Local Government Impact On Health - What Do We Know?

Introduction

Four functions assigned to local government in Sections 4 and 5 of the Constitution affect the health of residents: air pollution, cleansing, municipal health services, and water and sanitation services limited to potable water supply systems and domestic wastewater and sewage disposal systems. Table 1 indicates the available information about each in 2019.

Table 1

Note: GHS – General Household Survey

DWS – Department of Water and Sanitation

Transfers from provinces to municipalities for health services were made only in Gauteng (R 637 million), KwaZulu-Natal (R 225 million) and Western Cape (R 593 million), making up a total of R 1 415 million. Virtually all of these transfers were to the five largest metros.

Statistics South Africa’s Financial Census of Municipalities[1] indicates that municipalities spent R 4 980 million on health in the year ended 30 June 2019. Adding 6% to that number to produce an estimate for 2019/20 and subtracting the transfers from provinces, it is estimated local government spent R 3 864 million from own revenue on health.

Municipal services which have a greater, but indirect, impact on health are refuse removal, potable water and sanitation. They are considered in turn.

Refuse removal

Table 2 compares the distribution of households across refuse removal categories between 2002 and 2019. Not a lot has changed in the intervening seventeen years, with a marginal increase in removals at least once per week and a corresponding decrease in dumping refuse anywhere. The lack of regular removal of refuse poses a risk to health which rises with population density, so the low levels of weekly removal in metropolitan and non-metropolitan urban informal areas is cause for particular concern. So is the very low level in traditional areas, which now have the greater part of their population living in formally laid out townships or dense informal settlements[2].

Table 2

Water

Piped water is defined as water delivered to dwellings, yards, neighbours’ taps or communal taps. Table 3 indicates that the percentage of households receiving piped water rose from 82.3% in 2002 to 88.1% in 2019. It has not all been forward movement. While access to piped water increased substantially in the Eastern Cape and KwaZulu-Natal over the period, the percentage of households with access decreased in five provinces: Mpumalanga, Limpopo, Free State, North West and (marginally) Western Cape. Moreover, 2.9% of all households (half a million) in 2019 reported that they once had piped water but lost it because supply systems broke down.

Table 3

Source: GHS 2019

Some piped water is supplied by agents other than municipalities. 80.7% of households reported that they had access to municipal water in 2019[3].

Interruptions to municipal water supply services are common. Households are regarded as having an unreliable municipal supply if interruptions that lasted more than 2 days at a time, or more than 15 days in total, occurred during the year before the survey. Table 4 reports that just over a quarter of households had an unreliable supply in 2019. Unreliability was experienced by about one-eighth of metro households, one-quarter of non-metro households, a third of rural households, and a staggering two-thirds of households in traditional areas.

Table 4

The results of water quality tests for each of 144 water services authorities (WSAs)[4] under six headings are assembled by the Department of Water and Sanitation’s Water Services Knowledge System (WSKS). Table 5 sets out the outcomes for 2020.

Table 5

Source: Department of Water Affairs and Sanitation Water Services Knowledge System

Noteworthy are the large numbers of WSAs for which no reports are available, either because tests were not done or because they were not submitted to the WSKS. Widespread defects in the use of disinfectants, in operating standards and microbiological tests are apparent in Table 4.

Sanitation

Improved sanitation facilities are defined as flush toilets connected to a public sewerage system or a septic tank, or a pit toilet with a ventilation pipe. Nationally, the percentage of households with access to improved sanitation increased from 61.7% in 2002 to 82.1% in 2019. Progress was made in every province in the intervening period, and was strongest in Eastern Cape, Limpopo and KwaZulu-Natal.

Table 6 sets out the percentages of households with flush toilets connected to municipal sewerage. This is the appropriate form of sanitation in densely populated areas, so it can be seen that there is a considerable distance to go in metro and urban informal areas, as well as in formal townships and dense settlements in traditional areas.

In May and June 2019, AfriForum tested the sewage systems of 124 towns. There were 65 Sewage Treatment Works that did not comply with South African national water quality standards, in terms of which treated sewage may not contain more than 1 000 units of E. coli per 100 ml of treated sewage. This is a highly unsatisfactory state of affairs and risks microbiological contamination of drinking water.

