Health Systems Research Unit
Objectives and Methods
Linking
health and environment in Cape Town, South Africa: The view
from local government, July 1998
Aims and objectives
of the study
The process of restructuring local
government and developing and implementing new policies within Cape Town creates
an opportunity both to examine the process of policy reform at local government
level and to gather data which will inform that process. Walt et al (1994
p366) have argued that, historically, health policy has been focused on ‘…the
technical features of policy content, rather than with the processes of putting
policy into effect. As a result policy changes have often been implemented
ineffectively and expected policy outcomes have not been achieved. Policy
analysis cannot continue to ignore the how of policy reform.’
[italics in original] This criticism is certainly true of health and environmental
policy development in South Africa. While much attention has been paid to
technical aspects such as monitoring mechanisms for water quality or the composition
of the district health team, far less attention has been paid to identifying
effective interventions and to examining barriers to policy development and
implementation.
This study aimed, therefore, to
explore and map the development of local government policies in Cape Town,
focusing on the interface between environment and health policies. The objectives
of the study were as follows:
- 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 the policy.
- to examine how management structures and the
culture of the organisations involved impacts on policy making.
- to assess the extent to which the environmental
policy sets 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. While the Indian arm of the study focused on the development
and piloting of community based indicators, this study focused on understanding
existing relations between planners and community representatives and between
planners in different local government departments. The study therefore gathered
information on the ‘how’ of policy reform with the specific purpose
of informing future initiatives to improve dialogue between stakeholders and
the more general purpose of identifying constraints and opportunities for
policy development and implementation within the city.
Methods
The study used a range of qualitative
methods to gather and analyse data on the policy process within the environment
and health sectors of local government in Cape Town. This approach facilitated
examination of the complexity of the policy context, the actors involved,
the content of policies and the impact of these factors on the policy process.
For primary data collection, in-depth
semi-structured interviews were undertaken with policy actors, either individually
or with two to three respondents within the same department. Purposive sampling
was used to select respondents representing the major stakeholders within
policy-making (Guba et al 1989). Within local government these included Directors
(or senior representatives) of health, environment, environmental health and
urban planning departments of the CMC and the MLCs (11 interviews; 20 respondents)
and elected councillors (4 interviews; 4 respondents). Senior decision makers
within the Provincial Administration of the Western Cape (3 interviews) and
health and environment oriented NGOs (2 interviews) were also included. Finally
interviews were conducted with 2 environmental health officers working in
a low-income peri-urban community within Cape Town. The interview schedule
for local government civil servants and councillors is included as Appendix
1.
Where possible, and with the interviewees’
consent, the interviews were taped and then transcribed. Several interviews
could not be taped due to technical problems, and were reconstructed from
detailed notes taken during interview. Briefer telephonic interviews were
also undertaken with a number of respondents and recorded as detailed notes.
Non-participant observation of official
local government meetings, including sittings of the Cape Metropolitan Council
and subcommittees of the Council, was undertaken to assist in developing a
more complete picture of decision making. Particular attention was paid in
these observations to the relationships and communication between civil servants,
elected councillors and members of the public; the manner in which conflicts
were resolved and decisions taken in these fora, including the input of different
stakeholders into decision-making; agenda setting for the meetings and the
impact of management structures and organisational culture on policy making.
Discussions and observations were recorded as notes and supplemented by the
agendas and minutes of the meetings. Key documents relating to ongoing policy
processes within local government were also reviewed, including the development
strategy for the Cape Town Environmental Plan (Environmental Evaluation Unit
1997); the concept document for the Cape Town Healthy Cities Project (Working
Together for Health 1997) and relevant legislation or pending legislation
in the form of green and white papers.
Finally, the preliminary results
of the analysis were fedback to the respondents and other stakeholders through
a workshop. Respondents were asked to comment on the findings and the following
questions, identified during analysis, were discussed:
Data analysis was undertaken concurrent
with data collection to ensure that gaps in understanding could be followed
up with additional data collection. Notes and interview texts were content
analysed using open coding (Strauss et al 1990) to generate units of meaning
which were then labelled and categorised. Triangulation was used to enhance
validity. This included the involvement of researchers from a range of content
and theoretical backgrounds in the study team; the use of different research
methods and techniques, including in-depth interviews, non-participant observation
etc; and data collection from a number of different sources (Denzin [1978]
as quoted in Smaling 1992). The main themes were summarised and illustrated
with direct quotes from the interviews and field notes.
Limitations
There are a number of limitations
to the methods used in this study. Firstly, the study focused on eliciting
the views of officials within local government environment and health departments
and did not investigate the opinions of respondents in civil society (NGOs,
CBOs) or in other government departments, such as engineering services or
water affairs, in any depth. This was done in order to develop an in-depth
understanding of policy making processes within local environment and health
departments, as perceived by officials working within them. Secondly, the
study looked very broadly at the policy process within these sectors rather
than elaborating a case-study of the development and implementation of a specific
policy. While this may have restricted the extent to which the study was able
to focus, it also allowed for a very wide understanding of policy making in
the context of restructuring to be constructed. Finally, this study used a
cross-sectional approach rather than following the policy process over time.
The methods therefore relied on the recall of respondents regarding past events,
and this was taken into account during data analysis.
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