Health & Place 8 (2002) 251–261

Environmental health challenges in South Africa: policylessons from case studies

E.P. Thomas*, J.R. Seager, A. Mathee

Health and Development Research Group, Medical Research Council, South Africa

Accepted 1 November 2001

Abstract

In South Africa, the challenges of economic growth, job creation and effective service delivery are regarded as key to

the long-term development of the country. The provision of basic environmental health services is acknowledged as an

important factor impacting on the quality of living environments and the health of communities. This paper outlines the

environmental health challenges faced by local authorities in the context of national policy, the wider local government

development framework and the backlog in the provision of basic services. Using South African examples, the paper

concludes with a synopsis of the gaps in policy and delivery drawing on the policy framework of the World Health

Organisation, Health for All in the 21st Century. Many of the insights highlighted are likely to parallel the experiences

in other developing countries.

r 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Environmental health; South Africa; Health for All in the 21st Century; Integrated; Planning; Delivery; Local

Introduction

The aim of this paper is to provide an overview of

environmental health challenges facing South Africa, a

country in transition. The national context of change,

which includes a new focus on development, a redefined

role for local government and an accelerated effort to

address the imbalances and legacy of apartheid, is

outlined. The context within which the environmental

health challenges are discussed is illustrated using

material from a number of case studies. A framework

of the goals of the World Health Organisation’s (WHO)

Health for All in the 21st Century, is used to structure

the discussion. The paper concludes with an assessment

of the effectiveness of policies in the light of the

challenges and indicates gaps, which need to be

addressed.

Methodology

Drawing from a range of experiences in policy,

research and implementation, the paper reflects on the

South African local, provincial and national situation in

terms of the international environmental health context.

The case studies represent work in which the authors

have been directly involved. They include work on

access to basic services (Seager et al., 1999; Genthe et al.,

1997), intra-urban disparity in access to basic services

and health in Port Elizabeth (Thomas et al., 1999;

Seager et al., 1999), the impact of specific pollutants

such as blood lead and asbestos (Mathee et al., 1996;

Mathee et al., 1999; Mathee et al., 2000a) and state of

the environment reports for specific low-income com-

munities, Cato Manor: Durban (Thomas, 2000) and

Alexandra: Johannesburg (Mathee et al., 2000b).

Background

Rooted in the apartheid era, South Africa today faces

the environment and health consequences of poverty

*Corresponding author. Health and Development Research

Group, MRC, Centre for Health Policy, University of

Witwatersrand, PO Box 1038, Johannesburg, South Africa.

E-mail address: ethomas@mrc.ac.za (E.P. Thomas).

1353-8292/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.

PII: S 1 3 5 3 - 8 2 9 2 ( 0 2 ) 0 0 0 0 6 - 0

and inequity. The national population is growing, and a

process of rapid unplanned urbanisation, underway in

recent decades, has given rise to the formation of

sprawling informal settlements on the periphery of cities

and towns. In inner city areas, a shortage of housing has

led to overcrowding, in some instances extreme such as

Hillbrow and Betrams in Johannesburg (Mathee et al.,

1997). In addition, rapid and inadequately managed

industrial development has given rise to industrial

pollution. These forces, together with factors such as

poor economic growth and low levels of scientific

development, have contributed to environmental

pollution, and threats to health, in large parts of the

country.

A national census undertaken in 1996, determined the

population of South Africa to be 40.6 million people,

distributed into just over 9 million households. Fifty-

four percent of the population lived in urban areas.

Eleven percent was under the age of 5 yr. Amongst that

portion of the population aged 20 yr or more, 19% had

no schooling, whilst 6% had a tertiary qualification.

Only 66% of those aged 15–65 yr were economically

active (Statistics South Africa, 1998). In 1995, it was

estimated that 44% of the South African population

were ‘‘poor’’1 (May, 1998). There is a clear urban–rural

divide in terms of poverty. Rural areas house 46% of the

population (Statistics South Africa, 1998) but 75% of

the poor.

It has been useful, in South Africa, to use the

classification of ‘‘traditional’’ and ‘‘modern’’ environ-

mental health hazards. Traditional environmental health

hazards describe environmental risks associated with,

for example, a lack of access to safe shelter, water

supplies, sanitation and waste disposal services, and

indoor air pollution from the use of polluting fuels for

cooking, lighting and space heating. Modern environ-

mental health hazards on the other hand, may emanate

from industrial pollution and vehicular emissions. Some

communities, such as those living in informal settle-

ments located in close proximity to industrial sites,

experience exposure to traditional and modern environ-

mental health hazards simultaneously.

Access to basic environmental health services

Inequities in access to basic environmental health

services are evident by population group and province,

as well as across the urban–rural divide in South Africa.

