Health Systems Research Unit

Exploring the environment - health nexus
Linking health and environment in Cape Town, South Africa: The view from local government, July 1998

This section is focused on the environmental health domain. It examines, firstly, the state of the environmental health sector as perceived by policy makers. Secondly, it explores the extent to which linkages are being made between environmental driving forces, health effects and the related need for appropriate environmental management in the city. We then examine the question of community participation in decision-making as it relates to environmental health issues and, finally, discuss the role of environmental health indicators in monitoring services and in creating and sustaining dialogue between communities and local government planners.

Theme 3.2.A:  The state of the environmental health sector in Cape Town
One method of assessing the state and status of the environmental health sector is to examine its role in decision-making. To what extent is it an important actor? How are environmental health issues perceived and addressed by policy makers? To explore these questions it is useful to examine the relationships between the environmental health sector and health and other departments; as well as relations between environmental health departments at provincial, metropolitan and local levels.

Relationships between the health sector as a whole and environmental health departments have not always been unproblematic. Previous research (Lewin 1995) has indicated that EHOs saw themselves and their departments as the ‘cinderella’ of the health sector. They felt that the role of environmental health was not well understood and was generally undervalued by curative departments, who were seen to dominate health sector decision-making. This experience of being peripheral to the health decision-making has contributed to debate on the role of environmental health services and on whether they would be better located within engineering services, as is the case in other countries such as the United Kingdom. One respondent commented that, because preventive services are not seen as a priority, environmental health services will not be taken seriously ‘…until there is a major outbreak’ [of an infectious disease]. This perception was supported by comments from respondents in the provincial health department:

'[We are]…currently losing 8000 health workers out of a total of approximately 32 000 because of budgetary cuts. So it is difficult to employ 20 in an environmental health section. The focus is on curative health.’

While environmental health is still viewed as of low priority at the provincial level, an important question is whether its status has changed at local level following local government restructuring? Respondents within local authority health and environmental health departments appeared to have a much more positive view of the role and contribution of EHOs to health.

‘…I think that one thing though that I have been quite impressed with is respect for environmental health. I think they respect your profession…’.

Co-operation and liaison with other local government departments, such as engineering services, also seems to be improving. Respondents commented on better relations with engineers and on better access to policy makers:

‘I think we are fairly lucky in [this MLC] at the moment where we’ve got easy access to the people who count – and to our Executive Officer, and Councillors.’

‘…it’s [executive management] very easy to approach…If we do bring up our concerns they are dealt with immediately. It’s not a question of us complaining again. We have identified, for example, an informal settlement. At one stage there was a complete lack of toilets and the environmental health person brought it to the attention…We pushed it through …put in some temporary toilet facilities. So people are very receptive to what we did and I think that the whole concept of local government is now changing to the developmental role. It’s becoming even more important.’

There are a number of possible reasons for improved relations between environmental health and other local government departments at the local level. Firstly, restructuring has encouraged managers to re-examine the roles and functions of different departments and to look for methods of better integrating activities. EHOs now appear to have more easy access to decision-makers and committees, and this seems to have improved the manner in which requests for action are managed. Secondly, as alluded to above, the focus on the developmental role of local government means that more attention is being paid to improving environmental conditions and to issues, such as air and noise pollution, which impact on environmental health. This contrasts very sharply with the findings of an earlier study (McDonald 1997; McDonald 1998) which commented on the lack of interest of local government engineering departments in the so-called ‘brown issues’ in underdeveloped areas of Cape Town. The study painted a very bleak picture of the potential developmental role of local government which, at that time, was still extremely fragmented and focused on the needs of the wealthy, historically White areas. While many of these problems are still current, and will probably remain so for several decades, the views of respondents in this study regarding the will of local government to improve environmental conditions in historically disadvantaged areas now appear to be far more positive. These changes do seem to be creating an opportunity for EHOs to redefine their relations with other departments and their own roles within this developmental approach.

While respondents identified opportunities for change, they also identified a number of constraints. Questions were raised regarding the career structures for EHOs and the extent to which their formal training equipped them for their work in the field. There also does not appear to be clarity on how environmental health services will be integrated into the developing district health system, with one respondent commenting that district health teams have ‘…no conception of the work of the EHO’. Concerns were also expressed that environmental health legislation is lagging behind practice and needs to be revised. Another major challenge is the reform of the environmental health information system. This is discussed in more detail under Theme D.

