South Africa has a diverse population and is a third world country, and its economy is considered a dichotomy. One part of the population lives in extreme poverty with no to little access to clean water and sanitation. The other lives in relative comfort and has access to clean water and sanitation (Ataguba et. al, 2015). The population that lives in extreme poverty is generally found in rural areas, peri-urban areas, townships and squatter camps. Compounding this is that these communities are in areas where climate change, commercial farming and lack of water infrastructure has drastically reduced water availability.
South Africa has a growing burden of non-communicable diseases. This is worsened by rapid urbanisation, critical skills shortage, climate change, a high unemployment rate, poor special planning, and outdated policies that do not consider the rapidly changing world (Ataguba et. al., 2015). As is in many developing countries, South Africa appears to be overwhelmed or incapable of dealing with the expanding needs of the population and the required resources needed to ensure an adequate supply of basic services. Consequently, people from lower economic positions face extreme difficulties and are the ones who suffer a high burden of disease (Wandai & Day, 2015). Literature has provided a strong correlation between different social determinants and health risk factors (Baker, 2010). In South Africa particularly, unavailability and inadequate supply of clean potable water and sanitation is one social determinant that poses a risk to the public health system. The recent water shortages in the Eastern Cape particularly the province’s biggest city, Gqeberha is a case in point.
Access to clean water and sanitation is important for public health and socioeconomic development. According to the General Household Survey in 2017 by Statistics SA, roughly 11% of households in the country have inadequate sanitation services with 26% having no access to sanitation services (Stats SA, 2017). This was because of poor water infrastructure and minimal investments made to ensure that the infrastructure could meet the needs of a growing population.
The WHO (2019) estimates that at least 829 000 die annually from diarrhoea associated with drinking contaminated water and poor sanitation. Furthermore, the WHO (2019) estimates that in 2017, over 220 million globally had to take preventive treatment for schistosomiasis due to them consuming contaminated water. This, of course, could be very costly for a low-income country. The recent water safety and quality crisis in Gqeberha proves the negative impact contaminated water could have on the city. As reported by local media, it is alleged that the contaminated water led to the death of an infant. This was after the city issued a notice warning its over 1.4 million residents not to drink the water its supplies due to elevated levels of Escherichia coli (E.coli).
According to the WHO (2019), “Contaminated water and poor sanitation are linked to transmission of diseases such as cholera, diarrhoea, dysentery, hepatitis A, typhoid, and polio“. This then exposes the vulnerable population to health risks that could be easily preventable. This is because these health care facilities would not have adequate or clean water to clean the facilities, disinfect, wash the laundry and maintain acceptable standards of cleanliness and sanitation. In addition to this problem, many of the government’s state hospitals and clinics are dysfunctional and completely run down due to poor management, extreme incompetence, underfunding, political interference, and complete neglect (Von Holdt & Murphy, 2006).
These risk factors place additional risks of disease spread and even reinfection among patients and health care officials. According to the WHO (2019), at least 15% of patients develop infections while in a health care facility. Still, that figure increases in low-income countries, especially those with inadequate clean water and sanitation programmes. Furthermore, the lack of adequate skills to manage water, water infrastructure, wastewater streams, and technicians skilled in water testing and conversation adds to this problem.
Inadequate clean water and sanitation may have economic impacts as well. The amount of money spent on treating people needing preventive care negatively affects the country’s expenditure on health (Wandai & Day, 2015). The medical costs incurred by those seeking medical attention is also a disadvantage. In addition, those living in rural areas need to travel long distances to collect water affecting their ability to be economically productive.
Furthermore, the negative impact of children not attending school due to illness and its effects on their development and cognitive function could have dire consequences for the country’s long-term economic prospects. Caminade et al. (2019) state in their research paper that the world’s population must expect an increase in waterborne diseases due to climate change. In South Africa, this would be exacerbated by a lack of expertise and infrastructure investments to control and reduce increased pathogen loads in water. These pathogens are expected to emerge due to water temperatures increase and heavy urbanisation. According to Semenza & Menn (2009), temperature influences infectious agents’ life cycles, vectors and reservoirs.