As can be seen from Table 1, which gives a breakdown

of those living in poverty, those households without

access to basic environmental health services, and basic

health indicators by population group, large proportions

of the population, mainly black, remain without access

to adequate housing and associated environmental

health services.

The disparities across the spatial boundaries of the

nine provinces are strongly correlated with the level of

urbanisation. The majority of the poor live in rural areas

(and in largely rural provinces) and are further

disadvantaged by a lower level of services in these

regions.

Fig. 1 shows the wide diversity in access to basic

services between urban and rural communities.

The higher cost of service provision in rural areas

means that the provision of services is likely to continue

to lag behind that of urban areas. Four out of five poor

households were without piped water at home (80%), no

modern toilets (90%) or electricity (85%) (Friedman,

1999, p. 3). Alongside the disparities in rural areas,

inequities also occur in access to basic services and

health within urban areas. In some urban settings,

especially those with extremely high population density,

environmental health conditions may be worse than in

rural areas. One aspect, which highlights the disparity in

Table 1

Disparity in household poverty, access to basic services and health indicators by population group

African/

Black

Coloured Indian/

Asian

White Total

Percentage living in poverty (1995) 61 38 5 1 50

Percentage living in informal dwellings/shacks 15.3 0.6 0.02 0.05 16

Percentage with neither flush nor chemical toilet 23 12 0 0 18

Percentage with an indoor tap 27 72 97 96 44

Infant mortality ratea 1994 (per 1000) 49 23 9 8 41

TBb rate 1995 (per 100,000) 179 671 69 16 212c

a Infant mortality rate per 1000 live births (1998). Source Health Systems Trust, 1999, p. 401.b Reported cases of TB per 100,000 (1998). Source Health Systems Trust, 1999, p. 401.c 212 per 100,000 in 1996. Source SATCI Survey, reported by Department of Health, Strides and Struggles in TB Control, National

TB Control Programme.

1 ‘Poor ’ refers to the households who were unable to attain a

minimal standard of living measured in terms of basic

consumption needs or the income required to satisfy them.

E.P. Thomas et al. / Health & Place 8 (2002) 251–261252

access to basic services between urban and rural areas

and within urban areas, is that of types of fuel used.

Exposure to air pollution

Electricity is the main fuel used for cooking (around

47% of households in South Africa used electricity in

1996) with a further 23% and 22%, respectively using

mainly wood and paraffin for cooking purposes, as

shown in Fig. 2 (Statistics South Africa, 1998). Access to

energy for cooking is highly differentiated by race with

98% whites and 42% of Africans using electricity as the

main fuel for cooking. The use of solid, and to a lesser

extent liquid fuels, indoors, has been shown to

contribute to elevated levels of indoor air pollution,

and respiratory ill health. The risk of burns and

poisoning, especially amongst young children is also

associated with these fuel use patterns.

With contributions from industry, vehicular emissions

and domestic fuel use, ambient urban air pollution has

been of increasing co ncern in South African cities. For

example, in certain parts of Johannesburg, ambient

levels of suspended particulate matter were as high as

150 and 50mg/m3 during the winter and summer,

respectively of 1999 (Annegarn and Sithole, 1999). The

winter level is well in excess of both WHO and South

African particulate guidelines. Levels of nitrogen diox-

ide and ozone, associated with photochemical smog,

have also been increasing steadily in Johannesburg, and

are expected to regularly exceed international guidelines

by 2005 (Johannesburg City Council, 1993/4). Of

particular concern is the finding by the United Nations

Environment Programme (UNEP) that air quality

management capabilities in Johannesburg are limited

(UNEP/WHO, 1996).

Exposure to elevated levels of lead has been associated

with a wide range of detrimental health effects, especially

amongst young children (Needleman and Bellinger,

1994). These include damage to soft organs such as the

heart, liver and lungs, anaemia, deficits in intelligence

quotients, hyperactivity, and shortened concentration

spans. Studies undertaken in Cape Town and Johannes-

burg have shown that large proportions of children may

have elevated levels of lead in their blood (von Schirnding

et al., 1991a; Mathee, 1996). In certain parts of Cape

Town and Johannesburg around 90% and 80%, respec-

tively, of children had blood lead levels, which exceeded

the international guideline of 10mg/dl. Lead in petrol, and

in paint peeling from older housing, have been identified

amongst a range of risk factors for raised childhood

blood lead levels (Von Schirnding et al., 1991b).

In terms of industrial pollution, poorly managed

industrial processes have led, for example, to increased

exposure to asbestos in a number of South African

asbestos mining towns, associated with an increased

incidence of asbestos-related diseases such as TB and

asbestosis. In addition, concern has been expressed about

the potential for community exposure to asbestos from

degrading low-cost housing projects (Mathee, 2000b).

