Explaining health inequalities in South Africa: A political economy perspective

Abstract

In South Africa inequalities in health have been extensively reported. The poor suffer more ill health than the rich. This paper discusses the need to understand the historical, social and political contexts and power relations that have shaped inequalities in South Africa. This can be achieved in part through a cohesive intersectoral approach that addresses ‘the causes of the causes’. Yet more fundamentally, the authors suggest that success in tackling inequalities in health will only come when existing power structures in South African society are acknowledged.

Keywords:

• health inequalities
• power structures
• social determinants of health

1. Introduction

The link between absolute or average income levels and health has long been documented (Narayan et al., 2000; Deaton, 2002, 2003; Wagstaff, 2002). Low income levels (poverty) and ill health reinforce each other. There is also a growing body of evidence on the link between a broadly defined socioeconomic status and health (Mackenbach, 1992; Gwatkin, 2000; Mackenbach et al., 2008; Ataguba et al., 2011), education and health (Ross & Wu, 1995), and social protection and health (ADB et al., 2011). Generally, lower socioeconomic status, poorer educational attainment and absence of social protection are associated with poorer health and health outcomes. On this Deaton writes: ‘mortality and morbidity rates are inversely related to many correlates of socioeconomic status such as income, wealth, education, or social class’ (2002:13). While this link has been documented, the relationship between income inequality and health (or health outcomes) remains disputed (Coburn, 2000, 2004; Wagstaff & Van Doorslaer, 2000; Deaton, 2003; Macinko et al., 2003; Lynch et al. 2004a, 2004b; Wilkinson & Pickett, 2006).

A review by Macinko et al. (2003) of about 50 studies revealed that, while about 70% of the studies reported significant evidence of a strong negative relationship between income inequality and health and health outcomes, about 30% did not. A more recent review by Wilkinson & Pickett (2006), based on 168 analyses, found that even though some relationships were not statistically significant, a sizeable proportion of analyses support the inverse relationship between income inequality and health. In these authors' view this is related less to the link between income distribution and health and more to the degree of social stratification or social class differences. Thus they conclude that

income distribution is related to health where it serves as a measure of the scale of social class differences in a society … In small areas, where income inequality is unlikely to reflect the degree of social stratification in the wider society, it is [as the authors show] less likely to be related to health. The overwhelmingly positive evidence of studies of larger areas suggests that this interpretation is correct. The fact that social stratification is such a fundamental feature of social organisation explains why there are so many socioeconomic factors correlated with inequality. (Wilkinson & Pickett, 2006:1778)

Though the relationship is still contested, a number of pathways have been suggested via which income inequality affects health and health outcomes. These pathways, often discussed under the social determinants of health, include social cohesion, social trust, social capital, the health system, environmental factors and economic and political ideology (e.g. neoliberalism) (Coburn, 2000, 2004; Macinko et al., 2003). These can all be described as facets of the class or power structure within a society (Kawachi & Kennedy, 1997; Kawachi et al., 1997; Coburn, 2000; Macinko et al., 2003). The fact that more equal societies or egalitarian political regimes produce better health outcomes than neoliberal or market based systems, which are more prone to being class-based (Wilkinson, 1992; Coburn, 2004), serves to support class (and power structures) as being the key here.

In the context of South Africa, we argue for a broader, holistic and integrated approach to addressing health inequalities that recognises the social, political and economic determinants of health and, more particularly still, relates this to issues of mal-distribution and imbalances in power in South African society. We contend that too little attention has been paid both to understanding the underlying causes of income inequality (Coburn, 2000; Macinko et al., 2003) and deciding what interpretation is to be placed on income inequality. We agree with Coburn's argument that more attention should be paid to ‘understanding the causes of income inequalities and not just to its effects’ and that ‘understanding the contextual causes of inequality may also influence our notion of the causal pathways involved in inequality-health status relationships (and vice versa)’ (2000:135). The need to emphasise ‘the causes of the causes’ has also been echoed by the World Health Organisation (WHO) (Krech, 2011).

2. Beyond describing the social determinants of health

The WHO Commission on Social Determinants of Health (CSDH) was launched in 2005 to tackle increasing health inequities by compiling scientific evidence on the social determinants of health (WHO, 2009). These determinants are the social, political, economic, environmental and cultural factors that affect health status (Halfon et al., 2010). The CSDH recommends a collaborative and intersectoral policy action that would involve improving daily living conditions; tackling the inequitable distribution of power, money and resources; measuring and understanding the problem; and assessing the impact of action (CSDH, 2008; WHO, 2009, 2011).

While these areas of action are important, we argue that in South Africa we need to go further and first examine and secondly address the causes of inequalities in health. If we fail to understand the causes, the prospects of identifying appropriate specific strategies are diminished. Coburn (2000), Wilkinson & Pickett (2006), Navarro (2007), and Mooney (2009) identify class as the cause in western societies. We argue that in South Africa the cause is essentially inequalities in power. Though power can be defined in different ways, it is essentially related to domination and control of resources. Class and power are therefore linked. The class-domination theory, for instance, is linked to different bases or sources of power, including the Marxian economic basis (Domhoff & Webber, 2011). Other power bases are political, military, ideological and religious.

