep way beneath the superficial understanding of society. It enables a dynamic and deep understanding of power configurations, root causes, systemic and structural issues, meanings, social contexts, ideologies and other such foundational processes that shape societies.

Consistently ask yourself the following critical thinking questions – What? Who? Why? Where? When? How? Give answers to these questions as you undertake the critical reflection.

Challenge yourself to think beyond what is reported in the news. Even challenge yourself to disagree or debate with yourself – but why are you stating things the way you do? What about other understandings and answers that are different from yours?

Centering women in our analysis

Whenever we grapple with issues and questions of power, we will consistently try to analyse through the eyes or standpoint of the majority of women in our country (black working class/poor women), whilst also referring in this framing, to other oppressed, exploited and marginalised social groups. In line with the Tekano learning theory and approach, this approach is a deliberate exercise to consciously centre women in our analysis thereby deepening our feminist politics.

Remembering the broader South African context

In the Module One Framing Document, we introduced perspectives on the broader reality of what is happening in our country and the world we live in. We spoke about how the learning process cannot be delinked from this broader reality. 

We introduced what we consider as some of the key features defining the current context in our country and world today. With some amendments, these included:

  • South Africa remains the most unequal country in the world in spite of h aving a wide-scale portfolio of welfare grants that include cash transfers, free water and electricity, a National Health Insurance under construction, free AIDS medicines and subsidised tertiary education. Aside from the latter two victories from mass movements – the Treatment Action Campaign in 1999-2004 and #Fees Must Fall in 2015-17 – and some other common-ing of state services (such as electricity and water informally reconnected in so many poor areas), the life of ordinary people is so miserable – with around two thirds of our compatriots below a realistic poverty line (that R350/month is simply not good enough as a response). 
  • According to the UCT-based South African Labour and Development Research Unit (SALDRU), the real minimum cost of living in this country is close to R50 per person per day for a proper Upper Bound Poverty Line. And it is even higher if you consider the food baskets that incorporate all basic nutritional needs and other essentials. This is well framed by the ongoing monthly Pietermaritzburg Economic Justice and Dignity group research, that analyses and presents cost of living information. More than 3 million children go to bed hungry while a handful of CEOs have incomes of more than R1.7 million a year on average.
  • Covid-19 has made this situation worse with poor and working people the most vulnerable part of the population to infection and death from many diseases, not least Covid-19. This vulnerability of poor and working people is not because of unhygienic ways and locations in which they live. It primarily stems from the evolution of the country’s political economy during apartheid and the post-apartheid period. Central to this political economy has been a neoliberal policy framework which has resulted in poverty for millions, an immuno-compromised population among both young and old, in townships with no social services essential to the fight against Covid-19 (housing, water and so on), in violence against women and children, in unsafe townships, and in a collapsing health system – the list goes on. The lack of urgency, the lack of decisiveness, the lack of a pro-poor bias, the pro-business orientation and the corruption that characterised the state’s response to the Covid-19 pandemic are mere manifestations of the logic of neoliberalism. 
  • South Africa has a stagnating economy where mass unemployment is now way above 12,48 million people, this being a record high at 46.6% with the youth hardest hit at 66.5% (Statistics South Africa, 2021). The Covid-19 years from March 2020 have seen massive retrenchments and the employment of younger, newer labour at lower wages, limited or no benefits and worse working conditions. In other words, we are likely to have evidence of increased super-exploitation of employed workers in contrast to sustained profits by the very top of business owners, and precarity for a large number of vulnerable and informal workers adding to the dire conditions of the permanently unemployed mass. 
  • This dire economic situation means a deepening crisis of social reproduction as we see in the collapsing social fabric in the zones of rot and decay instead of sustainable and decent human development (poor and working class communities in the townships, informal settlements, peri-urban areas, inner cities, rural villages, and other locations where poor and working people eke out a life of poverty, misery and squalor). What happens to the 600,000 matriculants from the 2021 academic year? To the hundreds of thousands leaving the education system every year since 1990? What do they do? The overwhelming majority of them cannot be absorbed into the formal economy or post-school education. They have no possibility of further development and decent livelihoods. 
  • The above means that the zones of existence of poor and working people are fertile breeding ground for violence against women, criminality, drug abuse, gangster violence, the kind of social unrest we saw in July 2021, as well as reactionary discourses, ideologies and mobilisation as we see with the xenophobic Operation. This militates against emancipatory social change. A 10 February 2022 press statement from the Abahlali baseMjondolo social movement states: “The Report of the Expert Panel into the July 2021 Civil Unrest acknowledges the complete lack of political leadership in the KwaZulu-Natal province during the riots, the deep popular anger at corruption and the withdrawal of the Covid grant, the extent of social desperation and hunger, and that for a few days the riots took the form of a massive food riot by poor people, people who were mostly very far from being Zuma supporters.” 
  • As if the economic crisis was not enough, our collapsing state enables accelerated commodification and dispossession of poor and working people. Sustained corruption and cronyism are hollowing out the capacity of the state (in government departments, parastatals, municipalities and other public institutions) as mandated by the country’s Constitution. Not a single public institution has not been affected by the rot. The outcome of this decay and collapse of the state is the deepening marginalisation and sustained underdevelopment of those who were most oppressed and exploited under apartheid, who were supposed to be the main beneficiaries of a democratic, post-apartheid dispensation. 
  • The collapse of public services also worsens the burden of unpaid social reproduction labour carried by women. The majority of women are now pauperised and dispossessed and end up yet again having to bear the costs, burden and weight of reproducing society and thereby subsidising the profitability and wealth of the elite. 
  • The overall impact of this on health systems inequity should be obvious – collapsing hospitals and clinics, limited human resources for health, medicine stock-outs, etc.

