Developments in
Environmental
Health
10
Authors:
Mike Agenbagi
Thuthula Balfour-Kaipaii
Abstract
The importance of environmental health services in Primary Health Care and
health services in general, will be highlighted in this chapter. Outlined will be the
developments in environmental health services since 1978, including the impact
of various new pieces of legislation, such as the National Health Act. Challenges
with the devolution of environmental health services to metropolitan and district
municipalities are explored. An assessment of some of the main environmental health
components such as water, sanitation, food and malaria is provided. Furthermore,
the critical issue of human resources for environmental health will be discussed, and
recommendations are made for stronger support to be provided for the delivery of
environmental health services, especially by district municipalities.
i Ukhahlamba District Municipality
ii Development Bank of Southern Africa
149
Introduction
Environmental health is a critical and integral part of Primary
It encompasses the assessment and control of those
Health Care (PHC), as it contributes to the promotion of
environmental factors that can potentially affect health”.3
wellness and prevention of disease, primarily by controlling
environmental factors that negatively impact on health.
Investments in the control of hazardous environmental
factors, through environmental health, can lead to a
reduction in the burden of disease.
Globally, environmental health issues have evolved over time
to encompass a more holistic approach, as reflected in the
Report of the WHO Commission on Health and Environment.4
Sustainable development took centre stage and the effects
of environmental degradation, due to human activity, were
In 1999, the South African Health Review described South
included on the agenda as important contributors to poor
Africa as following a path addressing both ‘traditional’ and
health.
‘modern’ environmental health issues, due to the history of
the country that created two worlds.1 Since then, additional
issues regarding sustainability of the modern environment,
such as urbanisation, climate change and food insecurity
have gained prominence. South Africa needs to move
swiftly to address some of the outstanding ‘traditional’
environmental health issues, such as inappropriate and
insufficient sanitation, water, waste management, housing
and food quality. These issues may be neglected because
of international interest, with developed countries pushing
hard for action around long-term, emerging environmental
issues (e.g. climate change) and these dominating global
agendas.
A key development since 2004 was the policy of devolution
of most environmental health services to metropolitan
and district municipalities. This was done in terms of the
National Health Act (Act 61 of 2003), as part of a district
health system that provides uniform, equitable and
accessible health services.2 The legal, financial and staffing
arrangements regarding the delivery by municipalities of
these environmental health services, have gone through a
still-incompleted and protracted period of transition. This
Rapid urbanisation, climate change, globalisation, air
pollution, poverty and inequity are now additional concerns
for environmental health practitioners. Climate change is one
of the major challenges to health due to its effects on access
and quality of water supplies in the world, food insecurity
resulting from a reduction in arable land, and its contribution
to emerging and re-emerging infectious diseases, such as
dengue fever and malaria. Globalisation is also adding to the
rapid transmission of infectious diseases, such as influenza,
around the world, and the potential transmission of diseases
including severe acute respiratory syndrome (SARS) and
avian flu.
The link between environmental health and disease is
well established, with ill-health being directly related to
environmental hygiene and conversely, improvements
to environmental hygiene contributing to better health.5
Medical therapy alone is not sustainable as a public health
intervention, if environmental exposures that are associated
with diseases are not also addressed and prevented. The
burden of disease from environmental factors has been
quantified by the WHO (see Box 1).
process needs to be finalised to ensure that attention shifts
to service delivery, and to the development of an equitable
service based on the Alma Ata PHC principles of intersectoral
collaboration, community participation, appropriate and
Environmental health in South Africa
before 1994
evidence-based technologies, access, affordability and equity
Environmental health in South Africa was influenced by its
to all.
origins in England, in the early to middle nineteenth century.
Since the early 1800s local government played a key role
Background
in the delivery of environmental health services in South
What is environmental health?
Before 1994, environmental health services were provided
Environmental health is a diverse science, and its primary
environmental health services were run by the homeland’s
objective is to prevent disease and create health-supportive
health department, with a few capable local municipalities
environments. The World Health Organization (WHO)
(e.g. Umtata Municipality in the Transkei homeland and
perceives environmental health as addressing: “all the
Mmabatho Municipality in the former Bophuthatswana
physical, chemical, and biological factors external to a
homeland) providing services in their area of jurisdiction. In
person, and all the related factors impacting behaviours.
the rest of South Africa, most environmental health services
150
Africa.7
by different administrative authorities.7 In each homeland,
Developments in Environmental Health
Box 1:
Facts on disease and the environment

Worldwide, 13 million deaths could be prevented every year by making our environment healthier.

