Health Systems Research Unit

Health and environmental health services in Cape Town
Linking health and environment in Cape Town, South Africa: The view from local government, July 1998

Inequalities in environmental health services
The apartheid city not only ensured that race groups remained separate, but also, through the inequitable distribution of resources, ensured that White suburbs and communities enjoyed environmental conditions far superior to those of Black, Coloured or Asian areas.

In Cape Town these inequalities are demonstrated by differentials in access to basic services, such as adequate sanitation, solid waste removal, safe piped water and healthy housing; in exposures to polluted air, water and soil; and in risk of injury from motor vehicle accidents and violence. Figure 2 below, based on a recent household survey, compares different areas of Cape Town - a Black area (Khanya), a Coloured area (Grassy Park) and a largely White area (Parow) - on key indicators of access to basic services, and shows these inequalities.

Source: Barron B, Lewin S, London L, Rumbelow R, Seager J, Truter H (1996), The State of Housing, Water and Sanitation in the Greater Metropolitan Area of Cape Town, 1995, Published by the Health Systems Trust, Durban, South Africa.

The socio-environmental differentials that characterise the apartheid city are reflected in the large differentials in mortality rates between sections of the city and also in differences in mortality profiles between these areas (Lewin et al 1998). Clearly one of the major challenges facing planners in South African cities is redressing these inequalities through providing basic services to previously underserved areas.

Organisation of health and environmental health services under the new dispensation
Following the transition to democracy in 1994, the National Department of Health committed itself to developing a unified national health service based on comprehensive primary health care and the district health model (Report of the Committee of Inquiry into a National Health Insurance System 1995; A policy for the development of a District Health System for South Africa 1995). Strategic Management Teams were established within each province, and tasked with developing plans for the integration of existing services and the transformation of health care delivery. The Western Cape Province, with most of its population based in the Cape Metropolitan Area, was faced not only with the difficult task of integrating health services provided by a host of local authorities, vertical programmes and provincial structures, but of doing so within a reduced budget. Historically, the Western Cape Province has spent substantially more per capita on health care than most other provinces. In order to achieve better equity between provinces in per capita health spending, the Western Cape was expected to reduce spending so as to free funds for use elsewhere. Rapid reductions in the Province’s health budget, combined with the costs of expanding primary care services while maintaining a very large tertiary care system, constrained and, to some extent, undermined the implementation of the Provincial Health Plan (Draft Provincial Health Plan 1995; Finalisation of the Provincial Health Plan 1995). While there have been substantial improvements in access to primary health care in the province and the CMA, this has been paralleled by significant cuts in the budgets of referral facilities creating the perception that the Provincial Health Department and its facilities are in crisis. Attention has been diverted from the provision of primary health care and basic services to the state of the large tertiary hospitals within the city.

Within the Provincial Health Plan, very little attention was paid to environmental health services. This reflects the low priority and status of environmental health services in a system largely focused on curative care, and dominated by policy-makers from that domain (Lewin 1995; Derry 1994). Environmental health departments within both the provincial and local authority health services, staffed mainly by Environmental Health Officers (EHOs), are generally small and focused on the monitoring of air and water quality, food hygiene and living conditions. Although important, this monitoring function was not, in the past, closely linked to capacity for action to improve conditions. Intervention depended on collaboration with engineering, water and housing departments which provide basic subsistence services, but EHOs were often not seen as important players by these departments. At the community level EHOs were traditionally viewed as environmental health ‘policemen’. Furthermore, the distribution of EHOs between historically White areas and Black and Coloured areas was skewed, with White suburbs enjoying a far larger allocation of human resources than those areas experiencing the adverse effects of poor environmental conditions.

Despite the relative neglect of environmental health within the Provincial Health Plan, there have been moves within the sector to examine both the focus and the role of EHOs, particularly within the new district health system. This study will reflect on a number of these concerns, including linkages between the health and environment domains; the state of environmental health services in Cape Town; the impact of restructuring on the focus and organisation of environmental health services and mechanisms for monitoring environmental health at community, MLC and CMC levels.

In summary, local government in Cape Town is currently characterised by rapid shifts in a number of areas including structure and organisation; priorities for intervention; levels and lines of accountability; and financial and other resources. It is within this context that the results of this study should be placed.