It is important to note that while respondents saw the environmental health sector as functioning reasonably effectively at MLC and CMC levels, the provincial department was seen to be weak and struggling to fulfill its role. There are a number of reasons for this: firstly, the Province has lost EHOs both to the local authorities and through voluntary retrenchment packages. Severe budget constraints at the provincial level have meant that these posts have not been refilled, restricting the capacity of the department. Secondly, there is a view that environmental health is seen as a very low priority in the province. An example was given of Port Health Services, previously staffed by 5 senior EHOs, but now being run by one EHO who cannot manage the workload. New posts have not been approved despite the fact that South Africa has a legal obligation to adhere to the International Health Regulations Act on the control of communicable diseases and vectors. The lack of capacity at provincial level was reflected in the view that environmental health functions should be devolved to local authorities where the bulk of staff is located. It would seem that clarity on the relationship between provincial and municipal levels has not yet been reached as several respondents commented on tensions between the different structures and on the fact that local governments often see provincial interventions as interference.

In summary, the environmental health sector at local government level is more positive about its role and relations with other stakeholders than is the case at provincial level, as expressed by an MLC respondent:

‘[The provincial environmental health department] hasn’t been able to drive the thing from [their] side and up at a national level environmental health is just about non-existent. So, we tried to turn it the other way around so that we can start pushing it from the local government side and then going up again…The metropolitan area could be a start, but then one can go provincial and then national.’

Important questions regarding the functions of EHOs and their place within the district health system still, however, need to be resolved. These questions are tied to the manner in which environment-health linkages are understood and reflected in service priorities and organisation, as discussed below.

Theme 3.2.B: Environment - Health Linkages
Within provincial and local health, environmental health, urban planning and conservation departments and amongst councillors there appears to be a good understanding of the importance of making links between environmental driving forces and health impacts. Links were seen to be important both in terms of understanding causal mechanisms and in terms of taking action.

‘…maybe if we dealt with environmental issues a bit more thoroughly, we may not be sitting with quite the health crisis. If we spent more time on waste management issues in your dense urban environment, you may be able to reduce the load on the health department. And air pollution issues, there’s an absolute link between those issues and the load that the health department has to carry….but it’s not easy to make that direct link.’

‘…where I find it useful is that the environmental staff challenge the nursing and the other health staff, the more clinic based staff, to think more broadly and, on intersectoral collaboration, they’re the best at it than any of the clinic based staff are.’

However, the point was made by senior officials that policies which create and support these institutional links are not yet in place or not operationalised. Departments function largely within their own area of focus and interventions therefore tend to be narrow or fragmented.

‘Clearly there’s the intention and I believe the commitment to move in that direction, but per se, there’s nothing in place currently which says ‘we really need to work very closely together’, because what happens in that physical environment could have serious implications back on the health side of things.’

Councillors also were of the opinion that intersectoral collaboration was not adequate.

‘…we often speak about the intersectoral approach to development and yet, in reality, it’s not really applied in local government. I don’t know to what extent it is applied in provincial and national, but definitely in local government that’s not properly applied.’

Another councillor commented as follows:

‘I’m sure that there are councillors that can make that link and also officials, but in our Council you will find few exceptions to that particular rule, where people are not really seeing that link very strongly. If you come from an area like Constantia, for instance, it’s very difficult to understand the conditions under which people live.’

Departments outside of the health sector seemed to be positive about the possibilities and benefits of working with the health and environmental health departments. Within the health sector, however, there seemed to be more scepticism regarding the ease of working together, and examples were given of instances in which planning and engineering departments had failed or were reluctant to respond to environmental issues with important health impacts that had been identified by a health department. One of these examples, concerning a new informal settlement, is described below.

‘We just had an issue where we…need(ed) to supply basic services, water and sewage. So we…put in a report that said that, and of course the argument now is it’s going to cost money and effectively the engineers (said)…we’ve got to find money to do that….So we work with them, but it’s a little more, sometimes almost adversarial, almost sometimes we’re having to fight them. They would prefer not to do anything.’

