Health Systems Research Unit

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

Background

• Since the early 1990s, which saw the start of formal negotiations between the apartheid government and parties of the democratic movement, profound political and structural changes have swept through all levels of South Africa’s civil service. Following the first democratic elections in 1994, the new African National Congress (ANC) led government began implementing a range of policies to address the legacy of apartheid in the provision of basic services such as health care, water supply and sanitation, and to restructure civil service departments responsible for this provision.
• Environmental health and environmental management departments lie at the interface between environment and health. They have a particularly important role in developing and implementing environment related policy and in monitoring environmental conditions which impact on health. Local government restructuring creates an opportunity both to examine the process of environment and health policy reform at local government level and to gather data which can inform that process.

Objectives

• This study aimed to explore and map the development of local government policies in Cape Town, focusing on the interface between environment and health policies. The study had the following objectives:

• to explore and map the network of relationships and communication between:

• planners and managers in different departments and at different management levels of local government.
• planners in the Cape Metropolitan Council (CMC) and in the Metropolitan Local Councils.
• planners and elected community representatives (councillors).

• to explore how health information from different sources is used in developing policy.
• to examine how management structures and the culture of the organisations involved impacts on policy making.
• to assess the extent to which the policies set measurable goals and targets for implementation.
• to feed the information gathered above back to service planners and to document their responses to it.

• The study formed part of a larger programme of research in 3 Indian cities and South Africa examining the use of community-based indicators as a tool to facilitate dialogue between planners and communities. This research was co-ordinated by the London School of Hygiene and Tropical Medicine and funded by the United Kingdom Department for International Development.

Methods

• A range of qualitative methods were used to gather and analyse data on policy processes within the environment and health sectors of local government in Cape Town. In-depth semi-structured interviews were undertaken between October 1997 and March 1998 with the following key informants:

• Directors (or senior representatives) of health, environment, environmental health and urban planning departments of the Cape Metropolitan Council and the Metropolitan Local Councils (11 interviews; 20 respondents)
• Elected Councillors (4 interviews; 4 respondents)
• Senior decision makers within the Provincial Administration of the Western Cape (3 interviews)
• Health and environment oriented NGOs (2 interviews)
• Environmental health officers working in a low-income peri-urban community within Cape Town (1 interview; 2 respondents).

Non-participant observation of official local government meetings was also undertaken and relevant policy documents, legislation and agendas of council meetings reviewed. Preliminary results of the analysis were presented to the respondents and other stakeholders through a workshop, and points arising from ensuing discussion incorporated into the analysis.

• Notes and interview texts were analysed using qualitative approaches. The main themes were summarised and illustrated with direct quotes from the interviews and field notes. A framework for policy analysis which emphasises the interaction and interdependence of actors, processes, context and content was loosely used to guide analysis.

Findings
The local government policy in Cape Town

• 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 on how this could be achieved and on 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.

Exploring the environment - health nexus

• 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 within 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.

The impacts of local government transformation

• Restructuring, in the context of resource constraints, has had negative effects on efficiency. Many structures are not yet fully operational and liaison structures have been weakened. 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.

Conclusions
The local government policy process in Cape Town

• 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). 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.

Exploring the environment - health nexus

• 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.

The impacts of local government transformation

• 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.

Policy:  is it panacea for the problems of local government?

• There appeared to be high expectations of the ability of new policies to address both ongoing environmental health problems in the metropole and difficulties facing the civil service. This raises the question of whether policy development is being seen 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. 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. This may be a far more challenging exercise than the process of policy development itself.

Has restructuring achieved transformation?

• It is probably 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. However a number of the themes identified in this report perhaps indicate 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.

Policy analysis: a useful tool for decision-makers?

• It has been suggested that policy analysis has an important role not only in analysing the policy process, but also in the development and implementation of policies. 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. Secondly, the findings will inform the process of developing an environmental management strategy for the CMA over the next 2 years, by highlighting where policy making is weak and where it could be strengthened.

Recommendations

• Environment and health departments in local government should develop a policy which defines how communities will be incorporated into decision-making, and should establish a mechanism for the implementation of this policy.
• Methods and procedures used by councils, and specifically by health and environment departments, to facilitate community participation and empowerment with respect to service delivery should be evaluated and, where shown to be effective, strengthened and expanded.
• The feasibility of developing and implementing a training programme to build the capacity of councillors to participate in decision-making at local government level should be explored.
• Where existing administrative systems are not conducive to efficient functioning, attention needs to be paid to developing new systems that function efficiently within existing resource constraints, and that streamline bureaucratic procedures.
• Clarify the objectives of intersectoral / departmental collaboration and, if appropriate, decide on the most appropriate structures to achieve these objectives.
• Local government in Cape Town appears to be suffering from ‘restructuring fatigue’. In the context of debates on the ‘megacity’ option, the damaging effects of further restructuring should receive serious attention from local and national policy makers. If further restructuring is unavoidable, consideration should be given to the timing and the speed of implementation.
• There are concerns regarding the location of environmental health departments within the health sector. A multi-sectoral task team should be established to examine the role and functions of environmental health departments and to make recommendations regarding their location within local government structures.