All of these militate against emancipatory social change! In addition to this, we had a contextual analysis discussion in Module 1 that added angles that we have not considered above and which are also critically important: 

  • Climate change and environmental degradation
  • Phuza nation – the pervasiveness of alcohol abuse highlights our level of social crisis 
  • Growing lawlessness: “We are a violent, angry country”
  • Depoliticisation and disappearance of hope
  • Fragmentation and segregated activism

Political Economy analysis

In Module 2, we create an understanding of the political context and the politics of health through a political economy lens. This will not be presented as abstract. It will be presented as a story that presents real things concerning real people, a story of concepts and dynamics applicable to a critical understanding of the health system and for advancing health equity. Immediately, the approach to be followed in Module 2 will be tailor-made for application in deepening thinking on how to approach and conceptualise the Social Change Initiatives (SCIs). 

Simplifying the political economy concept 

Presenting political economy as real and applicable to everyday life, means breaking it down and simplifying it into the story of the life of human beings. This means the following core elements: 

  1. Life and survival. Every person needs food, water, clothing, shelter, human development and communication in order to survive and develop. 
  2. Resources. To meet the above basic needs, as part of nature every person seeks to access and exploit surrounding and available natural resources. Natural resources make life and survival possible. 
  3. Interests, struggles and contestations over resources. Dynamics developed over time to seek to control, reproduce and sustain these resources. In some cases, these dynamics led to the development of collective cooperation over the control, ownership and exploitation of natural resources. In other cases, these dynamics led to competition. In cooperative solutions, human beings remained a part of nature and their approach to nature was regenerative. In competitive solutions, human beings were separated from nature and developed an extractivist approach to the exploitation of natural resources. These processes were the basis of what we call the economy today. 
  4. The economy originates from human agency over resources. At its most basic, the economy is about the production, distribution, and consumption of goods and services drawn from a limited supply of natural resources. The economy is about life, survival and resources. Given the limited resources, interests, competition and contestations develop. In the modern economy, this has resulted in a few individuals accumulating and hoarding a disproportionate number of natural resources and wealth. This is often based on power over who has access to, ownership and control of resources leading to contestations and struggles over power and resources. 
  5. The capitalist economy is rooted in a hierarchical power paradigm. It is characterised by race, class, gender, and other forms of socioeconomic divisions and inequalities. It does not produce goods and services in a neutral manner. It is an economy that reproduces and replicates these inequalities and justifies the dominance of the Global North, whites, men, the heteronormative and the wealthy. As an example, in South Africa we see how acutely social production and reproduction are seen as less important than the production of goods, commodities and other forms of material wealth; contributing to a deepening of the systemic and ideological barriers that exist to women’s social, political and economic equality, their mobility and their opportunity to live full and free lives.
  6. Political and economic interests shape modern society. Modern society is based on struggles and contestations over the ownership and control over generation, production, distribution, consumption and regeneration of resources. It is out of these interests, struggles and contestations that political power, systems, inequality, structures and institutions are derived and shaped in modern society. In other words, politics and economics are related and intertwined. 
  7. Health is essential to life and survival. Health is not outside of politics and economics, or outside of political economy. The structures and systems that define health and determine health outcomes for different segments of society are shaped by the broader political economy. South Africa has a specific history and dynamics that shaped and reproduce a particular political economy of health. 