While some of these disagreements may be based on the questions of which department will ‘foot the bill’ for service upgrading, the example also shows that the engineering department, in this particular local authority, did not automatically or routinely accept a request from the health department for intervention. This may reflect issues of territory, with one department reluctant to accept intrusions into its area of operations from another department. Other comments, such as this one from a local authority councillor, support this view:

‘I think that there may be [moves] within council and within the various directorates to keep the departments narrow, but I think that these boundaries are being collapsed more and more because of issues.’

However, while territorial issues are characteristic of organisations, there is also a strong need for departments within local authorities to work more closely together in order to efficiently and effectively provide services. This raises questions regarding the efficiency of existing mechanisms for interdepartmental collaboration and how these mechanisms could be improved. A respondent at the provincial level made the following comment in this regard:

‘So we would definitely call them [the health department] in, and we have done, where there’s a need. But I don’t think we have formal liaison structures. Maybe we should…’

The point was also made that, while links may exist at senior levels across sectors, the links may be more tenuous on the ground and this may impede collaborative action.

‘…in linking generally across the organisation it’s probably quite good at senior level. I’m not so sure that it’s as good at lower levels. That’s something that we are going to have to work out.’

Co-ordination between the environment and health sectors, and other departments, is particularly important in implementing cross-cutting policies. This is discussed in more detail in the section on policy implementation above. An important point noted at the workshop held to discuss preliminary findings was that administrative systems are not structured to facilitate coordination and intersectoral collaboration, with performance "measured on what departments do, so it is difficult at this stage to work with other departments".

A major change from the past lies in the developmental orientation now required of local government, together with the need to work in an integrated and collaborative way with communities and other actors. However, as a councillor noted:

"But what does that partnership mean? Is it giving money, or is it sharing resources which includes human resources? Because they expect the community to put sweat effort into a product for free. ... And yet if you analyse it very few of these staff in Manenberg come out back into the area after hours … It’s okay as long as it is within their working hours… They probably claim overtime and if they are not paid overtime they won’t do it ... but they expect the community to do things for free, you know and not claim overtime. If they claim overtime then it’s fine. ... So, that’s the irony of partnerships."

Moving towards the future will clearly necessitate unpacking and defining concepts such as "partnership", "community" and "participation", and developing strategies to realise these. The perceived lack of commitment to community participation noted by councillors represents an element of the degree of polarisation between councillors and officials:

"The information is accessible but I think that the mindset of officials hasn’t changed very much. You therefore need to prod continuously to get the information that you want. I don’t think that they really understand the concerns of the people in the areas."

The way in which community participation is understood and applied in local government is discussed under the next theme.

There is a necessity, in view of the previously mentioned perception of the "tremendous control" exerted by the officials, to turn this mindset around, " So that people start to collapse and realise that we work as a team and not as separate entities, within the same organisations." The difficulties involved in facilitating intersectoral action are, however, well described internationally. A recent WHO report on health and environment commented that ‘Environment and health departments often suffer from low budgets and little influence over economic development decisions. These problems have been compounded by division of responsibility, with health-and-environment issues split between separate ministries that frequently have done little to co-ordinate their activities in this area.’ (WHO 1997 p14).

Theme 3.2.C:  Community participation in decision making

Defining 'participation':
Widely differing perceptions as to the meaning of ‘community participation’ in local government decision making, and the extent to which this is occurring, were expressed. A distinction can be made between the general thrust of councillor responses and that of remarks made by officials. In general, councillors appeared to be concerned that local government, and officials in particular, were not committed to meaningful participation:

"If you look at Council as a whole, I must say as a body and certainly officials, I don’t believe they’re really committed to public participation, I think as far as they’re concerned, it gets in the way. And a senior official has actually said to me, he will just do as he wants to do, he will ignore the councillor and the community."

"You see, I think that what has happened in South Africa is that we have lived for so long with a particular system in place, which has never been interactive with communities, it has always been authoritative in approach – we make the decisions, we implement the decisions, irrespective. I have a strong belief that although we continually speak of community interaction, at the end of the day it is not a reality as such. We listen to communities and we have all these workshops and we walk away and we ignore their statements, the implementation and the comments that they have made."