Globally, there have been concerted efforts by lawmakers, research institutions, and public health officials to improve health and health care among populations. This has been particularly aimed at reducing illnesses, the burden of disease and addressing the social determinants of health, which directly affect human health (Ataguba et al., 2015). Therefore, South Africa is not unique. Although there have been different policy interventions to reduce socioeconomic inequalities in health in South Africa, there has been little progress, specifically in health inequalities (Baker, 2010).
When one looks at the spatial location in most cities in South Africa, it is clear where illnesses or health problems are likely to occur. In poor communities, the inadequate supply of clean water could lead to acute infectious diarrhoea and other chronic gastrointestinal infections. This would be due to a high number of pathogens, , and harmful chemical residues that could affect people located in poorer areas.
Therefore, interventions to alleviate the social determinants of health must be integrated, comprehensive, and incorporate other sectors effectively.
It does not help that South Africa is a water-scarce country with an arid to semi-arid climate with rainfall averaging 465mm, half the world’s average (NWSMP, 2018). The Department of Water Affairs projections are that by 2025, the country will face extreme water scarcity if there are no effective interventions (NWSMP, 2018). Water scarcity has a direct impact on the country’s water quality, quantity and availability. As of November 2021, the country is facing an extreme water crisis caused by many factors, including climate change, years of neglect of water infrastructure, shortage of skilled water engineers, inequities relating to water access, and incompetence.
South Africa currently has many different pieces of legislation speaking to water provision, water quality and water infrastructure. Among these policies is the Water Quality Management (WQM) policy of 1991, which influenced the 1998 National Water Act (Act 36 of 1998) (NWA), Water Services Act (Act 108 of 1997), National Water Resource Strategy. While this policy was considered forward-looking and pragmatic 30 years, it has failed to capture and ensure the country is fully prepared for the significant changes over the years. The policy is outdated in the current context. In its infancy, the IWQM was largely focused on pollution control and specific effluent standards. However, as time passed, the shift moved to environmental impact, general water quality and availability. However, there has been a lack of integration among the different pieces of legislation, strategies, and regulations that govern water and sanitation provision. The lack of integration and oversight to see through the implementation of these policies has seen water issues being dealt with by different departments in an incoherent manner. For example,
- The department of water affairs looks at water conservation.
- The department of human settlements considers water provision in households.
- The department of health investigates the provision of safe water.
- The department of agriculture considers water conditions for farmlands.
- At the same time, municipalities are tasked with providing water within the municipal boundaries.
- and there is usually minimal interaction between municipalities and national governments responsible for water provision. This lack of coordination exacerbates water issues faced by South Africa.
The above indicates that there are many different stakeholders involved in water provision and the coordination between different departments and government levels is crucial to ensure provision of adequate and quality water. However, there are many instances where it is clear there is lack of interdepartmental and intergovernmental working relationships exacerbating the water crisis. The current water policies and legislation do not go further enough to guide municipalities, which are largely tasked with water provision, on newer methods for water treatment, measures to mitigate climatic impacts on water availability, and the extent municipalities can go to look for alternative water sources. While the policy and related legislation address desalination, micropollutants, erosion and eutrophication, informed redefinition and reprioritisation have not been done to consider the current context South Africa finds itself in.
In 2018, the South African government published the National Water and Sanitation Master Plan (NWSMP). This master plan has strategies to avoid future water deficits, including reducing the demand for water and managing water provision services.
The following statistics are indicated in the Master Plan:
- As of April 2017, 14,1 million people use sanitation facilities below the national standards, and of those, only 64% of people accessed reliable water supply.