South Africa has pursued predominantly neoliberal policies since apartheid ended in 1994 (see Bond et al., 1997). While neoliberalism can be understood in different ways, it is essentially ‘built on a single, fundamental principle: the superiority of individualized, market-based competition over other modes of organization’ (Mudge, 2008:706–7). It is an ideology based on the market system and has generally led to cuts in public spending on social services. International evidence suggests that neoliberalism can be detrimental to population health and could decrease social cohesion (see for example Coburn, 2000; McGregor, 2001; Navarro, 2007) and increase health inequality. This neoliberal ideology has not only exacerbated inequality in incomes in South Africa but also led to major deficiencies in social and health services and a concentration of power in a small elite which is in alliance with large corporations, especially in the mining and energy sectors (Williams & Taylor, 2000; Hallowes & Munnik, 2007; Baker, 2010). It has also fuelled the rapid growth in the private health sector, which caters for less than 20% of the population, and a decline in government commitment to health care (McIntyre et al., 2007). While apartheid is formally a thing of the past, in terms of education, health and social services there remains a major divide between black and white. Though inequalities in education, health and access to social services can be argued to go beyond racial divides (Seekings & Nattrass, 2002), it is still the case that race matters. The former white elite, even if not there in government, remain powerful especially in a neoliberal state in which there are such strong links between government and corporations.

Inequalities in health in South Africa have been extensively reported (Eyob & McIntyre, 2003; Zere & McIntyre, 2003; Ataguba et al., 2011). The poor suffer more ill health than the rich. These inequalities are of course not restricted to health and health care, as the poor suffer from multiple deprivations. According to Klasen, they ‘suffer from lack of access to education, quality health care, basic infrastructure, transport, are heavily indebted, have little access to productive resources, and are heavily dependent on remittances and social transfers, particularly social pensions and disability grants’ (1997:51). These problems, to a large extent, can be linked to history.

During the apartheid era, the South African health care sector was segregated. Health policy aimed to maintain economic and political power and a better quality of life for the minority white population (McIntyre et al., 2007). Health services for the black majority were severely underfunded and rural areas were neglected (Kale, 1995; McIntyre & Gilson, 2002). The same was true of the educational system that was described as the pillar of the apartheid system (Thomas, 1996). Though the current systems are evolving to address the existing inequities caused by the apartheid legacy, significant gaps still remain (DoH, 2011; Lam et al., 2011). A recent study using a nationally representative sample shows that the health system is inequitable (Ataguba & McIntyre, 2012), as the use of health services does not follow the distribution of need for such services.

In South Africa, capital is noted to retain ‘enormous power, not because of the voting power of capitalists in elections but because of their importance to the economy’ (Seekings & Nattrass, 2002:2). The implication of this is the development of capitalist institutions that have backed the growth of the private health sector in the country. Total private sector expenditure as a proportion of GDP has continued to exceed that of the public sector (see Figure 1). On this, Coovadia et al., for instance, write that the development of the private health sector:

was largely stimulated by corporate capital, particularly the mining houses. These capitalist institutions are far more powerful and have influenced the political economy of South Africa and its health system to a greater extent than in most other post-colonial African and Asian countries. (2009:826)

Figure 1: Health care expenditure as a percentage of GDP

More recently, uneven and unfair distribution of social power and relationships, and poverty and rural–urban differences have also been noted as underlying some of the existing inequalities in access to health care in South Africa (Harris et al., 2011).

A major challenge faced by the South African health sector has been the public–private mix (McIntyre et al., 2012), which is inextricably linked to the neoliberal policies of the country and the capitalist institutions. Coovadia et al. (2009) note that before the 1970s, private medical schemes in South Africa catered for the health care needs of white mine workers, with membership being restricted to white people. While this refers to the ‘old’ South Africa, a recent study using a nationally representative dataset also shows that a white South African has a significantly higher likelihood of being a medical scheme member and that blacks are disproportionately less represented as scheme members (Ataguba & Goudge, 2012). Membership of a medical scheme also follows income and employment levels: the poorest and the non-formally employed South Africans are almost invariably not scheme members (Ataguba & Goudge, 2012).

One can well argue that private medical schemes are not the same as public schemes or programmes and should not be viewed as such, and further, that public health services are available to cater for the majority of South Africans. However, these arguments need to be placed in the context of the current resource distribution between both sectors of the health system. Private medical schemes alone account for over 43% of total health care financing, while less than one sixth of the population, mainly the richest, are scheme members (McIntyre et al., 2007). The disparities in expenditure between the public and private sectors relative to the population they serve have widened over time, as reflected in the gap in per capita expenditure between the sectors (McIntyre et al., 2012). As Figure 2 shows, the ratio of private to public sector per capita health expenditure has been greater than 5 for the most part between 1997 and 2010.