Environmental health status at the city level

The City of Port Elizabeth may be considered a

microcosm of environmental health status inequity in

South Africa. As indicated in Table 2, which gives

household access to services by wealth category in Port

Elizabeth, the poor have the worst service coverage and

experience a higher exposure to a range of environ-

mental health hazards in the living environment. The

study by Thomas et al. (1999) shows, amongst children

under the age of 6 yr, an inverse correlation between

acute respiratory infection (ARI) symptoms (two week

recall period) and wealth category (p ¼ 0:017). Similarly,

children living in overcrowded conditions were more

Fig. 1. Household access to services in urban and rural areas,

1995. Source: HST Rural/Urban Inequity, Equity Report.

http://hst.org.za/hlink/equity.asp.

0

5

10

15

20

25

30

35

40

45

50

Electricity Wood Paraffin Coal Other

TYPE OF FUEL

% o

f H

OU

SE

HO

LD

S

Fig. 2. Fuel used for cooking in South Africa (1996). Source:

Statistics South Africa (1998).

E.P. Thomas et al. / Health & Place 8 (2002) 251–261 253

likely to suffer from ARI symptoms than those living in

less crowded conditions (p ¼ 0:001). Sharing a tap

(p ¼ 0:032) or a toilet (p ¼ 0:049) predisposed house-

holds to elevated levels of diarrhoea. The study also

found that children reliant on communal water sources

were additionally exposed to a number of environmental

risks, morbidity and mortality from water-related

diseases (Thomas et al., 1999, p. 65). The disadvantages

of not having a standpipe close to home were found to

be borne mainly by women and girl children who were,

mainly responsible for the task of collecting water from

communal standpipes. This highlights the need for

gender-sensitive development policies.

The above review highlights the wide disparity in

living conditions between rich and poor, between

population groups, within urban areas and between

urban and rural areas. Addressing these disparities is a

national priority and is core to the environmental health

challenges facing the country.

Environmental health challenges in South Africa

Delivery of basic2 environmental health services

Considerable progress has been made in delivery of

basic environmental health services in South Africa. For

example, a piped water supply has been provided to 3.5

million people in the period of 1994–1999 (South

African Institute of Race Relations (SAIRR), 2000, p.

149) and in recent years, Eskom, the South African

electricity utility company has been providing electricity

to around 450,000 dwellings each year. The Department

of Housing has provided subsidies, which have led to

over one million new formal dwellings being built in the

past 6 yr. However, in light of the shortfall to start with,

as well as the cost of major service delivery programmes,

much work remains to be done to ensure the provision

of basic services to all. Estimates near the end of 1999

were that 7.5 million people (19%) had no access to

running water and 21 million people (52%) had no

sanitation (South African Institute of Race Relations,

2000). The housing shortage was estimated to be 2.1

million units at the end of June 1998 (South African

Institute of Race Relations, 2000). The cholera epi-

demic, which initially mainly affected Kwa Zulu Natal

during 2000, has spread to other parts of the country,

underscoring the importance of adequate basic environ-

mental health services. In addition, the provision of

readily accessible safe water supplies as well as safe

sanitation becomes especially important with an increas-

ing proportion of people living in South Africa who will

be immuno-compromised due to the Human Immuno-

deficiency Virus (HIV). Estimates from the end of 2000

are that one in nine South Africans are infected with

HIV, constituting 12% of the total population (4.7

million people infected) and 24.5% of all pregnant

women attending public ante natal clinics (Department

of Health, 2001).3

Lack of integrated development linking health with

development

With political demand for accelerated service delivery,

as well as cost considerations, opportunities may have

been missed to ensure that the planning, design and

implementation phases of service delivery optimize

health gains. Housing policy has failed to prescribe

minimum building standards for health. For example, in

some housing projects, consideration has not been given

to the use of air bricks to promote ventilation, damp

proofing, or careful orientation of dwellings to maximize

energy efficiency.

Table 2

Distribution of a selection of socio-environmental factors by wealth category in Port Elizabeth

Proportion of households in each wealth group which

experience the following conditions:

Level of wealtha

Low Lower

middle

Middle Upper

middle

High

Head of household has tertiary education (%) 1 2 5 11 18

Access to piped water indoors (%) 11 27 57 82 98

Indoor toilet (%) 13 19 38 72 97

Rats/mice seen during past 24 h (%) 55 46 22 10 1

Electricity used for cooking (%) 19 36 84 94 100

Dampness in the home (%) 75 71 44 29 16

Problem with outdoor air pollution (%) 85 70 54 33 18

Own the land they live on (%) 33 40 65 69 89

2 ‘‘Basic services’’ refer to access to water, sanitation, energy

and housing as prerequisites for urban living.