In children under the age of five, one third of all disease is caused by environmental factors such as unsafe water and air pollution.

Every year, the lives of four million children under the age of five (mostly in developing countries) could be saved by preventing
environmental risks such as unsafe water and air pollution.

In developing countries, the main environmentally caused diseases are diarrhoeal disease, lower respiratory infections,
unintentional injuries and malaria.

Better environmental management could prevent 40% of deaths from malaria, 41% of deaths from lower respiratory infections and
94% of deaths from diarrhoeal disease; three of the world’s biggest childhood killers.

In the least developed countries, one third of deaths and disease is a direct result of environmental causes.

Environmental factors influence 85 out of 102 categories of diseases and injuries listed in the World Health Report.
Source: World Health Organization, 2008.6
were provided by local municipalities. District municipalities,
The
then
municipalities; namely metropolitan (category A), local
called
regional
services
councils,
provided
Constitution
promulgated
three
categories
of
urban
(category B) and district (category C). It gave municipalities
communities in small towns, which could not afford their
from categories A and C executive authority to deliver
own environmental health services. Environmental health
municipal health services, as defined by the Municipal
practitioners from the Department of Health (DoH) rendered
Structures Act and the National Health Act, promulgated
environmental health services mainly to government
in 2005. The National Health Act defines municipal health
premises
hazardous
services as including a range of environmental health
substances in urban and rural areas. These environmental
services (see Box 2), but excludes port health services,
health practitioners also provided general environmental
control of hazardous substances and malaria control, which
health services to towns where there were no local
have become provincial functions.2,7,11
environmental
(i.e.
health
services
hospitals)
and
to
rural
monitored
and
government environmental health services available.
7
Box 2:
The dominance of allopathic medicine in health service
delivery impacted negatively on environmental health
Municipal health services as defined by the
National Health Act, 2003

Water quality monitoring
practitioners were involved in other activities that were not

Food control
directly related to environmental health.1,7,8 Environmental

Waste management
health practitioners without transport became drivers for

Health surveillance of premises
PHC staff who had access to transport, but who did not

Surveillance and prevention of communicable diseases,
excluding immunisations
of

Vector control
administration and technical services, neglecting their own

Environmental pollution control

Disposal of the dead

Chemical safety
services,
to
the
extent
that
environmental
health
have drivers’ licenses.7,8 In other cases, environmental
health
practitioners
became
acting
managers
priority environmental health issues and only focusing
on environmental health-related complaints for 10% of
their time.7,9 Therefore, before 1994 environmental health
services were fragmented and resources depended a
Source: Republic of South Africa, 2003. 2
great deal on the resource levels of their administrative
authority.
Following the promulgation of the Municipal Systems
Act, the Cabinet decided in October 2002, that municipal
Developments in environmental
health services after 1994
The legal framework for the establishment of environmental
health services is rooted in the Constitution of the Republic
health services would be defined as including a range of
environmental health services. In May 2005, the National
Health Act came into force and the responsibility for
delivering municipal health services was thus formally left to
metropolitan and district municipalities.
of South Africa (Act 108 of 1996), the Municipal Structures
The Cabinet decision and the promulgation of the
Act (Act 117 of 1998) and the National Health Act.
National Health Act did not have a major impact on
2,10,11
151
10
metropolitan
already
have pollution control functions.10,16,17 The various
were
powers, functions and responsibilities for the different
mostly well resourced entities. For district municipalities,
categories of local government have been determined.
the implementation of the decision was fraught with
However, there is still uncertainty with regard to some
challenges, as these were newly established entities, with
environmental health services activities that are divided
little revenue generating powers, and were lacking in staff
between local and district municipalities. This should be
to oversee the process. Progress at this level was thus slow,
viewed against the legislative backdrop that has given
as it was also seen as an unfunded mandate.12 In 2006,
the function for rendering municipal health services
the National Treasury provided limited financial resources
exclusively to metropolitan and district municipalities
for environmental health services, as part of the equitable
(see Box 3).2,10,11,16 Most problems with powers and
share funding process (basic services component) to district
functions between local and district municipalities are
municipalities.12,13 The High Court of South Africa, on 10
being sorted out through consultation. Yet the split in
April 2008, made a ruling regarding the interpretation of the
provision of environmental health services is regrettable,
definition for municipal health services, as stipulated in the
as it makes planning for the services unnecessarily
National Health Act, to embrace PHC, which was rendered
complex.
providing
municipalities,
environmental
as
health
these
were
services,
and
by municipalities before the Act was enacted.14 This has
far reaching implications for municipalities and creates

