Module 3

Module 3 Framing Document

Situating this module within the Year Long Fellowship

Module 1 provided a foundational understanding of how the prevailing context matters for health equity and what is required of us as leaders for social change, Module 2 expanded on this by exploring the ways in which politics, power, and ideology all profoundly underpin and influence people’s health. For Module 3 we continue with unpacking the complexity of health provision, access, outcomes, and centrally its determinants.  As we learnt in Module 1, health is not just about the well-being of an individual.  Health is shaped by complex social, economic, political and ecological dynamics and factors.  Module 2 helped us understand how and why political and ideological opinions and choices matter!  In this Module we look more deeply at health determinants, and we do so with a grounded, local focus. Module 4 expands our horizons and we travel to engage with health movement activists in inspiring contexts. For 2022, we will visit Cuba to grapple more deeply with what universal healthcare praxis means, and in 2021, we visited Barcelona, Spain to engage with dynamic social change movements. 

We continue to shape and extend our understanding of health inequity, still with a political economy lens, but this time with a specific focus on determinants of health.  We deepen Fellows understanding of how the effects of well-established social, structural, industrial-commercial and political systems (determinants) underlie many health disparities. And how these determinants are significant drivers of disease risk and susceptibility within clinical care and public health systems. Significantly, we focus on this by exploring these determinants in a local context, with a specific focus on land and the social determinants of housing, sanitation, food, workers and women’s health.  This helps us explore the root causes of inequities, demonstrating how race, class, gender and rurality affects health outcomes.

Through exploring the determinants of health in general and by establishing a link to a specific locality, we hope we will provide the basis for deepening Fellows SCI work and identifying existing activist struggles to close the disparity gap in health-related outcomes that can provide ideas for our own advocacy and activism.

Module 3 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.  As we learnt in Module 2, these are pronounced depending on your class, race, gender, sexual orientation, geographical location.  Now that we understand that decisions, actions and general approaches by society around health inequity is political, we use Module 3 to deepen our understanding of these determinants, introduce a framework for their analysis and explore our agency as leaders for social change.

The theme for this Module is Unpacking the Structural and Social Determinants of Health. 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: The Political Economy of Land
  • Day 2: Determinants of Health 
  • Day 3: SSDoH+: Innovation Labs
  • Day 4: Leadership as Agency 
  • 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, and critically explore the innovations out there to support their own activism.

The overall approach to learning in Module 3 

As for previous modules, Module 3 stands on the following core pillars: 

  • Experiential and participatory learning which resonates with the approach of critical pedagogy – expanded below
  • Learning as a journey – implied in the section below 
  • Learning as a story – our stories, the stories of others, the stories of communities, curating new stories, the stories of alternatives etc.
  • Building a learning community – rooted in patience, respect and in valuing our difference

As a reminder, critical pedagogy is an approach to learning and teaching that enables learners and facilitators to question and challenge domination, and the beliefs and practices that dominate; in order to build critical consciousness and self-agency. Critical pedagogy thinks of learning as a continuous process, an everyday and an integrated part of what it means to be a human being. Critical pedagogy regards learning as being about how we change and become different from the way we were before. For real learning and capacitation to take place, facilitators are challenged not to behave like school teachers or lecturers: instead, the teacher must learn, and the learner must teach. 

Critical pedagogy digs deep way beneath the superficial understanding of society. Critical pedagogy 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. Critical pedagogy also includes relationships between teaching and learning. It is a continuous process of “unlearning”, “learning” and “relearning”, “reflection”, “evaluation” and the impact that these actions have on those who are learning and teaching. Ultimately, critical pedagogy is about building the tools of analysis for understanding society, building the tools for transforming society, and the development of transformative actors. 

It is an experiential learning approach, based on real lived experience, builds on existing knowledge, recognises the importance of feelings in the learning process, is an active and engaging learning process, is curious, is enquiry-based, is inquisitive, links theory and practice, and is holistic. It is also not neutral: it is clear, deliberate and creative about where it is coming from, what it is trying to achieve and why, and what socioeconomic interests it aims to serve. Therefore, this approach helps Fellows to develop tools for transforming society: in the process, Fellows can become a consciously transformative actor and strengthened leaders for social change.

