Health Systems Research Unit

Conclusions and recommendations
Linking health and environment in Cape Town, South Africa: The view from local government, July 1998

This section of the report presents the study conclusions and recommendations. These are organised as follows: firstly, the key findings and conclusions are presented for each major theme of the study. Secondly, a number of broad conclusions are presented. This is followed by the main recommendations emerging from the study.

Conclusions

The local government policy process in Cape Town
The following key points were identified:

• Policy, as understood by the respondents in this study, has a number of functions. These include setting standards and ensuring a minimum level of uniformity in implementation; providing a framework for action and for dealing with potentially sensitive issues; and promoting the transparency and accountability of service providers. In general, respondents appeared to have high expectations of the ability of ‘policy’ to influence the actions of environment and health departments.
• Environment and health departments at the local government level are engaged in a number of policy development and implementation processes. While, in the past, policies were inconsistent, adhoc, reactive and often impractical, officials felt that, under the new dispensation, policies needed to be realistic, adaptable and linked to budgets. It was also noted that policy could be used to bargain for more resources, particularly where these policies were formalised in law and therefore required enforcement.
• There was agreement on the need for wide-ranging public participation in policy development but councillors and officials differed with regard to how this could be achieved and the extent to which participation in policy making had been broadened to date. Public participation in, and awareness of, policies was also seen to be a method of enforcing the accountability of councillors and officials by reducing their discretion to take arbitrary decisions.
• A number of constraints to policy development were identified, including inadequate environmental and health data; lack of co-ordination and consistency between policies under development; inadequate attention to implementation mechanisms and lack of capacity amongst officials.

Conclusions:

• Particularly striking is the very large number of policies which are either under discussion, under development or ready for implementation, and which have either direct (e.g. the district health system) or indirect (e.g. Environmental Impact Assessment regulations) implications for local government health and environment departments. As is the case with restructuring in general, the capacity of departments and councillors to successfully participate in the development and implementation of these policies is very variable.
• Past experience and practices often do not provide a useful framework for policy making in the new dispensation, and this is compounded by the loss of experienced personnel during the restructuring process. New strategies for ensuring both cross-departmental and public involvement in policy making need to be explored, evaluated and implemented. However, several respondents pointed to the difficulty of establishing cross-cutting structures with real decision-making rather than advisory powers as these are sometimes seen to infringe on the territory of individual departments.
• While some decision makers saw policy implementation as a mechanism for generating resources and capacity, it was also acknowledged that inadequately trained or resistant fieldstaff could impede or derail implementation. It has been noted elsewhere that the implementation of policies by field workers is often hampered by a ‘...lack of clarity in [policy] goals or a lack of resources to achieve them’ (Hill 1993 p379). Hill goes on to comment that fieldstaff ‘...do make policy, but not in the way they would really like to. Coping strategies dominate their lives.’ (p379) In other words, actions that are perceived as ‘resistance’ may, in practice, be mechanisms evolved by field staff to enable them to cope with their working conditions and pressures. Policy implementation might therefore be facilitated if more attention is paid to developing the capacity of fieldstaff and middle management and to examining barriers to implementation at those levels.

4.1.2. Exploring the environment - health nexus
The following key points were identified:

• Despite a number of constraints, including lack of clarity on how environmental health services will be integrated into the district model and on the functions of EHOs, restructuring appears to have impacted positively on the status of the environmental health sector in local government. At the provincial level, however, the environmental health department is perceived as weak and in need of support and direction.
• There appears to be a strong awareness of the need to make links between environmental conditions and health impacts and therefore between environment management, environmental health and health departments. However, adequate linking structures are not yet in place or operationalised and administrative systems do not appear to be structured to facilitate co-ordination. Departments still tend to function within their own areas of interest, and the implementation of policies that promote cross-sectoral actions has been slow. This may be linked to issues of departmental ‘territory’ and a lack of formal liaison structures, particularly at middle-level management and field levels. The health sector seems to be more sceptical about the feasibility of working closely with other sectors, such as planning departments, than is the case in these other sectors.
• Officials and councillors were not in agreement on what constitutes meaningful community participation in environment and health policy making and how this could be achieved. Broad participation was viewed, by some officials, as an obstacle to the speedy implementation of policies, while other respondents acknowledged the difficulty of balancing the need for participation against the pressure for rapid improvements in service delivery.
• The difficulties of operationalising ‘community participation’ in the context of very diverse and often conflictual communities was acknowledged. Most respondents agreed that councillors have an important role to play in this regard, but they may be limited by lack of capacity and support and by lack of familiarity with the bureaucratic processes of local government. Other obstacles to effective participation include the apathy within communities; the bureaucratic and non-user friendly processes of local councils; and inadequate or inaccessible information.
• ‘Buy-in’ from senior politicians and officials and the establishment of integrated working groups were identified as important in effecting participation and cross-sectoral linkages.
• The role of indicators in informing decision making and facilitating dialogue between service providers and end users was discussed. Officials distinguished between municipal or metro-wide indicators, which most supported, and community-based indicators which, while seen to be useful, were not considered to be a priority for development at this time. The current focus of planning within the city is at municipal rather than community level and draws heavily on the ‘management by objectives’ approach. This may account for officials’ focus on macro- rather than micro-level indicators. Nevertheless, officials were aware of the need for accountability to communities and saw indicators as a potential way of improving this.