Legal compliance
District municipalities have to comply with different
further challenges to district municipalities with regard to
legislation, which addresses a vast array of issues to
the availability of resources, as well as organisational and
administrative arrangements.
facilitate appropriate service delivery. The Municipal
A number of studies have shown that the devolution of
77 and 78, that all municipalities should carry out
municipal health services has been uneven; while some
investigations (so called section 78 investigations) into
provinces such as the Eastern Cape, the Free State and the
their current and future capacity, when receiving a
Western Cape were doing well, others were struggling.
new municipal service or when a municipal service is
By February 2007, two thirds of the district municipalities
extended significantly.18 The metropolitan and district
provided municipal health services, with the other third of
municipalities should also be statutorily authorised by
local municipalities (category B) still playing a significant
the Ministry of Health under the Foodstuffs, Cosmetics
role in rendering environmental health services.12 There were
and Disinfectants Act (Act 54 of 1972) to enforce this
signs of progress, as municipal health services were fairly
Act.19
Systems Act (Act 32 of 2000) requires in sections 76,
well integrated into municipal planning processes (especially
However,
long-term processes). Furthermore, resources for services
a
study
by
the
Development
Bank
of Southern Africa showed that the section 78
were deemed to have improved at a macro level (i.e. national
requirement was not adhered to by 40% of district
and provincial) since devolution of service, but at micro
municipalities. Additionally, nearly 60% of district
level (i.e. metropolitan and district municipal) significant
differences continued to occur.7,12
municipalities had not been authorised by the Ministry
Studies also show that most of the key national and
and Disinfectants Act) by September 2007, to enforce
provincial role players, such as the South African Local
the Foodstuffs, Cosmetics and Disinfectants Act in their
Government Association (SALGA), the national Department
respective areas of jurisdiction, to control food quality
of Health (NDoH) and the Department of Provincial and
issues.7,12,19 Opportunities for improving the quality of
Local Government (DPLG), designated to lead the devolution
municipal health services rendered were thus missed
of municipal health services, played a very limited role in
as section 78 investigations gauge the capacity of the
giving support and direction to metropolitan and district
municipality to render any municipal service.
of Health (section 23(1) of the Foodstuffs, Cosmetics
municipalities.12,15

Staffing levels
The following are key challenges for district municipalities
Environmental health staffing levels have decreased
in implementing municipal health services.
in a number of provinces, following the devolution

Overlaps and conflict in the allocation of powers
of
and functions
municipalities.12,20 Transfer of environmental health
health
services
to
district
control,
staff from most provincial health departments and
where local and district municipalities, as well as the
some local municipalities, has yet to take place.12,15,20
Department of Environmental Affairs and Tourism
The reason for this is due to the uncertainty around
This
152
environmental
is
well
illustrated
with
pollution
Developments in Environmental Health
Box 3:
Illustration of overlaps in powers and functions

Air pollution can be categorised into ambient and indoor air pollution. Each requires specific interventions from a variety of role
players at different levels. Ambient air pollution control is mainly the responsibility of the Department of Environment Affairs
and Tourism and through the National Environmental Management: Air Quality Act (Act 39 of 2004) is enforced by national and
provincial Air Quality Officers. In section 14(3) of the same Act each municipality is expected to designate an Air Quality Officer to
coordinate air quality management within the respective municipal area.

Metropolitan and district municipalities are responsible for implementing the atmospheric emission licensing system by issuing
atmospheric emission licenses in their respective areas, as required by section 36(1) of the National Environmental Management:
Air Quality Act. At the same time, for metropolitan and district municipalities, environmental pollution control is a municipal health
service function, legislated by the National Health Act that addresses air, water and land pollution.

As part of their powers and functions under section 83(1) of the Municipal Structures Act, local municipalities are responsible
for air pollution control in their respective areas. However, the Municipal Demarcation Board of South Africa interprets district
municipality’s powers and functions for municipal health services to include air quality control in their respective areas.