Officials, on the other hand, felt that extensive community participation in policy making was not always required. Reasons provided included the time-consuming nature of participatory approaches within the context of need for urgent and large scale delivery of services, and the limited resources of local government. In the case of policy formulation, for example, it was felt that development by officials of a pro forma policy which would then be open to public comment was preferable to extensive initial grassroots consultation prior to policy development:

".. it’s perhaps not the ideal way, but in terms of the limited resources and capacity that we do have, I think it’s a major change in local government in this part of the world, to get that buy-in."

"… but what our Environmental Health Officers in Khayelitsha tend to do is spend most of their time in meetings so there's lots of community participation, but is that really all they should be doing? That's the question we're coming up with."

Particularly where local government officials are closely in contact with communities, as is the case for Environmental Health Officers, it was felt by some that these officials could represent communities. Other planners felt that community priorities were well known and that action was required to address these, rather than more consultation. This focus on technical action was recognised as a shortcoming by one provincial government official, who noted resistance from other officials at different levels of government to his suggestions for direct community representation on a provincial environmental health forum on the grounds that the "forum deals with technical issues".

Another motivation for the need to move ahead rapidly was that local government now needs to accept and act on its responsibilities to disadvantaged communities. This rationale was apparent in the responses of officials committed to transformation and the developmental orientation of local government, who are clearly having to carry out a delicate balancing act between maximum rapid improvement in service delivery and meaningful community participation, which they do recognise as the right of residents in their areas.

The role of Councillors:
With the perceived lack of effective community participation at local government level, a primary role for councillors, particularly from disadvantaged areas, in ensuring meaningful community participation was identified:

"If you understand that the background of our people in the country is that they have not been part of taking decisions or even participating in discussion you will see that there is that lack from our people. I see my role as councillor as that of bringing together the community and the authorities."

Within this context of councillors as ‘go-betweens’, with the responsibility of transmitting community priorities to local government officials, the nature of the relationship between councillors and officials will be an important determinant of the extent of participation. This relationship was found to be variable, depending largely on the process of building good personal ties. This in turn was dependent on characteristics of the actors involved, such as length of time in office of councillors, as well as their power base:

"It depends on the person. In my case in my position as chairperson of the standing committee, I am able to get whatever information I need, because I do interact with all the officials and the management in various departments. If I want to get any information I just tell them, and up until now they have been able to provide me with that information."

"I have learnt a lot since I have been in council, I used to think that it only worked through the political structure, but there are many things you can do through the officials depending on your relationship. I think that if I find that I am not able to make any headway through the officials because of funding, I have no other alternative but to put it into the council system. That in turn will then be referred to the various committees that will then analyse and investigate it and make an assessment and come up with a report around that particular area. So that is basically the process. If it is politically sensitive then the officials will of course not touch it with a ten-foot pole."

An issue is "put into the council system" by a councillor placing it on the order paper. This leads to the issue being put onto the agenda of the relevant council committee, after a screening process by officials, which is felt to sometimes be necessary but, on other occasions "…you're not too sure what the motivation is".

The problem, however, does not always lie with the official. As a number of councillors pointed out, not all of their kind are equally diligent, and many new councillors, commitment notwithstanding, are finding it extremely difficult to cope with the workload and alien bureaucratic procedures of council.

"You will, however, find councillors who are not open with regard to asking for information and will just go to a meeting. That is one problem."

"They’re not coping. There are councilors who have never said a single word … They do not open their mouths on any issue at any time about anything."

Councillors used a variety of different mechanisms to achieve liaison and feedback to community members, indicating different operational styles. These included a regular newsletter used by one councillor to inform constituency members, as well as a range of formal and informal structures for liaison and interaction. In many cases using existing bodies such as civic organisations, Reconstruction and Development Forums, union structures and political party forums were used for feedback and discussion. Other structures have been specifically created for the purpose of interaction, such as the ward liaison group mentioned by one councillor, and the ward committees noted by another.