Figure 2: Ratio of public to private per capita health expenditure

Williams and Taylor write that in South Africa the:

adoption of neoliberal principles has exacerbated inequality and increased the concentration of wealth in the hands of the privileged few. Apart from the ethically odious (and increasingly dangerous) prospect of living in one of the world's most unequal economies, such a polarised environment is fertile ground for social and political instability. (2000:37)

A prominent neoliberal ideology adopted in 1996 was the Growth, Employment and Redistribution (GEAR) policy. This policy led to the contraction of public health spending, with reductions in personal income tax rates that benefited the more powerful and affluent (Baker, 2010). The direct impact of the reductions in public health spending will most likely be felt by the poor (and powerless), who are most dependent on the public health sector. These reductions were, however, accompanied by the full abolition of user fees in 1996 for public sector primary health care services (McIntyre et al., 2007). This was intended to obviate financial barriers to the use of health services by the poor. However, this has not narrowed the widening public-private disparities that reinforce the distribution of power in the country. With the abolition of user fees, utilisation of health services increased among the poor (Gilson & McIntyre, 2005) with no corresponding increment in the share of total health care financing accounted for by the government. In fact, as Figure 2 shows, per capita private health care expenditure far outstripped that of the public sector.

The WHO notes that inequity in power ‘interacts across four main dimensions – political, economic, social, and cultural – together constituting a continuum along which groups are, to varying degrees, excluded or included’ within or across countries (2008:2). Though this issue is broader than the issue of political power, Drèze & Sen (1989) have noted elsewhere within the context of poverty and deprivation that the skewed concentration of political power in the hands of a few is the major driver of severe neglect of the basic needs of disadvantaged groups. These issues of power are not easy to address, especially as they are so often shaped by time and history (Young, 2010) and in the case of Africa generally still influenced by the power relations of colonial times (Ichoku et al., 2012). We argue that recognising these power relations and their distribution is critical to reducing health inequalities in pluralistic societies like South Africa. This will require that, as health economists, we turn more and more to the political economy of health to understand these issues.

Mooney, for instance, drawing on Navarro's development of a national health policy (2007), argues that there is a ‘need to embrace policies aimed at reducing inequalities in any national health policy’ and that, more fundamentally, a national health policy ‘must address issues of power’ (2009:178). He stresses that a national health policy is not just social but also political. And so also is public health (Navarro, 2011). If in our analyses we fail to consider society's power structures, much of our work will be in vain. It is these power structures that can be used to encourage policies that promote or hinder population health.

More generally, the importance of universal health coverage (Carrin et al., 2008; Garrett et al., 2009; Harris et al., 2011) has been stressed for tackling health inequalities. This has been embraced by South Africa in the form of a proposed national health insurance (NHI) (DoH, 2011), which would focus on the health care sector with only limited linkage to other relevant social service sectors. Largely separate and independent efforts exist in education, public works, and other social service sectors. The complementarity of sectors, through a coherent intersectoral approach, is required if we are to achieve significant reductions in health inequalities (Whitehead, 1992). For example, social and political forces affect health inequalities (Navarro & Shi, 2001). It is also the case that the educated, those who live in clean environments, the empowered, and those with better life opportunities, generally enjoy better health (Grossman, 1972; Wagstaff, 1993; Deaton, 2002).

While there is some recognition of these issues in the literature generally (Navarro & Shi, 2001; Ataguba et al., 2011), in South Africa, as in many other developing countries, there is yet to be a coherent and well-structured policy that draws on the existing evidence and builds on the existing structures and institutions to combat health inequalities. Though not explicitly acknowledging the social determinants of health, Deaton argues that the ‘U.S. system pays too much attention to health care delivery and to drugs and too little to the effects on health of the “upstream” social and economic arrangements’ (2002:27). Some of the problems in South Africa, as noted earlier, can be traced to its apartheid history and the struggles then and since faced by different racial and gender groups. South Africa can build on the social determinants of health (Marmot, 2011) and the NHI while recognising the underlying power distribution that has shaped health inequalities.

The anticipated gains from the NHI in South Africa can only be consolidated by strengthening and integrating other structures beyond the health sector. The broader determinants of health must be recognised, but it must also be acknowledged that it is the existing power structures that are driving these inequalities. Going down this route offers greater promise of reducing overall health inequalities in South Africa.

3. Conclusion

Deaton writes that any policy ‘cannot be intelligently conducted without an understanding of mechanisms; correlations are not enough’ (2002:15). We need to go beyond analysing the distribution of inequalities and also their correlations and use this as a starting point for addressing health inequalities in South Africa. While this is relevant, though, we insist that there is a need to get yet further than Deaton proposes. What we need is to understand the historical, social and political contexts and power relations that have shaped inequalities in South Africa and also how these have shaped the policies that have been used to address them. This further requires a coherent intersectoral approach that will account for the interrelatedness of factors that are associated with health inequalities in South Africa. Inequalities in power need also to be acknowledged. We contend that this is a better strategy to adopt in seeking to redress health inequalities than focusing on the health care sector or on other related sectors in isolation.

Acknowledgements

The authors acknowledge the invaluable comments and suggestions made by Gavin Mooney.

Notes