These examples show how legislation leads to confusion around the exact roles of each entity regarding ambient and indoor air
pollution control.
Source: Compiled by the authors, originating from different documents.10,11,17
responsibility for the provision of the service. This has
control are relatively well established throughout the
led to the loss of many practitioners, legal challenges
country. An active Inter-provincial Port Health Committee
to the transfer of staff from local municipalities, local
coordinates activities from the national level. Part of
municipalities keeping staff for their own services
the success can be attributed to the fact that powers and
and municipalities freezing posts.7,12,20,21 The ability to
functions are clearly defined and some of these services
recruit more staff by district municipalities will largely
were already being rendered by provinces.
depend on the resources available to each municipality,
including
funding
located
within
the
provincial
departments of health that could be transferred.

As can be observed, a framework has been put in place for
the delivery of municipal health services.2,7,8,10-13,16,18,20,22-24
Although not perfect, there is scope for improvement, if
Funding levels
there are concerted efforts and coordination by all relevant
Funding for municipal health services was a concern
stakeholders in environmental health. These include the
in 2002.21 This was however partly addressed by the
NDoH, the DPLG, SALGA, the South African Institute of
National Treasury.
Environmental Health (SAIEH), municipalities and tertiary
12,13
According to the Division of
Revenue Act (Act 2 of 2006), environmental health
institutions.7,8,12
services are basic services, which are funded through
the local government equitable share, together with
other basic services, including provision of water, basic
sanitation, refuse removal and electricity supply.13 The
continuing concern is that the amount of the equitable
Review of main environmental
health components
share allocated for this is inadequate, as it was set at
Developments in a number of specific environmental health
R12 per household per annum (R3.25 per capita) in
components will be reviewed, including water and sanitation
2006 and R18 per household per annum in 2008. This
as well as food and malaria control. Highlighted will be how
allocation was made despite the DoH recommendation
these services have evolved, as well as the successes and
that R13 per capita should be spent on the service.13,20,22
challenges that have arisen.
Despite this alleged inadequacy, not all district
Water and sanitation
municipalities had accessed, or planned to access the
available National Treasury funding by February 2007.12
The provision of sufficient quantities of safe water, facilities
A comprehensive costing of environmental health
for the sanitary disposal of excreta and promotion of sound
services is long overdue, as this will guide municipalities
hygiene behaviours can lead to significant improvements in
and National Treasury in budgeting sufficiently for the
health. Over 9% of the global burden of disease could be
service.
prevented through better management of water, sanitation
Environmental health functions provided by provincial health
departments, including port health services and malaria
and hygiene.25 Bartram also states that better management
Personal communication, E Bonzet, Western Cape Department of
Health, 7 August 2008.
153
10
of water, sanitation and hygiene, in turn, could lead to
Initially government followed a developmental approach
reductions of diarrhoeal disease incidence of between
in the provision of sanitation services. In 2000, the NDoH
25 to 37%.
envisaged water and sanitation services that involved
25
communities in the planning, design, financing and
Water
maintenance of services. They also defined competencies for
Since 1994, South Africa has made major strides in
increasing access to basic water to all communities in
the country, and prioritised the areas with the greatest
need. Access to ‘basic water infrastructure’ improved
from a coverage of 59% in 1994 to 94% in March 2007.,26
Aggregated at a national level, much progress is being made
in improving access to ‘basic water infrastructure’, but there
are still localities with persisting low safe water coverage.
An emerging issue for access to safe water, which is of
direct relevance to environmental health practitioners, is
the declining quality of water provided by municipalities.21,27
South Africa has always been renowned for high standards
of water quality, but this is no longer the case.27,28 The quality
of South Africa’s surface and ground water is declining, with
chemical and biological contamination, as well as rising
salinity as the major causes of this decline.29 Poor investments
and maintenance of waste water, and effluent infrastructure
has led to the illegal discharging of effluent with high faecal
coliform loads into rivers and streams.30,31 In addition to
the pollution of water sources, water treatment is also not
up to standard. A study in 2004 showed that only 43% of
municipalities adhere to drinking water quality standards.32
Although the monitoring of water quality is the responsibility
of water service authorities and the Department of
Water Affairs and Forestry (DWAF), environmental health
practitioners play a significant role in monitoring water
quality as part of their mandate related to municipal health
services delivery, with the aim of protecting the health of the
population.2,16,24 Environmental health practitioners conduct
tests on water quality at the point of use (i.e. the tap) and
report back to the municipality, the provincial DoH, and to
DWAF. Environmental health practitioners are also required