In addition to structures, all councillors mentioned interaction with individuals as an additional means to transmit community priorities and needs to officials. A difference, however, relates to the unequal demands placed on councillors from different socio-economic areas, as discussed in the section on new challenges for local government. A recent development to facilitate community participation has been the establishment of a Community Liaison Department within one of the MLCs, thereby institutionalising feedback to communities:

"The councillors also have the Community Liaison Department. This is a new department we have created because we saw that the councillors had a need for such a department to take responsibility for informing people of the councillors’ decisions and what is expected of them."

This department can be expected to play an important role in the intersectoral collaboration required to satisfactorily address environmental and environmental health issues.

What are the constraints to meaningful participation in decision-making?
Problems identified with respect to community participation related to the lack of a common understanding as to the nature of this concept, as well as inappropriate mechanisms to achieve this. Thus councillors noted the need for local government to define what is meant, and hence required, by 'community participation'. Integral to the need to clarify what is meant by community participation is the necessity for local government bodies to develop a unified understanding of what constitutes "the community". Clearly this might be different in specific circumstances. However, if the goal is broad based support and ownership of local development and decision making processes, limiting 'community' to well-organised formal structures or established interest groups, as some responses indicated, would tend to entrench the status quo, where participation in decision making is the prerogative of the elite.

In addition to unpacking the concepts of "community" and "participation", it is necessary to recognise that community participation itself will not automatically translate into consensus. Sensitive issues will require negotiation and compromise on the part of divergent interest groups and individual values. One councillor noted the problem of deciding on a course of action when there appears to be a split in the community with respect to a particular issue (in this case the holding of an open air film festival in a residential area):

"Now if you are an official, what do you do? So then you have to say what you think is what the true recollection of the community is. This film festival...it’s a split community. The ratepayers association said yes, we don’t mind, people in the area are saying no. Now what does the ward councillor do? Does he back a small group of people or does he back the association?"

When this happens, the issue becomes party political, in which case, in the opinion of the councillor, "…it’s unresolved because that doesn’t help. Taking it on party political lines doesn’t help." It appears that commitment to community participation differs between political parties, and this may be used by representatives of other parties to push for participation, or to manipulate council decision making for their own agendas. Non-participant observation revealed argument in council chambers between political parties concerning whether officials or councillors were accurately representing community needs and wishes. One revealing example consisted of councillors from white areas arguing with councillors from black areas as to whether the latter were correct in their representation of the wishes of their own constituents - shades of the old patriarchal mentality?! This once again highlights the need for transformation as opposed to just restructuring, discussed in more detail in the section on restructuring effects.

In general, responses raised the question as to the extent to which council structures and procedures facilitate community participation. Through non-participant observation of council and committee meetings, as well as from direct comments made by respondents, it is clear that many councillors feel that mechanisms to achieve community participation are not appropriate and thus wide involvement of constituencies is not realised:

"Here you find that there is a particular procedure in place and that procedure is so longwinded that people don’t really feel that they are interacting."

"They (the relevant officials) had said in a public meeting about the road issue 'we will have public participation', but to them in their minds it was putting an advert in the paper, to the communities' mind it was at least getting something in their box saying there’s going to be a public meeting. And so I put up and I complained 'we actually don’t believe in public participation' …"

It appears that there is some degree of inconsistency between the rigid and more hierarchical bureaucratic processes of council and more democratic procedures used by some councillors to interact with their wards. On the subject of workability of these two systems, one councillor from a ‘struggle’ background said the following:

"Well, they do work, but of course there are some difficulties. You will understand that the officials are not used to that kind of a system and the expectations of the community are quite high and because of the situation in our country, if someone puts something today, they expect results tomorrow. This cannot be the case. I will say that at least our officials are trying, under difficulties though, because they are not used to that kind of a system."

Additionally, information to facilitate public participation is not disseminated in an accessible fashion, if at all:

"I think mainly because they don’t know first of all a) who to go to, and b) they have the right to phone. That is the main crux of the matter. If it’s not information that is disseminated in the community, 'if you have a problem, phone X', you know and 'this is the number'. So, that should be part of the education process, you know."