3 The situation is particularly severe in South Africa due to

the unaffordability of anti-retrieval drugs to those infected.

E.P. Thomas et al. / Health & Place 8 (2002) 251–261254

In respect of communal water supply schemes in

certain areas, soak-away facilities have not been

installed, with the potential for elevated transmission

of disease associated with pools of stagnant water. Users

are also not always educated in the safe handling,

storage and disposal of water, despite evidence from

several quarters of rapid deterioration of water quality

between the supply point and end use (Thomas et al.,

1999; Genthe et al., 1997). While water supplies are

regularly tested for contamination in urban areas, in

some cities those involved in the testing concentrate on

the quality of the water in the pipes rather than the

quality of the water actually consumed by the end user.

A study in Port Elizabeth found that an important issue

in informal areas was the deterioration of the water

between the standpipe and the drinking cup, presumably

due to unhygienic water collection points and the further

deterioration of water quality during storage (Seager

et al., 1999; Thomas et al., 1999) The quality of the

water supplied was generally good, with about 99% of

routine samples from sterilised taps conforming to

national water quality guidelines. However, the samples

from unsterilised taps, containers and cups showed

extensive contamination. In general, water samples

collected from the tap were much cleaner than those

from containers and cups. The two highest levels of

contamination found were, according to the national

water quality guidelines (Anon., 1998), likely to cause

‘‘clinical infections, even with once-off consumption’’,

and ‘‘serious health effects in all users’’, respectively.

Contrary to expectations, there were numerous samples

from fully serviced areas, which had high levels of

contamination as well, indicating a need for health and

hygiene promotion in addition to the mere provision of

infrastructure (Seager et al., 1999).

Ongoing local government transformation

The legacy of apartheid necessitated major restructur-

ing of local government. A three-phase transition was

implemented in 1993. The December 2000 local govern-

ment elections paved the way for the final stage of

implementation of the new system. The transition has

involved the revision of the local government powers

and functions, the approach to local governance as well

as the re-demarcation of boundaries. The main differ-

ence is that of approach, where local government is

required to play a stronger developmental role in

achieving equity. New functions include local economic

development, co-ordination, facilitating community

participation in decision-making and integrated devel-

opment planning.

Revised boundary demarcations have resulted in a

major reduction in the number of local municipalities

across the country with the establishment of 284 new

local ‘wall-to-wall’ municipalities with many urban areas

and rural areas being combined. The rationale was

designed to improve service delivery, by increasing cost

efficiency and allowing cost sharing between rich and

poor areas. There has also been a major thrust to

eliminate the duplication and fragmentation of service

delivery characteristic of the Apartheid era. The

implications of the re-demarcation of boundaries for

health service provision are complex (Barron, 2000, p. 2)

and far-reaching. Examples include the reallocation of

functions between primary and tertiary health facilities,

cross subsidisation between central and local govern-

ment and the implementation of the district health

system.

Lack of an integrated approach to local level health

services

The ongoing local government transformation, which

has occurred since 1994, has impacted on the imple-

mentation of an integrated approach to primary health

care. A lack of clarity regarding the policy of who

should be providing what (health) services at a local

level, the mismatch of the boundaries between the health

districts and local municipalities, as well as the

fragmentation of services, are some of the problems,

which have been experienced. The new local government

structures were being set up during 2001. Environmental

health services will constitute a core component of the

district health team although they are currently located

at municipal offices.

The provision of environmental health services by

Environmental Health Officers

Environmental Health Officers (EHOs) are seen as the

main cadre of professionals responsible for environ-

mental health in South Africa, and are appointed mainly

at the level of local government. The scope of practice of

EHOs relates to, for example, water supplies, waste-

water management, waste management, land pollution,

food hygiene and safety, air quality, noise, environ-

mental impact assessment, research and surveillance,

disease outbreaks, and injury prevention. Amongst the

human resource challenges having an impact on

optimisation of environmental health status in South

Africa, are included an acknowledged shortage of EHOs

in the country (pers. Com. Mr T Pule, Department of

Health), the lack of an appropriate environmental

health policy and strategy for action, the lack of sound

information for priority setting and planning, the

absence of a suitable set of environment and health

indicators, and the lack of an appropriate performance

indicator system.

There is a shortage of EHOs country-wide, with only

around half the national ideal EHOs: population ratio

of 1:10,000 currently being in place. EHOs are also

E.P. Thomas et al. / Health & Place 8 (2002) 251–261 255

inequitably distributed in relation to prevailing environ-

mental health challenges. For example, the lowest levels

of coverage occur in the North West and Eastern Cape

provinces, where the most pressing environmental health

challenges also occur. Key settings, for example rural

areas, informal and squatter settlements, urban black

townships and inner city areas are also well known to be

under-provided with EHOs. For example, the EHO:

population ratio in Cato Manor, Durban, a major urban

area of informal settlements and new low-income

development, was found to be approximately 1:50,000

(Thomas, 2000). There is a recognised need to re-

orient the training curricula of EHOs, long designed to

address the concerns mainly of the white minority, to

suit current priorities and emerging concerns in the

country.