We therefore structure the learning process around:

  • Lived experiences (learning from Fellows, how knowledge is produced and mainstreamed or side-lined)
  • Concepts (theory)
  • Reflection 
  • Re-imagination and application 

We are also conscious of:

  • Power at macro and micro levels – how persistent exclusion and atomisation is under capitalism, especially for women who intersect with multiple layers and levels of marginalisation in being black, working class, unemployed, under-employed, etc – sharpening our feminist approach to change
  • Vulnerability, discomfort and conflict – enabling safety for Fellows to express their vulnerability and discomfort, and also any conflict that may arise in the learning process
  • Diversity – the need to embrace this to detect and tackle what is silenced, hidden and unsaid 
  • Disruption and uncertainty – effective and inclusive ways in which the learning process will positively disrupt received and dominant knowledge based on the core belief that education for social change is not neutral – that this is about the decoloniality of being and includes finding ways to hold uncertainty in the learning process 
  • Transformative change and its personal impact (personal transformation) – the political is personal, the personal is political; shaping and holding a learning pathway that enables Fellows to realise that real, genuine, thorough-going transformative change necessarily goes through pain, disturbance, disruption, vulnerability, discomfort and dis-ease 
  • Width and depth – what balance and inter-relationship? What basic minimum knowledge is required? What is left for the SCI and for life-long learning, and for reflection and application?
  • Dialogue and reflection – engaging in critical self-reflection as well as helping Fellows to unpack narratives – dominant narratives/hegemony – the story (how this hegemony developed) and ways to disrupt the comfort in the hegemonic story (interactive exercises on deconstructing the dominant narrative) 
  • Reflection on the learning process – space for each Fellow to consciously reflect on the learning process and to bring that reflection into the common learning space (including the possibility of publishing the reflections where appropriate); 
  • Tangible outcomes – consolidating the learning journey into tangible learning outcomes and impacts
  • Careful listening – to each other, and drawing this engagement into the learning process
  • Follow up – noting issues that may require follow-up after the Module and ensuring follow through. 

For Module 3 we once again bring this critical pedagogy into our learning space.  While of course the learning environment is starkly different, the learning theory, principles and pedagogy is applied here too.

As a reminder, 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. Learning takes place by analysing our own experience and by engaging in critical discussion with others. It happens in stages, moving from the analysis of experience, to seeing patterns within that experience, to planning action, to reflecting on and evaluating action, and on to looking for patterns again.

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

Support learning and education as organising tools and always about self-emancipation and self-organising by the oppressed, not substitutionalism by professionals, NGOs, etcetera.   

We wish to remind Fellows of the concept on neutrality in education we introduced as part of Module 2.  It is critically important; given the orientation Tekano has adopted.  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 remaining neutral we are not ensuring a “neutral” education, we are just ensuring that someone else is dictating the purpose of what we want to do. We are essentially just reinforcing and maintaining the status quo. By claiming neutrality in education, you won’t be able to identify the ideological, processes, politics, and power at work.   And this is necessary for creating a fairer, more inclusive and socially just world.

Learning as storytelling

Learning as storytelling was introduced in much detail in the framing document for Module 2 and was used in activities during the module. We therefore do not outline this in detail here.

Like in Module 2, for Module 3 the preceding objectives speak to a learning journey and help shape how Module 3 will enable Fellows to understand the story and history behind structural and social determinants of health (SSDOH), the story of how these impact the health and wellbeing of South Africans today and the story of how political players maintain the inequities that continue to exist. 

This Module presents the Eastern Cape province and its political economy, historically and today as a microcosm of what we are experiencing in South Africa.  From studying this province, we will continue the story of how different interests, locations, the exercise of power, policy and the ‘live’ socioeconomic impact of these contestations impact on the health and wellbeing of those in the Eastern Cape.

Through telling the story of the Eastern Cape, we locate the province in 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. By doing so we are grounding our understanding of the SSDOH and ultimately of health inequity.  We hope that through doing so we can locate Fellows in the story; navigating the narration of deeper systemic and structural issues that connect with, and deepen Fellows’ experiences, perceptions and understandings. 

Our journey thus far

The journey of the Fellowship thus far, has aimed to use and demonstrate a growing evidence base of the relationship between the health of our nation and their living and working conditions.  Our own understanding and experiences of hierarchies of power, privilege and access to resources surfaced through reading, seeing and learning about how class, race, gender, space, power, conditions of work, etc. all intersect and affect the health of individuals and communities. 

If health equity is to be achieved, it is only possible by starting from an understanding of how health is more than just about access and individual choices.  At the core is a need to understand colonialism (as an earlier period of capitalism with its form today being neoliberalism), poverty, powerlessness, apartheid’s legacy of structural racism, land dispossession, patriarchy and its sexist and violent manifestations and discrimination.

Module 1 saw us looking at how SSDOH manifest under neoliberal capitalism, and are mostly responsible for health inequities, the unfair and avoidable differences in health status we see so prevalent throughout South Africa. 

Module 2 continued this exploration by allowing us to see how the SSDOH are rooted in the institutions and processes of the political economy.

Module 3 takes us into the Eastern Cape where we will further explore structural determinants and how these produce and replicate class, race and gendered divisions.  The Eastern Cape also presents a critical backdrop for understanding the social determinants of health in the South African context.