to promote health and hygiene awareness, including hygiene
around water issues.21
the involvement of environmental health practitioners.
The
developmental
sanitation
approach
emphasises
to
the
demand-driven,
provision
of
community-led
and participatory methods for the delivery of sanitation
services. However, this developmental approach takes
time, but the benefits outweigh the time taken to deliver
services.
The 2001 White Paper on Basic Household Sanitation
advocated for: community participation in sanitation;
provision of sanitation that was responsive to the demands
of people; a strong emphasis on health and hygiene; and
local government supporting households in improving
their own sanitation.28 With local government taking over
responsibility for provision of sanitation and its inclusion in
basic services delivered by municipalities, there was a shift
from the demand-driven approach to a more supply led
approach. Pressure was exerted on municipalities to fasttrack the delivery of basic services, including sanitation. The
developmental approach to the provision of sanitation was
thus abandoned as municipalities were more concerned with
meeting targets for infrastructure delivery.27
The institutional mechanisms outlined in the White Paper
on Basic Household Sanitation regarding the provision of
sanitation are very complex, with roles for DWAF, the NDoH,
the Department of Housing and Public Works, as well as for
municipalities. It was envisaged that, with the involvement
of municipalities, environmental health practitioners would
play a more significant role in sanitation advocacy and
hygiene promotion, which are coordinated by the NDoH.
Regrettably, these expectations came at a time when the
restructuring of municipal health services was also taking
place. There was also uncertainty about the future of
these services, resulting in under-investment in the service
by municipalities and no guidance and support from the
NDoH, the DPLG, SALGA and National Treasury.7,12,21,27
Other challenges emerging from the sanitation programme
Sanitation
are inappropriate technology, design and management. There
In 2008, on the occasion of the International Year of
are cases, for example, where ventilated pit latrines (VIPs)
Sanitation, the Director-General of the WHO was quoted as
are full, but municipalities have inadequate knowledge or
saying: “Lack of sanitation kills. It degrades health - especially
equipment to empty these. This, coupled with contamination
that of children - and undermines education. It affects whole
of ground water through badly placed VIPs is posing a major
communities but consistently those most severely affected
health hazard.27
are the poor and disadvantaged”.
32
The Department of Water Affairs and Forestry describes ‘basic
water infrastructure’ as availability of infrastructure, without taking
into account quality considerations.
154
Improvements in the delivery of sanitation have been slower
than that of water. The current situation, based on data
from the 2007 Community Survey is presented in Figure 1.
Developments in Environmental Health
Although there is some overall improvement, in the areas
Food control
where sanitation is worst, there has been relatively little
change in levels of sanitation. The map also shows areas that
Food control is a mandatory regulatory activity of
still have very high levels of ‘inadequate sanitation’.
enforcement by national and local authorities to provide
consumer protection, and to ensure that all foods are
A 2006 survey found that hygiene awareness is low in South
safe during production, handling, storage, processing and
Africa, with almost half the population underestimating the
distribution. It also ensures that foods are wholesome, that
effectiveness of hand washing in preventing the spread of
they are fit for human consumption, that they conform
disease.34 The result of poor hygiene education is that South
to quality and safety requirements, and are honestly and
Africa experiences episodic outbreaks of diarrhoea, and in
accurately labelled as prescribed by law.35
a number of cases, person-to-person transmission (rather
than water being the main route of transmission).27,28,34
Through the Foodstuffs, Cosmetics and Disinfectants Act,
the Directorate for Food Control at the NDoH is responsible
Much progress has been made in the provision of
for the safety of food for all South Africans. Enforcement
infrastructure for both water and sanitation. However, what
of the Act is at local level for foodstuffs manufactured and
is lacking is a more developmental and sustainable approach,
sold locally, and at provincial level for imported foodstuffs
which integrates environmental health practitioners more
covered by the provisions of the Act and the related
integrally to ensure that hygiene education is a major part
Regulations published by the Minister of Health.7,19,35
of water and sanitation programmes. Cholera, typhoid
and diarrhoeal outbreaks in Mpumalanga, KwaZulu-Natal,
Historically, most local authorities (local municipalities and
the Eastern Cape and the North West provinces serve as a
forerunners of district and metropolitan municipalities)
reminder, that more still needs to be done in this area.21
were authorised to enforce the stipulations of the
Figure 1: Percentage of households with inadequate sanitation, 2007
Percentage of households with inadequate sanitation, 2007
LIM341
LIM351
Gauteng enlarged
LIM331 LIMDMA33
LIM362
LIM367
LIM364
JHB
NCDMA08
EKU
NW395
NW381
GT483
GT423
NC081
NCDMA45
NW382
NC451
NW393
NW394
NC452
NC453
NCDMA08
FS173
FS172
FS161
FS171
FS162
NCDMA07
NCDMA06
FS163
NC075
NC064
NC074
NC072
EC144
NC066
EC131
WCDMA05
EC101
NCDMA06
WC012
WCDMA01
ECDMA13
WC013
ECDMA10