Importance and difficulty of sustaining inter-sectoral

initiatives

In many parts of the world, the importance of inter-

sectoral collaboration for environment and health has

been recognised, but progress has been slow (WHO,

1997). At a time of rapid change in South Africa,

opportunities to maximise benefits for the environment

and health have been heightened, but simultaneously,

inter-sectoral collaboration has been particularly chal-

lenging to achieve success. In many respects, at the

national level, the opportunity for the environmental

health sector to guide the development of policies, and

provide guidelines in relation to, water supply, housing

delivery, sanitation, energy and township planning, have

in part, been missed. Similarly, at the local level, there is

a particular need to develop appropriate mechanisms for

environmental health input into priority setting and

planning of living and working conditions, to ensure

health promotion and protection against ill health and

injury. Many of the reasons for the lack of progress on

inter-sectoral collaboration between the environmental

health and other sectors are discussed elsewhere in this

paper (sections 4.2–4.5), and relate to, for example,

inadequate training of EHOs, insufficient personnel,

rapid and extensive change in the policy and manage-

ment arenas and the sectoral nature of departments.

This problem is further compounded by the narrow

discipline-focus of built environment development pro-

fessionals (such as engineers, planners and housing

specialists) based on a limited understanding of the

linkages between a range of development issues and

health.

Various initiatives have been established which

endeavour to promote inter-sectoral action around

health and development. Two of these are the World

Health Organisation’s Healthy Cities project and the

Local Agenda 21 programme, which is a local imple-

mentation framework for sustainable development,

which arose out of the Rio Earth Summit in 1992. In

development work, stakeholders frequently accept the

importance of inter-sectoral co-operation but existing

structures often make this co-operation difficult. In

many cases, particular departments are legally con-

strained in terms of which areas they may address and

therefore substantial changes in the way local authorities

operate may be necessary for effective inter-sectoral

action to be possible. In developed countries, there are

more than a 1000 Healthy Cities projects, some of which

have been operating for over 10 yr (Dooris, 1999). These

provide a model for inter-sectoral collaboration around

the common good of health.

Lack of environment and health data

As experienced in other countries, there is often a lack

of suitable data at appropriate levels of aggregation for

policy making. Research studies usually generate issue

and settlement specific data. Few comprehensive studies

have been undertaken which highlight the linkages

between environmental hazards and health outcomes

although there are a number of issue-focussed studies

(Genthe, 1997; Mathee, 2000a; Von Schirnding,

1991a, b; Terblanche et al., 1992). Data highlighting

health and environment variations within cities is

seldom available. The data presented often ‘‘describes

health and environment problems in broad, integrated

ways, with little reference for example, to environment

and health problems among high risk groups, or

marginalised groups’’ (Von Schirnding, 1999, p. 61).

An exception is the Household Environment, Health

and Wealth study undertaken in Port Elizabeth by

Thomas et al. (1999), which highlights variations in

intra-urban living conditions, wealth and health differ-

ences and priorities for intervention. Unfortunately this

level of detailed data is seldom obtainable. Three recent

reviews of environment and health issues in Johannes-

burg and Durban (Mathee, 2000a; Thomas, 2000;

Mathee and Rohman, 1997) highlight the paucity of

environment and health data available for assessing the

spectrum and severity of environment health risks. The

studies were all carried out in urban areas, two of which

are the focus of considerable upgrading and develop-

ment investment. Despite the massive infrastructure

investment, health and environmental data had not been

collected in any comprehensive way to inform the

development policies and process. The lack of data

being collected on a regular basis in these high

profile areas suggests a dearth of environment and

health linked data in most settlements countrywide. The

Department of Health collects and publishes noticeable

disease information, but the data is ‘‘disease’’ focussed

rather than linked to it socio-economic and spatial

contexts.

E.P. Thomas et al. / Health & Place 8 (2002) 251–261256

Summary of environmental health challenges in

South Africa

The overview highlights the great disparity in access

to basic services between groups, within cities, across

urban and rural areas and between provinces. Both

poverty and socio-economic driving forces underpin the

disparities. The restructuring process of local govern-

ment during the 1990s has undermined the attempts to

address the health and development linkages as well as

limited the response of the environmental health cadre

to the challenges. A lack of data linking health and

development issues further limits the extent to which the

linkages can be highlighted. There is a need to ensure

that development policy and services implemented are

health promoting, especially for vulnerable groups.