Table 6

Source: GHS 2019

Conclusion

The poor quality of local government outside Western Cape and Gauteng has been a problem ever since the introduction of the current system twenty years ago. As indicated in the Annexure, the problem has been getting worse in recent years. One initiative after another has failed to make a significant dent in the mess. The jury is out on the latest programme – the District Development model.

As a result, most local governments are doing less than they should in promoting health and conditions, and some are seriously deleterious to the wellbeing of their inhabitants. Turning the situation around will not be easy, especially in a period of fiscal stress.

Charles Simkins
Head of Research
charles@hsf.org.za

Annexure - Summary comments on local government finance from the Auditor-General’s Municipal Finance Management Act Report 2018/19

EASTERN CAPE

A widespread lack of financial controls and project monitoring, an ongoing culture of a lack of accountability as well as a tolerance of transgressions resulted in a further regression in audit outcomes in the province – improvements were rare and the general trend over the past three years remained negative. Eight municipalities were unable to adequately support the information reported in their financial statements and received disclaimed opinions.

FREE STATE

The audit outcomes in the province continued to regress for the third consecutive year. Ten municipalities did not submit financial statements on time – even more than in prior years, which resulted in eight audits not having been completed by the time of this report. Additionally, three municipalities received disclaimed opinions. This means that almost half of the municipalities in the Free State have not yet accounted for the manner in which they used taxpayers’ money in 2018-19 or did it so poorly that their financial statements cannot be trusted.

GAUTENG

The picture in Gauteng held steady with all municipalities again maintaining their good audit outcomes for completed audits. This was the only province in which all the municipalities had unqualified audit opinions, but as in prior years only Midvaal obtained a clean audit opinion. This continued to elude the other municipalities as we observed good financial accounting but inadequate monitoring of the preventative controls necessary to ensure compliance with legislation and accurate reporting on service delivery achievements.

KWAZULU-NATAL

There was little change in the audit outcomes of the province, accountability was not adequately practised and enforced by leadership, and the failure of key controls continued.

LIMPOPO

Six municipalities in the province improved their audit outcomes and three regressed. The improvements were mostly consultant-driven, but despite the province having spent R122 million on consultants for financial reporting purposes, many municipalities continued to receive qualified opinions. There was a high reliance on consultants, skills were not transferred, and some officials became complacent when consultants were appointed and did not perform the jobs they were appointed to do, raising questions about municipalities paying for officials and consultants to do the same job. Millions were spent to improve the outcomes, but there were no consequences for poor performance.

MPUMALANGA

Deteriorating accountability and financial management coupled with weakened oversight is at the centre of the significant regressions in audit outcomes in the province – six municipalities regressed and only two improved. There was a breakdown in internal control across various municipalities, which included basic financial disciplines such as record keeping, reconciliations and verifications.

NORTHERN CAPE

The province is in a prolonged state of undesirable audit outcomes, with yet another overall regression – six municipalities regressed and only three improved. As in prior years, not all the audits were completed on time for inclusion in this report, as the financial statements were submitted late.

NORTH WEST

The regression in audit outcomes completes a three-year downward trajectory in the province: nine municipalities received disclaimed opinions and eight received qualified opinions. The availability of documents or evidence to support financial activities remained a vast challenge across the municipalities, as evidenced by the number of repeat disclaimed opinions. The inability of the province to reverse the trend of negative audit outcomes points to a culture that is not proactive in dealing with control weaknesses flagged in prior years.

WESTERN CAPE

The largest concentration of clean audits remained in the Western Cape (45%), with 93% of the province’s municipalities receiving unqualified opinions on their financial statements. Eight municipalities retained their clean audit status – six of which have maintained this status for the past five years or longer.

This was the last report signed by the late Kimi Makwetu, a highly competent and committed Auditor-General. We mourn his passing, and we look forward to the maintenance of the standards he set.

[1] Statistics South Africa, Financial Census of Municipalities for the year ended 30 June 2019, Statistical Release P9114, 9 July 2020, Part 4