The above speaks broadly to what the learning journey of Module 2 will look like and cover. The above assists in understanding the Tekano perspective that takes a decolonial approach to political economy, with an overt feminist framework, away from deterministic meta-systems thinking. 

The module is designed to offer tools for deeper analysis of among others our world, of our country, of its people and of health inequity. It is Tekano’s hope that when you have these additional or honed tools, you can better work in social change spaces and make an increasingly honed or nuanced activist contribution. 

Conducting Political Economy Analysis

Example 1: The DFID Tool

One way of applying the political economy approach has been developed by the British Government’s Department for International Development (DFID). It allows for a sectoral-based analysis grounded in political economy. When conducting a Political Economy analysis of the health sector, for example, it will be useful to break down your analysis into the following components:

Roles and responsibilities: Who are the key stakeholders in the sector? What are the formal/informal roles and mandates of different players? What is the balance between central/local authorities in provision of services?

Ownership structure and financing: What is the balance between public and private ownership? How is the sector financed (e.g., public-private partnerships, user fees, taxes, donor support)?

Power relations: To what extent is power vested in the hands of specific individuals/groups? How do different interest groups outside government (private sector, NGOs, consumer groups, the media) seek to influence policy?

Historical legacies: What is the past history of the sector, including previous reform initiatives? How does this influence current stakeholder perceptions?

Corruption and rent-seeking: Is there significant corruption and rent-seeking in the sector? Where is this most prevalent (e.g., at point of delivery, procurement, allocation of jobs)? Who benefits most from this? How is patronage being used?

Service delivery: Who are the primary beneficiaries of service delivery? Are particular social, regional or ethnic groups included/excluded? Are subsidies provided and which groups benefit most from these?

Ideologies and values: What are the dominant ideologies and values which shape views around the sector? To what extent may these serve to constrain change?

Decision-making: How are decisions made within the sector? Who is party to these decision-making processes?

Implementation issues: Once made, are decisions implemented? Where are the key bottlenecks in the system? Is failure to implement due to lack of capacity or other political economy reasons?

Potential for reform: Who are likely to be the ‘winners’ and ‘losers’ from particular reforms? Are there any key reform champions within the sector? Who is likely to resist reforms and why? Are there ‘second-best’ reforms which might overcome this opposition?

Example 2: The Political Economy Matrix for Critical Analysis

The matrix tabulated below demonstrates how political economy is a useful tool for thinking critically about seemingly complex political and economic processes. The matrix is built on six everyday questions: What? Who? Where? When? Why? How? 


… is happening in a given situation? 

… are the foundations or root causes of this situation?

… are the main features or character of the given situation or context?

… maintains this situation or context?

… are the power dynamics in the situation?

… are the sources of power and influence in the situation?

… are institutions, systems and structures that exist and define the situation?

… are the possibilities, possible openings, factors, forces and dynamics for this situation or context to change or that may block or limit change?

… are the social/class positions and interests at play?

… are the gender and race aspects?


… benefits from this?

… is it harmful to?

… makes decisions about this?

… has power?

… has no power?

… is most acutely affected?

… are the key social forces, players and others relevant to the situation?