However, the failure at this stage of local government in the CMA to interact meaningfully with civil society was not only laid at the door of officials - one councillor noted the apprehension of councillors regarding this:

" … one of the buzzwords in the X municipality is: community participation. It hasn’t really happened and this is one of those crucial things. I think that councillors feel very threatened and intimidated because of the expertise lying out there ... I think that our councillors would run away, because if you want to debate on a technical level, you will be out-debated by the civil society. And if you don’t listen to them, next time you will not be around. … I was in a couple of meetings where our councillors interacted with the community and were continually very defensive. I think that is the wrong approach. You need to listen, you need to open your ears and be a good listener. Because only then will you be able to use those debates that have been levelled at you, when you debate in council. But if you close your ears then you are not really reflecting the views and aspirations of the community."

A further structural obstacle to effective community participation is the apathy engendered in disadvantaged communities through the years of neglect and discrimination. In the words of a councillor from such an area:

"And I think in disadvantaged communities, they are too passive, you know in accepting what is pushed down by local authorities. … And they think that is how it should be, because it’s always been like that."

A lack of rigorous evaluation of innovative strategies was also raised. One official noted that groundbreaking participatory projects initiated outside the local government arena are not receiving the necessary support - "These crucial experiments are not being properly evaluated, or networked or supported." A related point was the need for integration of similar participatory initiatives being driven by different actors, highlighted by the following response from an official:

"I go to all the NGOs or whoever is involved in the area, in other words wherever they’ve got meetings, I try and attend them as far as possible so that we don’t get lost in the interim they’re doing something and we’re doing something, we try and get it under one blanket so that we can actually work together and previously that was a problem. People would go into … a squatter area and they’ll do their thing and actually we are doing a very similar service within that area, but now lately we seem to come together and we discuss it and whatever they do we try not to do so there’s not that kind of thing."

Innovation to facilitate participation:
Having identified community participation as an important problem, what strategies have been developed to address this? Responses to a question probing how community priorities would be incorporated into policy making were largely answered in a non-specific manner, such as "through the law, I think" or "a massive education process" or "by bringing in NGOs and community organisations". This appears to indicate that officials are still grappling with the means to achieve this incorporation of community priorities - that is, community participation remains rhetoric rather than reality in the Cape Metropolitan Area.

Multi-sectoral initiatives:
A broad response to the problem of achieving intersectoral collaboration and meaningful public participation was to drive issues through programmes such as the Healthy Cities or Local Agenda 21 initiatives (Feedback Workshop Minutes 1998). However, early attempts to set up a Local Agenda 21 Model Communities Programme (MCP) in the low income area of Hanover Park were largely unsuccessful. A critique of the programme throws some light on reasons for the failure, citing the fact that the MCP was driven through a co-management model as a primary factor. Officials and councillors reportedly perceived this as usurping the functions of the council. In the words of a respondent from the NGO sector, this was perceived as "not so much as a threat, but more that they did not understand what it was aiming to do". Further problems related to lack of support from higher levels of management, who had supported the project initially but when initial funding for the project was lost, support was rapidly dropped.

Despite the fact that MLCs are coming up with more innovative means of tackling cross sectoral issues by involving a range of stakeholders, such as the integrated working groups of one municipality, the extent to which these structures are accessible to the community is uncertain. The accessibility might be more theoretical than real if information concerning these structures is not widely publicised and the nature of the structures excludes those without a high degree of literacy and the right connections.

Identifying and involving opinion leaders
In addition to effective public participation, political buy-in at a sufficiently influential level has been shown to be necessary to support progressive changes in the environment / health field. Thus an official from one of the more proactive local government structures noted the high degree of support from "senior political people in the council who have an environmental background". Where support of progressive environmental management measures is perceived to "boil down to political mileage", local government is felt to be "on the brink of opportunity now". This is apparently not the case for all local government structures in the CMA. In addition to political buy-in from powerful councillors to introduce new ideas, the media was also stated to have a role to play in this regard.

The role of opinion leaders or champions in achieving change in a bureaucratic system prone to inertia became apparent from dialogue with officials and councillors, as well as from observation by researchers. Repeatedly, where progressive local steps had been achieved in the environmental management or environmental health spheres, initiatives had been driven by committed and dynamic individuals. The following quotation highlights one example provided by an official:

"We initially had an environmental ad hoc committee, just a set of councillors, driven by Councillor X. He was a powerful councillor anyway. He was a big driving force, he wanted some environmental management system. So, a lot of this came from him, through his pressure."