WC022
WCDMA02
WC051
WC023
EC107
WC025
EC132
WC041
WC045
WC026
WC031
EC141
WC034
WC042
WC043
WCDMA04
WC044 WC048 WC047
WC032 WC033WCDMA03
EC109
EC153
EC155 EC154
EC157
EC135
less than 10%
EC124
EC123
EC127
10.0 - 19.9%
EC125
EC126
EC105
ECDMA10
EC106
NMA
Sanitation (inadeq)
no data
EC121
EC122
EC102
EC108
EC137
ECDMA13 EC134
EC104
WC015
CPT
WC024
EC136
EC103
WC052
KZN272KZNDMA27
KZN265 KZN273
KZN434KZN211
KZN433KZN435
KZN212
KZN213
KZN214KZN215
EC442
KZN216
EC151
EC152
EC138
EC128
WC053
WC014
EC142
EC143
EC133
WC011
KZN263
FS194
EC156
NC071
KZN272KZN271
KZN262
KZN253
EC441
NC073
NC065
KZN252
KZNDMA22
KZN221
KZN293KZN292
KZN222
KZNDMA43KZN224 KZN225
KZN432
ETH
KZN431KZN227KZN226
NC077
NC076
WCDMA01
FS192
FSDMA19
FS191
NCDMA07
NCDMA08
NC062
FS181
NC091
NC078
NC084
FS195
KZN254
KZN241
KZNDMA27
KZN266
KZN242
KZN274KZN275
KZN232
KZN285
KZN233
KZN281
KZN244 KZN286
KZN283
KZNDMA23KZN235
KZN282
KZN234
KZN284
KZN245
KZN236
KZNDMA23
KZN294KZN291
KZN223
FS184
FS182
NC067
MP303
KZN261
FS201
FS183
NC093
NC092
NC082
NC061
MP304
FS205
FS193
NCDMA09
NC086
NC085
MP302
MP305
FS203
FS185
MP324
MP301
MP307
FS204
NC094
NC083
MP322
MP323
MP313
MP312
GT423
GT421GT422
MP306
NW404
NW396
MP321
LIM472
MP314
NW405GT483
NW402
NW403
NW392
MPDMA32
MP325
MP315
GT482 JHB EKU MP311
NW401
NW391
GT422
MP316
GT461
GT481GTDMA48 GT462
NW384
LIM475
LIM473
TSH
NW374
NW383
GT421
NW371
NW372
NW373
LIM335
LIM471
LIM366
NW375
NW385
LIM334
LIM355
LIM474
LIM361
GT481 GTDMA48
LIM333
LIM354
LIM365
GT462
LIM332
LIM353
LIM352
GT461
TSH
GT482
LIM342
LIM343
LIM344
Boundaries
20.0 - 39.9%
Provincial
40.0 - 59.9%
District Municipalities
60.0 - 79.9%
Local Municipalities
80.0% and above
Source: Statistics South Africa, 2007. 33
‘inadequate sanitation’ includes: no toilet, bucket toilets or pit
latrines without ventilation.
155
10
Foodstuffs, Cosmetics and Disinfectants Act, but since
Johns on the east coast in 1927, and as far as Gauteng in
1 July 2004 this responsibility was shifted to district
the early 1930s.37,38 During bad years, these epidemics
municipalities and metros.7,23 The activities of district
resulted in up to 20 000 deaths in a single season.39 Residual
municipalities and metros regarding food hygiene control
spraying with insecticides (dichlorodiphenyltrichloroethane
include: evaluation of food premises and sampling of
(DDT) and later pyrethroids) and surveillance were the main
foodstuffs; health education of food processors, handlers
control interventions introduced in 1946. These interventions
and
prospective
reduced malaria to low levels associated with seasonal
entrepreneurs on requirements relating to food premises;
focal outbreaks, following favourable climatic conditions
and the safe handling of food and controlling illegally
and the movements of infected migrants.40 Indoor residual
imported foodstuffs offered for sale.
spraying with DDT eliminated malaria from large areas of
consumers;
advising
existing
and
7,23,35,36
Outstanding issues regarding food control are related to
the authorisation of municipalities and environmental
health practitioners, under the Foodstuffs, Cosmetics
and Disinfectants Act and the National Health Act.
Authorisations for local authorities, that existed prior to
2004, should be repealed by the Minister of Health in terms
of the Foodstuffs, Cosmetics and Disinfectants Act. They
should also be replaced by authorisations of the current
metro and district municipalities.7,23,35
A study conducted by Agenbag in September 2007, showed
that all metros were authorised, while 58.7% of district
municipalities had not been authorised in accordance with
section 23(1) of the Foodstuffs, Cosmetics and Disinfectants
Act.7 This does not, however, mean that none of the other
district municipalities had applied to the Minister of Health,
but rather that some applications still needed to be processed
by offices of the relevant provincial health departments.
It is also the requirement, under the Foodstuffs, Cosmetics
and Disinfectants Act, that there should be authorised
officers who are mainly environmental health practitioners.
The
same
study
by
Agenbag
found
that
64%
of
municipalities indicated that functional environmental
health practitioners were authorised by the municipalities.7
A similar situation pertains to authorisations under the
National Health Act. Two studies, one in 2006 and the other
in 2007, revealed that only a quarter of the municipalities
could confirm that their environmental health practitioners
were authorised under the National Health Act.7,12,15
the country and reduced it to low levels in three provinces,
such as eastern parts of Limpopo and Mpumalanga and the
north eastern parts of KwaZulu-Natal, where it continues
to occur. Occasionally, small malaria outbreaks develop in
the Northern Cape and North West provinces. During these
mentioned interventions, eliminated were the Anopheles
funestus mosquito and greatly reduced was the density
and distribution of Anopheles arabiensis, which is the main
vector of malaria in the country.
Annual reported malaria cases varied between 2 000 and
13 000 during the 1975 to 1995 period. However, reported
infections increased significantly to a peak of 64 222 cases
and 458 deaths in 2000. These increases have been attributed
to climatic conditions, as well as resistance to the parasite
drug and insecticide. There has been a sustained decrease in
the number of nationally reported malaria cases and deaths,
between 2001 and 2007.
This success is a result of a combination of effective vector
control, good case management and sustained political
and financial support. Sustained control has been achieved
through the ongoing strengthening of health systems, with
strong monitoring capabilities and evaluating results. This