Development professionals are sometimes inadequately

informed about the health impacts and links between

health and development issues. As a result, these issues

are not adequately addressed in development policies.

There is a need for policies to be informed by research

that highlights the linkages between environment and

health. Integrated approaches to health and environ-

ment issues are required at a local level. Ongoing efforts

to promote inter-sectoral action are needed. There is a

new opportunity with refocused developmental local

government now in place.

Given the difficulty being experienced in South

Africa in responding to the scale and range of

environmental health challenges, it is appropriate to

review and assess the international and local policy

responses.

International policy responses to environmental health

concerns

In reflecting on the progress made in the 5 yr after the

Rio Earth Summit, the then Director General of the

WHO, Nakajima noted that: ‘‘The basic human need for

a safe environmentFone which provides clean water,

and adequate food and shelter, and in which different

people can live together in peaceFis the same for all of

usy . The dreams and aspirations of a healthy future

for the next generation can be accomplished only if we

use our current knowledge wisely and take action in

solidarity’’ (Nakajima,1997).

The WHO has recently committed itself to the Health

for All in the 21st century policy recognizing the

principle of the enjoyment of highest attainable standard

of health as one of the fundamental rights of every

human being (WHO, 1998a). The Health for All in the

21st century policy was informed by a series of major

world conferences held in the 1990s. One of the first, the

Rio Conference (1992) resulted in recognition by world

leaders of the importance of people’s health and

environment as a precondition for sustainable develop-

ment (WHO, 1998b). Some of the initiatives arising

from these discussions include:

* Local Agenda 21 initiatives that have been launched

incorporating inter-sectoral committees for national

planning and follow up.* National Environmental Health Action Plans (NE-

HAP) which have been formed and adopted by

various countries in response to the Helsinki con-

ference on Environment and Health in 1994, while in

other regions, environment and health considerations

have been taken forward through health planning,

regional planning, political commitments, etc.* Healthy Cities Movement of WHO.* Sustainable Cities Movement of UNCHS.* Model Communities Programme of the International

Council for Local Environmental Initiatives (Von

Schirnding, 1999b).

The priorities for a new development agenda, which

supports the attainment of Health for All, were

informed by the priorities which emerged from the

series of development related conferences held during

the 1990s. Some of these principles that relate to

environmental health include:

* Development should be centred on human beings.* Central goals of development include the eradication

of poverty, the fulfillment of the basic needs of all

people and the protection of human rights.* Investments in health, education and training are

critical to the development of human resources.* The improvement of the status of women, including

their empowerment, is central to all efforts to reach

sustainable development in all of its economic, social

and environmental dimensions.* Diversion of resources away from social priorities

should be avoided (WHO, 1998b).

The Health for All in the 21st Century framework

makes explicit three goals. These are:

* An increase in the life expectancy and improvement

in the quality of life for all.* Improved equity in health between and within

countries.* Access for all to sustainable health systems and

services (WHO, 1998b).

Two policy objectives are highlighted as needing

to be realised for the Health for All goals to be met.

These are:

* Making health central to human development and* Developing sustainable health systems to meet the

needs of people (WHO, 1998b).

E.P. Thomas et al. / Health & Place 8 (2002) 251–261 257

In terms of Health for All in the 21st Century, the

central role of health in development is based on an

understanding that ‘good health is both a resource for,

and an aim of development’ and that the health of

people is an indicator of the soundness of development

policies (WHO, 1998b). Community participation in

policy development is also considered, inter alia, a

component of a sustainable health system.

Health for All in the 21st Century policy proposes a

series of actions needed to make health central to

development. These are described as aiming to combat

poverty, promote health in all settings, align sectoral

policies for health and include health planning in

sustainable development (WHO, 1998b). While not

encompassing all the actions, environmental health falls

clearly in the interface between health and development

and is therefore critical to the goal of ‘‘making health

central to human development.’’ The policy recognises

that achieving rights and Health for All is a process

rather than being an endpoint as the goals and

challenges are enormous.

The South African environment and health policy is

now reviewed.

African and South African environment and health policy

initiatives

The South African Constitution, adopted in 1996

contains within it a Bill of Rights, including specific

mention of health and environmental rights. The Bill of

Rights states that ‘yeveryone has the right to an

environment that is not harmful to their health or well

being,4 and to have the environment protectedy‘The

health section states that everyone has the right of access

to health care services, sufficient food and water, and

inter alia that the state must take reasonable legislative

and other measures, within its available resources to

achieve the progressive realization of these rights.5 A

range of policies, guided by the principles in the

Reconstruction and Development Program (African

National Congress, 1994) have been developed in post-

apartheid South Africa to enable the meeting of the

above rights. Many policies impact directly and or

indirectly on environmental health. These include

policies which deal with access to basic services, (water,

sanitation, housing, pollution, waste services), and local

government restructuring, (primary health care, district

health, etc.). The White paper on Transformation of the

Health System in South Africa (Department of Health,

1997) identifies primary health care as the means of

providing caring and effective services to promote and

monitor the health of all the people in South Africa.