… controls key institutions and strategic levers of power?


… are the sources of this situation or context located?

… are the key social forces and role-players located socially, politically and economically?

… is the power that shapes the situation or context located?

… are those affected located?

… are the key, core and driving decisions made?

… are minor and less powerful decisions made?

… are women and men located?

… is the situation and context developing towards/tending to?


… did this situation or context develop or change?

… has this played a part in our history? In our communities? In our workplaces?

… were major decisions made?

… can we expect change?

… would this benefit society?

… would this cause a problem?


… is the situation or context as it is?

… is it a problem/challenge?

… has it been like this for so long?

… have we allowed this to happen?

… is there a need for this today?

… is it relevant to me/others?

… is this the best/worst scenario?

… are people influenced by this?

… should people know about this?


… does this benefit us/others?

… does this harm us/others?

… does this affect different groups of people?

… do we know the truth about this?

… do we understand its root causes?

… do we understand its different aspects or dimensions?

… do different factors, aspects or dynamics affect it?

… do we see this in the future?

… can we change this?

… can we act?

… can action and change transform the situation or context?


The answers to the above questions are the foundations of political economy analysis. This matrix is open-ended as it can be expanded and adapted depending on the issues being analysed. 

Political economy enriches and is enriched by other tools of analysis 

Political economy cannot on its own explain the entire complexity of social problems. As an analytical tool, it needs to be combined with other tools such as social determinants and intersectionality. Ultimately, we need to use political economy as a foundation and springboard into which we bring in additional tools of critical analysis that may enrich our understanding of issues and take up causes of action towards social justice and health equity. 

Political economy as a tool for action

Beyond analysis, political economy is also about action. Political economy serves as a platform to think about ways of democratising social and economic policies as well as decolonising and indigenising the health system.

But do we need reminding ‘what is health?’ 

The definition of health that has conventionally been used has two interrelated aspects to it: health is both considered as the absence of disease (biomedical definition) and as a commodity (economic definition). These both focus on individuals, as opposed to society, as the basis of health: health is seen as a product of individual factors such as genetic heritage or lifestyle choices, and as a commodity that individuals can access either via the market or the health system. In this sense health is an individualised commodity that is produced and delivered by the market or the health service. 

According to this definition, inequalities in the distribution of health are therefore either a result of the failings of individuals through, for example, their lifestyle choices; or of the way in which health care products are produced, distributed and delivered. In order to tackle these inequalities, political attention is directed towards the variable that is most amenable to manipulation—the healthcare system.

We know that this limiting, one-dimensional view of health is common. However, the World Health Organisation (WHO) has offered what some have argued is the first widely known definition of health, going back to 1947. It says that health is:

a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity/ (WHO 1948)

This definition of health recognises many requisite elements of what constitutes wholesome health and wellbeing and can be used as a compass preventing us from drifting towards very narrow conceptions of health such as the absence of disease. It has also been expanded to consider contextual realities that necessitated a health focus beyond individuals to one that focuses on populations. 

It has been argued that the WHO definition is honoured and repeated but rarely applied. Our site visits should help us confirm or deny this.

This definition has come under loads of criticism particularly for its absolutism and despite its expanded concept, its focus on the health of individuals rather than on the health of populations.

This has led to health being defined as a collective condition with the property of a public good, i.e., whereby the enjoyment of it by one person does not diminish its use by others:

Health is a condition in which people achieve control over their lives because of the equitable distribution of power and resources. Health is thus a collective value; my health cannot be at the expense of others nor through the excessive use of natural resources.

And is there only one way to understand health as a human right?

Again, the WHO espouses its United Nations framing of the right to health:

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition (WHO 1948).

It is common currency that the right to health for all people means that everyone should have access to the health services they need, when and where they need them, without suffering financial hardship. No one should get sick and die just because they are poor, or because they cannot access the health services they need. Everyone must be able to enjoy the benefits of good health, no matter their age, sex, race, religion, health status, disability, sexual orientation, gender identity or migration status.

Good health is also clearly determined by other basic human rights including access to safe drinking water and sanitation, nutritious foods, adequate housing, freedom from violence, education and safe working conditions.