has ensured that malaria mortality and morbidity stay low.
With control at the current levels, within the borders of
South Africa, it might now be feasible to achieve malaria
elimination by reducing malaria transmission to zero.41
Environmental management played an important role during
the eradication phase historically. This application remains
under-utilised today and needs to be further explored.
Food safety is receiving much attention worldwide, as
consumers become more educated and conscious about the
subject. It will become even more important as South Africa
prepares to host the 2010 FIFA World Cup, and municipalities
will need to ensure that all their authorisations, as well as
those of their staff are in place.
Human resources in
environmental health
Environmental
health
services
are
service
delivery
orientated, and are therefore mainly dependent on human
resources for effective delivery. In 1999, the NDoH adjusted
Malaria control
the national norm away from the WHO norm of, one
environmental health practitioner per 10 000 population
Large parts of South Africa were historically affected by
for developing countries, to one environmental health
malaria, with epidemics spreading as far south as Port St
practitioner per 15 000 population. This led to an apparent
156
Developments in Environmental Health
improvement in the environmental health practitioner
implementation of municipal health services at district
to population ratio from a national perspective, because
and metropolitan levels.7 The placing of environmental
the shortfall of environmental health practitioners was
health
less.7,20,21
planning. This planning includes budgets and resources,
The
Western
Cape,
with
an
average
of
just
over
13 600 population per functional environmental health
practitioner, is the only province achieving the national
coverage goal, while the Eastern Cape has over the past
few years moved closer to the national norm, with an
practitioners
in
municipalities
requires
more
such as equipment, transport and offices, which need to be
made available at a municipal level.
Conclusion
average of 22 479 population per functional environmental
Environmental health services are at the core of PHC services
health practitioner (see Figure 2). National environmental
and the prevention of disease. Major health benefits are
health practitioner to population figures normally include
possible when these services are running well.
7
environmental health practitioners, such as those at
management level in municipalities, who fill environmental
health practitioner posts, but are utilised in areas not related
to environmental / municipal health services. These national
environmental health practitioner to population figures, also
include the ‘community service year’ of environmental health
practitioners, who are contractually appointed by provincial
departments of health only for a period of a year.7,9,20,22
to district municipalities arose due to a lack of strong
leadership, support and guidance to district municipalities,
many of which were grappling with the provision of several
other new services when they were required to take on this
function. This led to the uneven devolution of the service
as local leadership and resources determined how much
support was provided to the establishment of environmental
Figure 2: Comparison of functional environmental health
practitioners (EHP) per population in South Africa,
2006/07
health services. This is likely to impact on the future equitable
provision of the service.
There are many lessons to be learnt from municipalities who
60 000
Community members per EHP
Current problems regarding the devolution of the service
managed this process well; lessons which should be shared
with those who are struggling. Hence, a need exists for
50 000
relevant role players to assist in documenting and sharing
40 000
such lessons.
30 000
The restructuring of environmental health services into
municipal health services, mostly provided by metropolitan
and district municipalities, will improve coordination of
20 000
the service and will make it possible to provide it in a more
equitable manner to all localities.
10 000
0
EC
FS
GP
Median population per EHP
KZN
LP
MP
NC
NW
WC
National EHP per population norm (1:15 000)
Source: Agenbag, 2008.7
Community
health
Recommendations
The process of devolution and consolidation of municipal
service
for
environmental
health
practitioners was initiated in 2003, with 206 environmental
health officers participating in the programme in 2006.42
Provincial health departments have benefited most as
placing of new environmental health practitioners was
not a problem. The Eastern Cape DoH’s strategy to absorb
health services needs to be finalised speedily, through more
support and leadership from the NDoH, provincial and local
governments, as well as from other key stakeholders such as
SALGA and SAIEH. More coordination and monitoring with
clear targets and responsibilities between these bodies will
fast track the establishment of the service.
environmental health practitioners, who receive a bursary
A need exists for the development of a section 78
from the department, has lead to the Eastern Cape
investigation
moving closer to the national norm of one environmental
assessment) that can be used by municipalities that have
health practitioner per 15 000 of the population.7 This
not yet done their section 78 investigations, and such
holds its own challenges when calculating the availability
a guideline could be used as a monitoring tool for those
of
municipalities that have previously completed it.
environmental
health
practitioner
staff
for
the
guideline
(current
and
future
capacity
157
10
A suggestion for such a guideline was tabled at the Eastern