Conclusion:
While environmental management and environmental health departments share many of the same concerns, and increasingly make the links between environmental driving forces and health impacts, there is still very little real co-ordination of policy making and implementation across these sectors. Co-ordination, where it is does exist, is focused on ‘downstream’ issues, such as air pollution monitoring rather than on ‘upstream’ issues such as policies on industrial development. By shifting environment - health policy co-ordination ‘upstream’, it is possible that these departments could have a more substantial impact on the environmental driving forces that often result in poor environmental conditions and health.

4.1.3 The impacts of local government transformation
The following key points were identified:

• Restructuring, in the context of resource constraints, has had negative effects on efficiency, with many structures not yet fully operational and a weakening of liaison structures. Organisational morale was also perceived to be low, but this was very context dependant.
• Despite a range of problems in the short term, restructuring was seen to be potentially positive, in terms of local government functioning, in the medium and long terms.
• There appears to be a lack of clarity on the division of functions between spheres of local government. Building trust between different structures was highlighted as a mechanism of facilitating ‘co-operative governance’.
• The roles and functions of elected representatives is a contested area, but one in which there appears to be a healthy debate.

Conclusion:
The overall impression is of profound and far-reaching changes within local government structures, with very different impacts across departments and between levels of management and field staff. Senior managers, many of whom were involved in driving these changes, seemed generally positive about their outcomes but it was also clear that middle management was struggling to cope both with the flood of changes and with decreased capacity and increased demand. Fieldstaff, although not explicitly included in this study, were perceived to be demoralised and even, in some cases, paralysed by the restructuring process. That the impacts of local government restructuring have been experienced differentially across levels and departments within the health and environment sectors is not surprising, but this makes it extremely difficult to generalise regarding the nature and scope of these impacts. Furthermore, it would imply that strategies to address both the structural issues arising out of restructuring, such as the need for new interdepartmental structures, and the fears and anxieties of staff, will need to be carefully tailored to the settings in which they are applied.

4.1.4 Policy: is it a panacea for the problems of local government?
While there were widely diverging views on what constitutes ‘policy’ at local government level, policy was seen to have wide-ranging functions including ensuring consistency of actions; setting parameters and standards (e.g. across the metropole); promoting transparency and accountability; dealing with politically sensitive issues (e.g. informal trading); and enabling service delivery. These high expectations of policy, seen together with the large numbers of policies currently being developing in the health and environment sectors, often in an unco-ordinated manner, begs the question of whether policy development is being used as a ‘panacea’ for a range of ills or problems in these sectors? While policies need to be revised and new policies developed, there is a danger that policy making will divert attention away from other important issues relating to the transformation of local government, such as the need to build the capacity of councillors and officials and to find methods of accommodating widely divergent organisational cultures within the new MLCs. As is the case with ‘restructuring’, policy making and policies cannot, in themselves, result in the transformation of organisations. For meaningful transformation to occur, attention will need to be paid to the organisational barriers impeding transformation, from the historical maldistribution of resources to poor staff morale. This may be a far more challenging exercise than the process of policy development itself.

In contrast to this, while officials had high expectations of policy and were engaged in a number of policy development initiatives, the process of organisational restructuring itself was not generally perceived to be explicitly or implicitly driven by policy. Restructuring was generally seen as a technical and very rational process of organising people and resources into manageable and effective units. This links to the issue raised earlier in this report of whether local government structures should follow function or whether function will follow from these structures. Within the health and environment departments in Cape Town, the latter approach would seen to be predominant, although the boundaries between these two approaches were not always clear.

4.1.5 Has restructuring achieved transformation?
A number of respondents highlighted the difference between ‘restructuring’, which involves re-organising the components of local government, and ‘transformation’ which implies a more profound shift in the form and nature of local government, impacting on the entirety of functioning from the attitudes of staff to organisational policies. It is perhaps too early to comment on whether the restructuring processes described in this report have in fact resulted in the transformation of environment and health departments, and how (and indeed whether) this process of transformation is reflected in policy development and implementation. Having said that, a number of the themes identified in this report, including the focus on participation in policy making, on developing cross-sectoral structures for that process and on trying to achieve equity in resource distribution across the city, while not novel in themselves, are important in the extent to which they appear to be receiving significant policy attention. While these issues were often raised prior to restructuring, the shift towards action perhaps indicates that local government is undergoing a significant transformation in its modus operandi. Further research would be needed to ascertain whether these promising trends are maintained over time.

4.1.6 Policy analysis: a useful tool for decision-makers?
Walt et al (1994) have examined the role of policy analysis in health sector reform and have suggested that policy analysis has an important role not only in analysing the policy process, but also in the development and implementation of policies. Others have suggested that stakeholders in implementation need to understand when certain strategies of action are likely to pay off and when they are not (Elmore in Hill 1993). This necessitates an understanding of the different models of policy implementation and how they can be applied to the implementation of social programmes.

This study may prove useful for decision-makers in two ways: firstly, the findings have been fedback to key stakeholders and have already generated useful debate (Minutes of Feedback Meeting, 1997). Secondly, the findings will inform the process of developing an environmental management strategy for the CMA over the next 2 years (Environmental Evaluation Unit 1997), by highlighting where policy making is weak and where it could be strengthened.