The quotation refers to the passing by council of one of the MLCs of an environmental policy, prior to the restructuring of local government in the CMA. It appears that this progressive step was also facilitated through the actions of middle-level officials who were able to cut through red tape and interact with different departments at senior level. Thus opinion leaders are not necessarily in senior positions, but display the ability to interact successfully at all levels of the bureaucracy. Although such champions may play important roles in breaking new ground, when they move on, as was the case for the above example, much of the momentum for the initiative is lost. This highlights the need for systems to be set in place to facilitate vertical and horizontal linkages, rather than achieving these desired interactions through personalities alone.

Developing the capacity of councillors
Councillors too face new challenges, many of which are greater in disadvantaged areas. Additionally, many new councillors are still in the process of coming to terms with council systems, while 'old guard' councillors may be resisting the changes:

" ... now you have a different mixture of councillors in council with different needs. Not only that you also have different councillors having different work loads, because say in an impoverished area, you would have the councillor having to deal, like I have to deal with a crime problem, which is not a council function. To deal with social welfare problems, which is not a council function. People ask me for advice from HP to legal advice which is not the role of a councillor. As in the white community, the rate payers, that councillor interacts with the rate payers, every now and then an odd phone call about dirt not being collected or verges not being cut and so on. So the workload is totally different and diverse, and here you have to be practically on duty for 24 hours a day. So, that is one of the main differences between the work loads that you would have."

Responses concerning community participation and decision making in local government matters and policy making underlined the range of actors involved in policy making around environment and health. The extent to which each plays their role will determine transformation of the current state of community participation, as one respondent noted:

"You know, is it social workers who bring about social change or is it the whole community? The same with the environment, who will bring about that change, attitudes. ... Is it going to be the council officials, is it going to be councillors, is it going to be the community on their own .. ?"

Party politics and systems of governance provide further dimensions of the context within which actors operate, which may have important consequences of varying degrees of predictability for local government policy making. Power relations between political players, as expressed in ‘party politics’, is one of the major factors shaping policy development and implementation. This is particularly true of the Western Cape Province which is the only province in South Africa ruled by a National Party government. City level structures are also split between the two major parties - the National Party (NP) and the African National Congress (ANC) – with ANC councillors generally representing historically disadvantaged areas and NP councillors representing wealthier areas.

Communities and their representatives are therefore just one of a range of actors engaging with a very complex process of decision-making. Their power in this process will probably be dependant on their ability to mobilise support and build coalitions within local government structures. Nevertheless, current efforts by civil servants to facilitate participation may catalyse this process of building strong civil society involvement in environmental health decision-making.

Theme 3.2.D: Indicators as a planning tool
This section explores the extent to which indicators are currently being used in planning environmental and health services and whether they would be useful in promoting dialogue between communities and planners.

Respondents within local authorities 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 MLC health and environmental departments at this time. A number of reasons were given for this. Firstly, the development of community based indicators across the city was seen to be an expensive and labour intensive process which would be difficult to undertake and sustain:

‘We do not have the luxury of being able to develop our own indicators, every single one of us [referring to MLCs], separately, in our own capacity, and then to measure them ourselves’

Another senior planner commented that:

‘We need a metropolitan agreement on what indicators….But if one explores the ‘what indicators’ question at a community level…Does that community have the capacity to sustain the monitoring and measuring programme, does it have the capacity to …analyse the results? And I think we as policy makers must take responsibility for answering the question….Having gone through the monitoring programme at a community level, has it really helped them? They can’t compare with what’s happening in the community next door, and if they can’t compare with what’s happening in other cities around the world…how well are we doing relative to others? That must be as important part of an indicator programme as it is comparing how well we’re doing to how well we did a year ago. And I think with those caveats…before we do that we should get our act together in terms of those indicators which are of collective needs, and on an individual case…one could facilitate individual community monitoring programmes.’