Cape municipal health summit in 2006.24,43
van Zyl and Chakane Sibaya, from Fezile Dabi District
Municipality; Billy Barnes and Joof van der Merwe, from
Municipalities need to plan for and support environmental
Mangaung Municipality, for assisting with the provision
health services, as with any other municipal services. The
period of uncertainty around the devolution of the service
is mostly over, and strengthening it through adequate
resources and standardised systems is now required.
Stronger
leadership
Environmental
and
Health
stability
Directorate
in
is
the
National
required.
This
coordination body, which can give direction to, as well as
evaluate and monitor the programme to influence national
policy direction, resource allocation, facilitate role players
to support systems development, and to standardise
environmental health in South Africa.
Arising from a Development Bank of Southern Africa
dialogue, where the results from a national study were
shared with key relevant role players such as the NDoH,
the DPLG, National Treasury and municipalities a number
of issues were raised. One of the most important was that
municipal health services should be debated at a MINMEC
(committee consisting of the National Ministers and
Provincial Members of the Executive Councils) level and that
the NDoH, supported by the DPLG, should facilitate such
interaction to determine the way forward.
critical
issue
requiring
intervention
is
the
establishment of a national environmental health forum. In
the absence of support and national leadership for municipal
health services, the environmental health fraternity, at local
and provincial levels, has approached SALGA to establish
a national municipal health services working group. This
group, which was in principle approved by the national
Executive Committee of SALGA towards the end of 2007, has
not met as yet.
Acknowledgements
The authors would like to acknowledge the following
people:

Philip Kruger, from the Department of Health and Social
Development, Limpopo; Aaron Mabuza, from the
Department of Health and Social Services, Mpumalanga;
and Sakkie Hatting, from the Department of Health,
KwaZulu-Natal, for their input on malaria control.

Dries Pretorius and Penny Campbell, from the National
Directorate: Food Control at the National Department
of Health, for their input on food control.
158
of information.

Jerry
Chaka,
from
Ekuruleni
Metropolitan
Municipality and President of the South African
Institute of Environmental Health; and Francois Nel,
leadership will ensure the establishment of a proper
Another
Zies van Zyl, from Sedibeng District Municipality; Andre
from Chris Hani District Municipality and National
Secretary
of
the
South
African
Institute
of
Environmental Health, for their guidance and advice.
Developments in Environmental Health
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