Environmental health is seen as part of the primary care

package and leading from the White Paper, its vision is

to create ‘‘A sustainably healthy and safe environment

for all South Africans [in which] to live, work and

recreate.’’ (Department of Health, undated). Specific

environmental health conceptual frameworks and ap-

proaches used in South Africa are outlined below.

Pretoria declaration on health and environment

in Africa

In Southern Africa, one of the responses to the

challenges of health and environment post the Rio

Conference, was the adoption of the Pretoria Declara-

tion of Health and Environment in Africa. This took

place in September 1997 at the International Conference

on Health and Environment in Africa in Pretoria

(Thomas, 1997). The Conference proposed that an

African Charter on Health and Environment be adopted

by an African conference of Ministers of Health,

Environment and other sectors. Since the conference,

the WHO has given the declaration of its support and

circulated copies to African countries.6

In South Africa, the Pretoria declaration has provided

the framework for environmental health policy and

action. While the declaration provides the broad

principles, such as participatory approaches, inter-

sectoral action, partnerships, sharing of best practice,

etc. in terms of which the Environmental Health

Directorate of the National Department of Health is

working, a more specific document has been prepared.

The draft South African Environmental Implementation

Strategy for 2000–2004 has been given in principle

approval as an interim policy document and is currently

being reviewed regarding its resource implications (see

footnote 4).

WHO-AFRO healthy cities initiative

Although the WHO healthy cities movement has been

widely implemented elsewhere, the African Region has

lagged behind, with formal adoption of the programme

only just getting started in many countries. There are,

however, several established Healthy Cities projects,

including Johannesburg and Cape Town, in the region.

The WHO African Region now subscribes to the

views of the WHO Global Management Development

Committee but recognises the fact that the structured

programme has to be implemented somewhat differently

in the Region due to the unique characteristic of the

African setting. Healthy Cities are thus perceived not as4 Environmental Rights in South Africa are set out in Section

24 of the SA Constitution and the health rights in Section 25.5 Environmental Rights in South Africa are set out in Section

24 of the SA Constitution and the health rights in Section 25.

6 Mr T Pule, Department of Health, pers. commun., January

2001.

E.P. Thomas et al. / Health & Place 8 (2002) 251–261258

ends in themselves but as processes involving specific

sets of actions that any city can undertake to achieve

healthy living conditions.

The WHO Regional Office for Africa has decided to

systematically promote the healthy cities concept and

included four healthy cities workshops in its 1998–1999

Programme Budget. All the 46 countries of the WHO

African Region are actively reorganising and preparing

healthy cities plans of action.

Inter-sectoral action in South Africa

Several South African cities have initiated inter-

sectoral health-related initiatives. These include Healthy

Cities projects, (Cape Town and Johannesburg) and

Local Agenda 21 (Durban and Cape Town) initiatives.

State of the Environment Reports have also been

prepared for the Eastern Metropolitan Sub-Structure

(Johannesburg), Alexandra (Johannesburg) and Cato

Manor (Durban), in which the inter-sectoral linkages are

highlighted. The experience of the authors is that inter-

sectoral initiatives are focussed in major centres and are

often difficult to sustain.

Integrated development planning

Each local authority is required in terms of legislation

to prepare an integrated development plan (IDP) ‘‘which

links, integrates and co-ordinates plans for the develop-

ment of the municipality; aligns the resources and

capacity of the municipality for the implementation of

the plan; forms the policy on which annual budgets must

be based; and inter alia is compatible with national and

provincial development planning requirements binding

on the municipality in terms of legislation.’’7 All the 284

new local councils will be required to prepare IDPs

during 2001. The Integrated Development Planning

process provides an ideal opportunity for health issues

to be raised and addressed in an integrated way in plans,

resource allocation and budgets.

Environmental health research to inform policy

The Medical Research Council identified Health and

Development as one of its priority research thrusts some

years ago and has recently established a Health and

Development Research Group, which includes environ-

mental health, multi disciplinary and inter-sectoral

approaches. The WHO Collaborating Centre for Urban

Health, a partnership involving the MRC, University of

the Witwatersrand and the Johannesburg Metropolitan

Council, also conducts research and provides training in

urban environmental health and development. Some of

the Technikons8 have also begun to promote integrated

health and development training and raised research

funds from international agencies.