This quote also highlights the second point raised by planners: the difficulty in using community-based indicators to compare performance across areas within an MLC or across the metro area. This point is perhaps indicative of the very different approaches and needs of planners and residents with regard to monitoring. Planners seem particularly concerned with being able to compare performance between areas i.e. has this area improves or worsened in terms of access to a service when compared to adjacent areas? Other studies have shown, however, that residents are concerned not only with relative performance and impact, but also with absolute performance i.e. has the service met local needs and standards? (Stephens et al 1994) For example, knowing that one’s neighbourhood receives 2 hours of water per day, and that the situation is similar in adjacent neighbourhoods, is not necessarily helpful if this two hours of service indicates a deterioration in service delivery over time for that area. This difference reflects not only the different orientation of planners and communities, but also the legal framework within which planning is taking place in South Africa. Local authorities are now legally required to develop Integrated Development Plans (IDP) and Key Performance Indicators (KPIs), designed as an objective measure of implementation, form a part of these plans.

While most planners shared these views, there were some differences of opinion. One senior EHO felt that, while indicator guidelines needed to be developed at the metropolitan level by the CMC, the indicators themselves would need to be area specific. It is possible that this opinion reflects both the understanding that priorities may vary across the city and the anxiety, expressed by a number of senior MLC employees, that the CMC would intervene unduly in their work, in this case through enforcing the use of city-wide set of indicators. The environmental health department of one of the largest MLCs is already developing EHIs for use by its department and hopes to extend this process to other departments within the Health Directorate.

Both councillors and planners agreed on the usefulness of indicators as prompts for municipal action. One planner commented that:

‘If you put them [indicators] into a tool you’d use for overall management on a regular basis, you’re constantly irritating a little thing, you create an awareness just because you are accounting for that’ …..’Only when you have an indicator that you require to report on …publicly in the press, every six months or every year, at your expense…do you have actually have any means of checking if that actually gets done. And then you have to put in place, like the gender development index, something which is easily measured and is measured anyway by somebody else.’

A councillor noted that:

‘Yes, that [community based indicators] would be a better tool, and then people would start understanding how it affects your lives, and once they get involved, the more involved they get the more demands they would make of the local authority. And the more they would see a greater need.’

In this sense, indicators were seen as having the potential to improve dialogue between service providers and communities and, through that process, improve the delivery of services. It is interesting that planners also saw the need for, and were in favour of institutionalising public mechanisms to, monitor their own performance. This may reflect a range of issues including a broader move towards increased transparency within government departments in South Africa; the desire of new local authority (LA) department heads to use KPIs to both monitor and shift the orientation of their departments towards dealing with the needs of underdeveloped areas; the growing understanding that, in future, LA grants from Provincial level may be based on monitored performance and, finally, the desire of new MLCs to show that they are achieving their service goals. Clearly, elected councillors also have a vested interest in a monitoring system which allows them to demonstrate progress in achieving goals but, of course, need to balance that against the possibility of the system showing no progress or, in the worst case, deterioration, which may reflect on their performance as councillors. One respondent commented that he had been asked by the ‘politicians’ to come up with a set of 8 to 10 ‘health for all’ type indicators for the environmental health status of the metropole. It is possible, then, that the selection of the city- or MLC-wide indicators mentioned may be a highly contested process with both councillors and planners trying to ensure that the indicators chosen are those most likely to reflect achievement of their service objectives.

It is also interesting to note that respondents in Urban Planning departments expressed more enthusiasm regarding indicators than those in Health departments. This may reflect both the implementation of the IDP strategy by Urban Planners and, perhaps, Health departments’ poor past experience with indicator development and monitoring.

Although the quality of existing data was not discussed in detail, respondents did raise this issue. One councillor gave the example of health data presented at the monthly meeting of the Amenities and Health Committee of an MLC and commented that, ‘It just doesn’t make sense, and yet it gets given every month in the same format.’ A department head commented that:

‘I’m also worried that too much information is gathered and you don’t do [much] about the actual results of what you get out of the information. That’s what I’m scared of because your staff is getting more and more stretched towards doing more book work than actually seeing to the patients and that is bothering me a bit….’.

In summary, city-wide indicators were seen to be useful as part of a range of mechanisms for monitoring the performance of local authorities and for maintaining accountability to consumers. Planners, while supportive of the concept of community-based indicators, did not generally think that it would be feasible to develop them at this time. Efforts are underway, however, to develop Key Performance Indicators at the MLC level as part of the Integrated Development Planning process.