The right to health also means that everyone should be entitled to control their own health and body, including having access to sexual and reproductive information and services, free from violence and discrimination. Everyone has the right to privacy and to be treated with respect and dignity. Nobody should be subjected to medical experimentation, forced medical examination, or given treatment without informed consent.

When people are given the opportunity to be active participants in their own care, instead of passive recipients, their human rights respected, the outcomes are better and health systems become more efficient.

Critiques of the United Nations rights-based approach to social development hold that its limitations are rooted in its western countries market-based philosophy and framing. This critique argues that the entire system created around the Universal Declaration of Human Rights is based on the principles of supply and demand. Duty bearers (the state) have obligations to supply the right, within resource limitations (a caveat in all country constitutions that adopt a rights-based approach). Rights holders (those living in the country – not only citizens!) are required to claim the right. The key critique of the human-rights based praxis is that it entrenches pressure on those most vulnerable and marginalised in society, to have to not only suffer the burdens they face to simply survive, but that the onus is on them to find sanctioned ways to claim a right being denied them. We can hear how closely this critique resonates with a political economy approach to health and to grappling with the social and economic determinants of health, as it is about where power and resources sit. 

We see one example of this persistent and curious demand in western democracies on civil society to take on ‘greater advocacy’ as the best route for rights to be realised, in Leslie London’s 2013 paper that is part of your reading pack for this module (Reading 10 see conclusion): 

…civil society mobilization must underlie all the different modalities by which a human rights approach can work for health, whether it involves holding government accountable for delivery on the right to health, pro-actively developing policies and programs, or securing redress for those whose rights have been violated. South Africa’s experience of translating the constitutional promise of human rights for all its peoples has shown that definitions of what constitutes human rights and a rights-based approach do matter, because framing access to health care and the conditions for health as a matter of service delivery is a political choice that demobilizes effective rights advocacy. Indeed, for rights to be made real, there have to exist mechanisms that both foster public participation and enable meaningful agency on the part of those most affected by policies that limit or violate rights.” 

As health equity activists, we need to reflect on and debate why we promote this additional burden on struggling civilians (individually and collectively), rather than having states holding responsibility for high quality and equitable health provision that is based on a system that invests increased resources for those most precarious in society, and on preventive rather than palliative and curative healthcare.

If we had time: missing Module 2 elements

As always it is not possible to cover everything that we would have wanted to in just one module. We encourage Fellows to do their own thinking and research to further deepen knowledge and analysis. We are also hoping to hear from you, if there is something that you think is critical within the broader module framing and thematic area, that we absolutely must consider.

While there are many issues that we could have included in this mode, we note the following five angles of political economy that we would have wanted to include, but just did not have the space for:

  1. The evolving draft National Health Insurance (NHI) legislation for South Africa, what it is about, its potential, its limits, where it is at present, struggles and contestations over it, its likely trajectory and alternative models.
  2. The political economy of health financing and budgeting – who decides how much to allocate to health, the politics and interests that shape it, the systemic and structural issues in this regard, etc. 
  3. A deeper analysis of the role of the state, critically understanding political economy influences on the key policy direction and their impact on health
  4. An exploration of how the current flow of resources in the global political economy affects countries’ ability to adequately resource equitable and just access to health services. 
  5. A deeper analysis of the current makeup of the global political economy particularly in relation to existing trade relations and the effects this has on health equity here in South Africa.

Our Learning Approach

You will remember the Tekano learning approach from Orientation. Below is a brief reminder of key features of the approach. Do look back at the Orientation Pack for the more comprehensive version. 

The Tekano pedagogy is inspired by the Brazilian educator and philosopher, Paulo Freire, combined with pedagogies rooted in the promotion of decolonised and feminist knowledge production and dissemination. This learning pedagogy is premised on social theory that holds that adults learn and change most sustainably when we enter new angles of learning through own lived experience and we look at patterns within that experience, with others. We then engage in critical discussion and dialogue, learn new knowledge through research and/or reading where this is needed. As social change activists, we then always plan action to contribute to shifting social problems that we see as patterns. We then reflect on and evaluate our actions to look for patterns again that demand further or different attention and action. This cycle or iteration of ‘Action-Reflection-Learning-Action’ continues as our tool for meaningful collective social transformation.