Discussion

The Health for All9 policy framework provides goals

(WHO, 1998b, p. 26), objectives and actions. The

realisation of the goals and objectives is sought through

a series of actions. This section will assess the ways in

which the approach being taken to environmental health

issues in South Africa compares with that put forward in

the Health for All policy. As with all goals, the Health

for All goals provide the broad-brush approach to be

followed and do not set targets.

A key component of the policy is contained in one of

the objectives of Health for All that, with its associated

actions will be used for the purposes of analysis. The key

policy objective relating to environmental health is:

‘‘making health central to human development’’ (WHO,

1998b, p. 33). Four actions needed to ‘make health

central to development’ are described in the policy.

These are: aiming to combat poverty; promote health in

all settings; align sectoral policies for health and include

health planning in sustainable development. Each will be

considered in turn in relation to the extent to which

‘‘making health central to development’’, the Health for

All objective, has been achieved in South Africa.

* Aiming to combat poverty

Addressing underlying socio-economic injustice and

access to basic services is a critical area but this needs to

go beyond the mere description of the injustices to

addressing them. The South African Constitution sets

out the environmental and health rights and there are a

number of extensive initiatives aimed at addressing

both economic poverty as well as the inequitable

access to basic services. Nevertheless, in view of the

enormous backlogs inherited by the democratic govern-

ment in 1994 and the high levels of unemployment,

there is a long way to go in addressing basic needs.

Combating poverty will need to remain a central

activity in the future especially due to the anticipated

severe impact of HIV/AIDS on poor household’s

resources.

* Promotion of health in all settings including aligning

sectoral policies for health

Health for All highlights the importance of policies

for all sectors that directly or indirectly affect health

7 South African Municipal Systems Act 2000 (Section 23).

8 Technical tertiary educational colleges.9 ‘Health for All’ hereafter refers to the Health for All in the

Twenty First Century WHO policy.

E.P. Thomas et al. / Health & Place 8 (2002) 251–261 259

needs to be analysed and aligned to maximize opportu-

nities for health promotion and protection. This extends

to the importance of multidisciplinary research being

undertaken to identify new opportunities for health

promotion and protection through inter-sectoral action.

The Pretoria Declaration endorses this approach in its

framework but there has been minimal national

guidance or strategy to support the principle. The

inter-sectoral activities under the auspices of Agenda

21 and the Healthy Cities programme remain limited to

major urban areas only. While there is an increasing

range of activities being undertaken by the MRC’s

Health and Development programme to focus attention

on the health aspects/implications of development

policy, there is little research and policy expertise in

the country bringing together the health and develop-

ment sectors.10 There is an important role for health-

sensitive development actors to play in the policy

formation process at all levels of government and to

pioneer the debate around the moral, political and

economic arguments for improved infrastructure (San-

ders et al., 1996). The integrated development planning

process provides an ideal opportunity for health and

development issues to be addressed at a local level.

* Including health planning for sustainable develop-

ment

Health for All suggests that health considerations

need to receive the highest priority in sustainable

development plans. Health professionals are seen as

being important players in making sure that the links

between the health and other sectors are made. Further,

the introduction of health indicators is seen as being an

important contribution to improve decision making in

Environmental Impact Assessments. Although this is

important, it is a new and growing field and in the

development phase. Work by Lerer (1999), on Health

Impact Assessment (Lerer, 1999), suggests appropriate

methodologies to take this forward. In addition, the

new Integrated Development Plans, the preparation of

which is a legal requirement for all local authorities,

makes provision for wide public consultation to identify

key issues to be addressed. It is anticipated that District

Health Officials will also play a role in making sure that

health issues are integrated into the planning and

budgeting process at a local authority level.

The above brief analysis has shown that there are

some gaps in the way in which health and development

is linked in South Africa that will need to be addressed.

Some of the issues raised in the Health for All analysis

highlight the need for more concerted action regarding

implementation of basic services and in addressing the

underlying poverty. In addition, further policy and

planning-linked inter-sectoral understanding is needed

to promote development policies that are in fact health

promoting.

Conclusion

The South African Constitution provides an en-

trenched commitment to wide reaching environment

and health rights. Poverty, an economic injustice, is a

major factor impacting on the health of the nation and

must be addressed. The large proportion of the South

African population with inadequate access to basic

services provides a major challenge to those responsible

for the delivery of these services. Policy makers and

decision-makers must be kept aware of the health

rationale and importance of basic service delivery. The

Health for All policy framework focuses on the

importance of ‘‘making health central to human

development.’’ This objective and its concomitant

actions highlight the need for South African policy to

promote inter-sectoral action and consider health in its

broader developmental context. These insights are also

of relevance in other developing country contexts. The

new refocused developmental local government in South

Africa, with a strong emphasis on local level integrated

planning, provides an opportunity for meeting the

challenge of Health for All.

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