- Roughly 56% of 1 150 municipal wastewater treatment works in critically poor condition needing urgent rehabilitation, with 10% of this being hopelessly dysfunctional
The above statistics indicate the crisis that South Africa face. The Master Plan lists the following objectives:
- Suitable and buoyant water supply;
- Universal water and sanitation provision;
- Water provision that is shared and allocated equitably
- Maintaining well-operated water infrastructure and effective management
- Reduction of future demand for water
However, this master plan does not consider the rapid population growth, the rapid unplanned urbanisation and the ageing infrastructure. In addition to that, the focus is only on the technical skills needed to ensure water provision. Still, there is minimal focus on poor municipal governance which is one of the key areas that need attention. According to the Master Plan (2018), South African municipalities, on an annual basis, lose about 1660 million m³ through nonrevenue water costing R6/m3, amounting to R9.9 billion annually. This is due to the lack of political will to minimise loss, poor management, and a complete lack of operations management. Political instability in South African municipalities and incompetence among municipal officials make it extremely difficult for experts to listen to their solutions. While the South African government is working towards “reducing water demand, protecting ecological infrastructure and managing effective water services.”, there are no practical and pragmatic solutions to implement effective short-term to medium-term water availability.
Furthermore, although according to the NWSMP (2018) many households, estimated to be 89% of the population, have access to water, there is no certainty that all those households have access to water that complies with SANS 241:2015 standard for potable water (Moyakhe, 2014). The reliability of supply has also come to the fore. In many parts of the country, there have been reported water-shedding due to ageing infrastructure and drought. There has been no concrete plan or strategy to ensure that the ageing infrastructure is attended to minimise water losses. The current strategies mainly focus on the population reducing water consumption, and they do not consider the contribution of ageing water infrastructure to water losses.
In terms of sanitation, the master plan put access to sanitation to 80% in the country without any specific reference to how these figures have been collected. In the Master plan, it was further indicated that the figure is uneven due to some municipalities having only just 50% of its residents accessing adequate facilities for sanitation.
In conclusion, public health is not only about health-related factors but also concerns many other factors that would not be necessarily considered health-related factors. For the public health system to function, there must be a capable state with an executive recognising the relationship between public health and other social factors. It must be acknowledged that South Africa has made some strides in providing services to the larger population since the fall of Apartheid in 1994. The government has been steadily ensuring equitable access to health over the years and must be commended. The large budget allocated for service provisions, including free services, also speaks to this. Some of the failures and inefficiencies the country is experiencing now can be apportioned to Apartheid (Moyakhe, 2014). Still, many of the failures are due to a complete failure by the current government. Unfortunately, the population that bears the most brunt is that of the low social and economic class. This is because populations from low socioeconomic positions usually experience a lack of amenities, and poor conditions, determining one’s health prospects.
Moreover, it is imperative to institutionalise public health by promoting collaboration between all role players, including those not traditionally seen as public health role players. It must be realised that social determinants of health have a direct impact on health outcomes. Thus, government interventions must consider public health and cross to other sectors that may influence public health. Collaboration is needed between public health and non-health stakeholders, who may impact the health outcomes.
Availability of clean, potable water and good sanitation is an example. While waterborne illnesses and diseases that come about because of poor hygiene and inadequate water supply are health issues, the supply of clean water, infrastructure and human resources to deal with water shortage is not. Therefore, the government must realise that these social determinants, including spatial planning, rapid urbanisations, development of new human settlements, etc., directly impact population health and could be very costly.
Government and relevant stakeholders should use evidence-based approaches that rely on credible and reliable information to make decisions affecting public health. To salvage the South African public health system, there need to be concerted efforts to develop new models and suitable approaches that will consider the uniqueness of the challenges the country faces. There should also be a consideration to the critical skills and competencies that the public health system needs, which looks at health workers per se and goes beyond the department.
The failure to address social factors is due to budget allocation and mismanagement, the lack of technical skills, lack of vital skills, institutional capacity, and capacity constraints that are largely influenced by the politicisation of the state. These critical skills that are not readily available include adequate management and leadership skills, financial management skills for appointed officials to manage public funds better, engineers who must assist with water infrastructure, environmental scientists who can assist with advising technicians concerning pollution, etc. Specific to water, contributory factors to inadequate supply of potable water include is the minimal budget allocation for capital projects and maintenance of existing water infrastructure. There is also poor planning, inefficient supply chain processes, poor internal controls and lack of consequence management. These factors are management functions that require a firm political will to resolve.
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