According to Freire, the role of the teacher or educator is to:

  • Break down the barrier between teacher and taught 
  • Speak the ‘same language’ as the learner 
  • Be aware of how they construct their universe of meaning 
  • Be aware of learning needs 
  • Start from where the learners are 
  • Encourage them to learn and explore their own experiences. 

We will be digging into the question of neutrality in education as part of Module 2. This is critically important for us to grapple with as it is also the foundational notion of political economy analysis – in social life, nothing is neutral. Let’s start with two quotes from Paulo Freire:

  • There’s no such thing as neutral education. Education either functions as an instrument to bring about conformity or freedom.
    (From Pedagogy of the Oppressed)
  • The educator has the duty of not being neutral.
    (From We Make the Road by Walking: Conversations on Education and Social Change)

These quotes point us to how education is inherently and intentionally political and revolutionary and how it’s a fallacy to think that it can be neutral. By taking a supposedly neutral stand, we’re not ensuring a ‘neutral’ education, we are just ensuring that someone else is dictating the purpose of what we want to do, and this is usually about keeping the status quo (the existing situation or balance of power). By claiming neutrality in education, you won’t be able to identify the ideological processes, politics, and power at work.  This is obviously necessary for creating a fairer, more inclusive and socially just world. So in Tekano, we consciously combine theory and practice (known as praxis) using a pedagogy and approach that encourages:

  • Drawing on the experience that Fellows bring into the learning environment. 
  • Participation as the process of harnessing the presence, energy, ideas, feelings and actions of Fellows. Effective participation is critical to the success of collective thinking, actions and change. 
  • Reflecting on and contextualising this experience and deepening collective understanding by complementing this with analysis and a strong theoretical understanding. 
  • Valuing and integrating relevant information and research into the learning process. 
  • Developing skills for leadership development.
  • Moving into action by practicing what is learned through social change initiatives.
  • Building on this to move into a new cycle of learning made up of experience, reflection, new knowledge, analysis and action.

So in sum, Tekano believes that our Fellows, as adults, learn best when:

  • Motivated and taking responsibility for their own learning, and when everyone’s opinion is respected – we encourage a democratic learning environment.
  • Learning is relevant and contextualised – with Tekano attempting to ensure that our Fellowship Programme reflects the needs, context, principles and values for building health equity and broader social justice.
  • A variety of methods are used which are active, innovative and participatory – we use methodologies with an emphasis on group activities, practical activities and application, as well as short and focused inputs.
  • Learner experience provides the basis for further learning – acknowledging that every Fellow comes with important and relevant experience, so Tekano encourages the sharing of experiences, learning from each other and using experiences to build and extend knowledge and skills.

In this and remaining modules, we will continue with learning and support tools outlined in the Orientation: 

  • Learning Circles and/or Learning Groups (for collective reading, reflection and analysis)
  • Journaling and Reflective Writing
  • Storytelling (we expand on this a bit more below)
  • Coaching 
  • Mentoring
  • Psychosocial Support
  • A Feminist Ethic of Self-Care

Learning as storytelling and understanding contesting narratives at play

This learning journey approach will enable Fellows to grapple with the core features of the story of the political economy of health in South Africa today. This is about presenting political economy as a stage of society wherein different narratives about what people see to be happening or believe to be happening, co-exist and contest. 

These narratives represent different interests, social locations, exercise of power and real socio-economic impacts of contestations over resources. In such narratives or stories, there are different characters, role-players, interests, protagonists, various scenes, crescendos, climaxes, outcomes, and impacts. 

The story-telling technique is about time, place and context where narratives are imagined, told and acted out by different characters in a given setting. Whose story is being told, or elevated matters. Applied as an interactive tool, the story-telling technique enables both the storyteller and others to engage the story as active participants.

The purpose of this approach is to “ground” political economy as a concept in a real socio-economic context in which the phenomenon under study (in this case, health equity) occurs. Further, the story-telling approach helps learners to locate themselves in the story. This approach starts with the Fellows’ forms of cognition and moves from there to navigate the narration of deeper systemic and structural issues that connect with, and deepen Fellows’ experiences, perceptions and understandings. 

Typically, a story has a beginning, a middle part, the climax and an ending. The story is a journey. Similarly, the Fellowship as a whole and Module 2 are a learning journey. The story-telling technique will enable a learning journey, helping to realise the Module’s objectives in an inter-active journey of critical learning and discovery. 

Some Food for Thought

Learning as storytelling1 and grappling with narratives and their power

The way in which the story technique can be applied to political economy will involve the following core elements: 

  • The setting. Putting forward as set of basic contradictions or contrasts as the frame and at the beginning of telling the story of political economy (this helps to identify what is potentially affecting and engaging and begins the learning process in a manner that is vivid and brings to the fore why the content matters). 
  • The dynamics and impacts of the basic contradictions. The narration moves to elaborate the dynamics and impacts of the basic contradictions put forward in the setting. 
  • Conclusion – often in a story, there is a conclusion with either a resolution or mediation of the conflict set up at the beginning. In the case of political economy, our conclusion will be to work out the implications that the political economy concept as a tool has for achieving health equity. 

Here is a demonstration of this story-telling technique in facilitating learning on political economy: 

  • Identifying importance and relevance. What is important about this topic? Why does it matter? What is affectively engaging about it? 
  • Finding and presenting the basic contradictions or contrasts or opposites. What basic contradictions or contrasts or opposites best express and articulate the importance of the topic? 
  • Organising content in story form. What content most dramatically articulates the basic contradictions or contrasts or opposites, in order to provide access to the topic? What content best articulates the topic into a developing story form? 
  • Conclusion/drawing the implications and learning for action. – From the perspective of health equity, what is the best way of resolving the dramatic conflict inherent in the basic contradictions or contrasts or opposites? What degree of strategy can emerge from a critical understanding of the concept? 
  • Evaluation. How can we use the story-telling technique to assess the extent to which the topic has been critically understood, its importance grasped, and the content learned? 

Reading Pack

You will receive an electronic and printed pack of readings. As mentioned at the start of this Framing Document, they offer you depth where our time together is limited, and they are also aimed to support your grappling with your Social Change Initiatives (SCIs). Do scan-read as many as possible during our Module 2 week together, and feel free to email and engage us with questions and reflections that arise: 


To Decolonize Global Health, We Must Examine the Global Political Economy


A Political Economy Analysis of the Impact of Covid-19 Pandemic on Health Workers: Making Power and Gender Visible 


What a people-centred response to Covid-19 would look like


South Africa Suffers Capitalist Crisis Déjà Vu


What matters in health (care) universes: delusions, dilutions, and ways towards universal health justice 


21st-century capitalism: structural challenges for universal health care


Can the NHI achieve Health for All? 


Putting gender in International UK political economy analysis: Why it matters and how to do it


National Health Policy Reflects Conflict Between Public Health and Neoliberalism 


Growth with inequality: the political economy of neoliberalism in Sri Lanka 


What is a human-rights based approach to health and does it matter? 


Limpopo hospitals in dire state 


South Africa: a 21st century apartheid in health and health care?


Chile’s Neoliberal Health Reform: An Assessment and a Critique


Towards a politics of health


The State Of Neoliberalism In South Africa: Economic, Social, And Health Transformation In Question 


Hopefully, this Framing Document gives you a clear idea of the core learning shaping Module 2. It will serve as a reference point throughout the module, with express elements being integrated into the module content. 

We continue to ask that you use what is being introduced for your own leadership development. This is critical in deepening your activist role and leadership. 

Phambile maqabane!

  1. In addition to Tekano planning discussions, this section is based on, expands and adapts the paper by Kieran Egan (Memory, Imagination, and Learning: Connected by the Story, published in Phi Delta Kappan journal, issue 70, no. 6, p455-59, February 1989: