A SWOT analysis of contemporary gaps and a possible diagnostic tool for environmental health in an upper-middle income country: a case study of South Africa

ABSTRACT

This study evaluated the state of environmental health in the Republic of South Africa using the strengths, weaknesses, opportunities, and threats (SWOT) analysis framework. The internal and external factor evaluations were conducted by reviewing existing literature searched using a combination of keywords and boolean functions. The weighted score for the strengths and weaknesses was 0.79 and 1.04, respectively. The external factor evaluations findings revealed that environmental health has an equal amount of threats and opportunities, however, the threats outweigh the opportunities. The total weighted score for the internal and external factor evaluations was 1.83 and 2.25, respectively, which were below the average value of 2.5. The internal-external factors matrix indicated that environmental health in the Republic of South Africa needs to be refocused and re-aligned to public health protection. Failure to address the weaknesses and threats and optimise the strengths and opportunities may further weaken the provision of environmental health services.

KEYWORDS:

• Environmental stressor
• exposure
• public health

Introduction

Exposure to environmental stressors can lead to adverse health outcomes, some of which are irreversible (Borchers et al. 2006). Physical, biological, and chemical environmental stressors account for approximately 13.7 million deaths per year globally, and low to middle-income countries are the most affected (World Health Organization 2016a). In the African region, 2.5 million deaths per year are attributed to exposure to environmental stressors and the burden is highest among children and the elderly (World Health Organization 2016a). Furthermore, the highest number of deaths per capita was reported in sub-Saharan Africa (Mboera et al. 2014; Joubert et al. 2020). It was further reported that approximately 40% of the burden of diseases in sub-Saharan Africa is due to exposure to environmental stressors (Mboera et al. 2014). Moreover, approximately 5% of the deaths that occurred in poorly resourced countries was attributed to poor environmental conditions (Wright et al. 2017). However, Wright et al. (2017) emphasised that the deaths could have been prevented with effective public health interventions, where EH is a central focus point of improved environmental hygiene. Therefore, there is a need to protect public health against such environmental stressors to promote sustainability and quality of life amongst populations (Prüss-Ustün et al. 2016).

A preventative approach, usage of available datasets, frequent biomonitoring, surveillance of environmental stressors, and research, particularly longitudinal studies are encouraged to address this public health issue (Mboera et al. 2014; Vardoulakis et al. 2016; Bornman et al. 2017). Studies (e.g. Musoke et al. 2016; Morse et al. 2020) have highlighted that environmental health (EH) is a key component in protecting public health. EH is concerned with all aspects of the natural and built environment that may adversely affect human health (Dhesi 2019; Papadopoulo et al. 2019). Environmental health practitioners (EHPs) are responsible for rendering environmental health services (EHS) to prevent environmental-related diseases and injuries (Whiley et al. 2019; Brooks et al. 2019). The main responsibilities of EHPs are to identify and characterize risks to human health and propose preventative measures to protect public health (Brooks et al. 2019). Therefore, EHPs are the first line of defence since the profession is on the prevention side rather than the curative side (Agenbag and Balfour-kaipa 2008; Whiley et al. 2019). Moreover, EHPs are responsible for various functions that impact the health and lifestyle of people (Howze et al. 2004; Resnick et al. 2009).

Food control, water quality monitoring, environmental pollution control, vector control, and solid waste management are some of the main functions of EHPs in the RSA (Department of Health 1991). EHPs are also responsible for the control of communicable and non-communicable diseases including the investigation of outbreaks (Department of Health 1991). Therefore, the multidisciplinary nature of EH requires EHPs to always be ready to protect public health with appropriate skills and knowledge (Dobson et al. 2019). However, the EH profession is faced with numerous unaddressed challenges such as the lack of human resources, technological resources, lack of involvement in scientific research, and workforce development (Wright et al. 2014; Mbola et al. 2019; Gerding et al. 2020). Despite scientific evidence on the prospects and drivers of poor environmental conditions and exposure to environmental stressors, there is a lack of implementation of interventions. The lack of implementation is attributed to insufficient research development and incapacity in the political domain or the professional space. On the other hand, there is also no political nor professional will to implement scientific evidence from academic and research institutions (Newman et al. 2016).

Studies (e.g. Oosthuizen and Ehrlich 2001; Muller et al. 2003; Davies and Mundalamo 2010; Kamunda et al. 2016; Morakinyo et al. 2016; Buthelezi et al. 2019) assessing environmental stressors and their impact on human health have been conducted in RSA. However, there is a dearth of scientific studies evaluating the state of EH in the country (Thomas et al. 2002; Mathee 2011; Shezi et al. 2019). Furthermore, there is no state of EH report that has been published in the RSA thus far (Wright et al. 2014). Hence, this study was conducted to evaluate the state of EH in RSA using the strengths (S), weaknesses (W), opportunities (O), and threats (T) (SWOT) analysis as shown in Figure 1. To the best of our knowledge, this is the first study to evaluate the state of EH using the SWOT analysis framework. The SWOT analysis is predominantly used in the business management sector as a strategic management tool (Helms and Nixon 2010). However, it may also be used in other sectors including energy (Liu et al. 2011; Agyekum 2020), education (Thamrin and Pamungkas 2017), and healthcare services (Van Durme et al. 2014).

Figure 1. The SWOT analysis framework.

The strengths and weaknesses fall under the internal factors and can be controlled from within the organisation or profession (David et al. 2019; Li et al. 2020). The opportunities and threats fall under the external factors, which can be of harm or beneficial and are beyond the organisation’s or profession’s control (David Fred et al. 2019; Li et al. 2020). How the strengths and weaknesses are matched with the opportunities and threats to determine the success and survival of an organisation (Mbachu and Frei 2011). Therefore, the SWOT analysis is central to strategy formulation, implementation, and review. Given the importance of EH services in protecting public health, it is important to know such information so that improvements through research-informed decisions can be made.

Methods and materials

Published literature from multiple electronic research databases from 2000–2020 were reviewed. The literature review was done to identify trends, development, practices, and policies over 20 years. Searched databases for peer-reviewed literature included Science Direct, ProQuest, Google Scholar, Web of Science, Sabinet, SpringerLink, SAGE online, PubMed, Nature, MDPI public health, and Taylor and Francis.

The databases were searched using a combination of keywords and boolean functions that included ‘environmental health OR “public health” AND “developing countries” OR “low-middle income countries” AND environmental stressors’ OR ‘environmental hazards’ AND ‘exposure’ AND ‘research’ ‘SWOT analysis’ AND ‘South Africa’ AND ‘burden of disease’ AND ‘environmental pollution’ OR ‘contamination’. Furthermore, the snowball effect was applied when reviewing the selected journal articles. In addition, web pages, literature, and official reports from the government, World Health Organization, and the National Institute of Communicable Diseases were used. The search was done from January to December 2020 and only literature published in English was used.

The sources were then screened by reading the title and abstracts, the different sources used are presented in Table 1. The information was then used to evaluate the state of EH in RSA using the SWOT analysis. The SWOT analysis technique enables decision-makers to find solutions aimed at minimising the weaknesses and threats before they become catastrophic and optimise the opportunities and strengths to ensure sustainability (Reinsberger et al. 2015).

Table 1. A summary of the selected resources used to gather information.

Category	Number	Focus area
Journal articles	80	Environmental stressors, environmental pollution, solid waste management, indoor and outdoor air quality, community service, environmental exposure, SWOT analysis, population statistics, EH challenges and opportunities in RSA, human health, diseases outbreaks, data collection and research, bursaries, and higher education, pest control, food safety, political stability, disease prevention, risk assessment, and communicable diseases, disaster management
Books/chapters	6	Environmental health and sustainability
Conference proceedings	3	Environmental health and SWOT analysis
Policies	3	National Health Policy, constitution, EH guidelines, national health act, national environmental health policy, and rights
Organisational documents	4	EH scope of practice, hazard mapping institutions offering EH
Web pages	11	Invisibility of EHPs, fake EHPs, number of registered EHPs, population statistics

A list of the SWOTs identified during the literature review was compiled and they were extensively discussed among the authors and colleagues. The discussions were done in groups of three to eight individuals which allowed brainstorming thus preventing the dominance of individual-based perspectives which could have affected the SWOT analysis results. Based on the discussions, each author was tasked to assign weights and ratings to the identified SWOTs. The weighting was assigned based on the negative impacts of the weaknesses and threats and the positive impacts of the strengths and opportunities identified. For example, the community service backlog challenge was identified as a weakness because it further contributes to the shortage of EHPs in the country. Furthermore, the CS backlog has been a long-standing challenge and not much has been done to resolve it and was therefore assigned a higher weight and lesser response. Where there were disagreements and a huge difference between the scores and ratings of the different authors, EHPs in academia and the field were consulted telephonically at times through face-to-face interviews. In cases where the weights were different, the values were added and divided by the total number of values to get an average which was then used as a weight.

The consulted pool of individuals is employed by the Gauteng Department of Health, University of South Africa, University of Johannesburg, City of Johannesburg Metropolitan Municipality, Ekurhuleni Metropolitan Municipality, Ehlanzeni District Municipality, Gert Sibande District Municipality, and Mpumalanga Department of Health. Similar to Van Durme et al. (2014), the consulted individuals were identified through formal and informal networking and were selected based on their years of experience. A total of 15 EHPs were consulted and most of the interviewed individuals had over 10 years of experience and expertise covering the SWOTs identified in this study.

The internal and external factor evaluations were used to grade the identified strengths, weaknesses, opportunities, and threats. Each identified factor was assigned a weight ranging from 0.0 to 1.0 representing the importance of the factor. A weight of 0.0 represents a factor of less impact, whereas a weight of 1.0 represents a factor with a high impact on EH and the sum of all the weights must be equal to 1. The ratings in the internal factor evaluation (IFE) represent how strong or weak are the identified internal factors, while the ratings in the external factor evaluation (EFE) describe how effectively EH responds to the opportunities and threats (Table 2).

Table 2. Criteria used to score the identified SWOTs for environmental health in South Africa.

Internal factor evaluation		External factor evaluation
Rating	Meaning	Rating	Meaning
1	Major weakness	1	Poor response
2	Minor weakness	2	Average response
3	Minor strength	3	Above average response
4	Major strength	4	Superior response

The weighted scores were obtained using Equation 1(1) $Weightedscore=weight\times rating$(1) . Equation 2(2) $\mathrm{T}\mathrm{o}\mathrm{t}\mathrm{a}\mathrm{l}\mathrm{w}\mathrm{e}\mathrm{i}\mathrm{g}\mathrm{h}\mathrm{t}\mathrm{e}\mathrm{d}\mathrm{s}\mathrm{c}\mathrm{o}\mathrm{r}\mathrm{e}=\sum _{i=1}^n{x}_i$(2) was used to calculate the total weighted score. For example, the total weighted score for the IFE was obtained by adding the weights of the strengths with the weights of the weaknesses. In SWOT analysis, a total weighted score of 2.5 is considered as an average score. The total weighted scores from the IFE and EFE were then used to plot the internal-external factor matrix to evaluate the state of EH services in RSA.

(1) $Weightedscore=weight\times rating$(1)

(2) $\mathrm{T}\mathrm{o}\mathrm{t}\mathrm{a}\mathrm{l}\mathrm{w}\mathrm{e}\mathrm{i}\mathrm{g}\mathrm{h}\mathrm{t}\mathrm{e}\mathrm{d}\mathrm{s}\mathrm{c}\mathrm{o}\mathrm{r}\mathrm{e}=\sum _{i=1}^n{x}_i$(2)

The structure of environmental health service in RSA

EHS is the responsibility of the Minister of Health at the national government. The national EH directorate is responsible for the facilitation, implementation, and provision of EHS programmes in the country as per section nine of the National Environmental Health Policy (Department of Health). The EH directorate is also responsible for developing national policies, strategies and research and defining norms and standards that govern institutions that render EHS (Eales et al. 2002; Mbola et al. 2019). The provincial and municipal spheres of government have been allocated certain functions and responsibilities by the National Department of Health (Mbola et al. 2019). The municipal sphere of government includes metropolitan municipalities, district municipalities, and local municipalities (Agenbag 2015). RSA consists of 228 local municipalities categorised into 44 district municipalities and eight metropolitan municipalities (Shezi et al. 2019). Figure 2 presents the different EHS offered at different levels.

Figure 2. The structure of environmental health in South Africa and functions at different levels.

The conduct and practice of EHPs are regulated by the Health Professions Council of South Africa (HPCSA), an independent statutory body that regulates all the health professions in the country (Health Professions Council of South Africa 2019). The registration requirements for health professionals and academic institutions are stipulated by the HPCSA (Health Professions Council of South Africa 2019). The HPCSA also guides and informs the curriculum development procedures and ensures that learning and training institutions adhere to the fundamental competencies and training frameworks (Health Professions Council of South Africa 2020a). The HPCSA has a responsibility to protect the integrity of EH by ensuring that EHPs are provided with an opportunity to practice independently for what they qualified for and to secure their practising space (Health Professions Council of South Africa 2019). Therefore, the HPCSA must ensure that no one unlawfully practices in the EH space (Health Professions Council of South Africa 2019).

Results

Table 3 presents the SWOTs for EH in RSA that were identified during the literature reviewand the weights allocated in consultation with EHPs in the field and academia. Based on our findings, it can be noted that EH in RSA has many weaknesses than strengths and more threats than opportunities.

Table 3. A summary of the SWOTs identified for environmental health in South Africa and their weights.

Strengths	Weight	Weaknesses	Weight
S1 Policies and regulations	0.1	W1 Shortage of human resource	0.1
S2 Political stability	0.05	W2 Community service backlog	0.2
S3 Knowledge sharing platforms	0.05	W3 Failure to render environmental health services	0.07
S4 Continuous professional development	0.03	W4 Lack of public awareness	0.07
		W5 Lack of training	0.05
		W6 Lack of standardisation in EH courses	0.01
		W7 Misdirected and misunderstood profession	0.1
		W8 Lack of data science approaches	0.06
		W9 Lack of research and development	0.06
		W10 Lack of specialisation	0.05
Opportunities	Weight	Threats	Weight
O1 Access to higher education	0.1	T1 Risk of outbreaks	0.3
O2 Research	0.05	T2 Lack of funding	0.3
O3 Specialisation	0.05	T3 Illegal practising and impersonation of EHPs	0.2

Table 4 presents the IFE results. The strength and weaknesses are considered internal because they are within the organisation and can be controlled through corrective measures. From Table 4, it can be noted that the strengths have a lower weighted score compared to the weaknesses. Furthermore, the total weighted score was significantly lower than the required average score of 2.5.

Table 4. Internal factor evaluation results.

Internal factors	Weight	Rating	Weighted score
S1 Policies and Regulations	0.1	4	0.4
S2 Political stability	0.05	3	0.15
S3 Knowledge sharing platforms	0.05	3	0.15
S4 Continuous personal development	0.03	3	0.09
Total	0.23	-	0.79
W1 Shortage of human resource	0.1	1	0.1
W2 Community service backlog	0.2	1	0.2
W3 Failure to render EHS	0.07	1	0.07
W4 Lack of public awareness	0.07	1	0.07
W5 Lack of training	0.05	1	0.05
W6 Lack of standardisation in EH courses	0.01	2	0.02
W7 Misdirected and misunderstood profession	0.1	3	0.3
W8 Lack of data science approaches	0.06	2	0.12
W9 Lack of research and development	0.06	1	0.06
W10 Lack of specialisation	0.05	1	0.05
Total	0.77		1.04
Total weighted score	1	-	1.83

The EFE results are presented in Table 5. It can be noted that the opportunities had a lower weighted score relative to the threats. Also, the total weighted score was almost the required average score of 2.5.

Table 5. External factor evaluation results.

External factors	Weight	Rating	Weighted score
O1 Access to higher education	0.1	2	0.2
O2 Research and development	0.05	3	0.15
O3 Specialisation	0.05	2	0.1
Total	0.2	-	0.45
T1 Lack of funding	0.3	2	0.6
T2 Risk of outbreaks	0.3	2	0.6
T3 Illegal practising and impersonation of EHPs	0.2	3	0.6
Total	0.8	-	1.8
Total weighted score	1	-	2.25

Figure 3 presents the internal-external factors plot which was plotted using the total weighted scores from the IFE and EFE. It can be noted that EH in RSA was rated weak when it comes to the internal factors and medium for the external factors.

Figure 3. Internal-external factor matrix.

Discussions

Strengths

The strengths focus on the excellence of EH and the advantages it has in the country.

Policies and regulations

The profession has seen many pro-EH legislations been promulgated. The role of political principals has been distinguished and national stakeholder platforms that share best practices have been created (Mbola et al. 2019). The country’s legal system is mainly based on the constitution of the RSA (108 of 1996), followed by Acts, Regulations, policies, and standards. Section 24(a) of the constitution of the RSA as the mother body states that everyone has the right to an environment that is not harmful to their health or well-being (Department of Health). Therefore, EHPs are mandated to uphold section 24(a) of the constitution and protect the health, safety, and well-being of the public from environmental stressors.

Laws governing EH in the RSA include the National Health Act (61 of 2003), National Department of Health), Foodstuffs, Cosmetics and Disinfectants Act (73 of 1972), National Environmental Management: Air Quality Act (39 of 2004), National Environmental Management: Waste Act (59 of 2008), National Environmental Management Act (107 of 1998), National Water Act (36 of 1998), and Meat Safety Act (40 of 2000) (Department of Health). The National Health Act (61 of 2003) stipulates the roles and responsibilities at each sphere of government (Department of Health). Chapter 10(83) of the National Health Act stipulates that if an EHP has reasons to believe that there is the existence of a condition that (i) contravenes section 24(a) of the constitution, (ii) constitutes pollution that is detrimental to human health, (iii) is likely to or constitutes a health nuisance, the EHP must investigate such condition. To ensure integrity in the profession, the professional code of conduct and ethics that EHPs must abide by are stipulated by the Health Professions AmendmentAct (29 of 2007).

Political stability

Political instability can affect the progression of a country and how essential services such as EHS are rendered (Radu 2015). Studies have revealed how political instability can negatively affect the health systems, delivery of service, economy, and higher learning institutions (Shumetie and Watabaji 2019). RSA has had political stability since 1994 post the apartheid era, therefore, EH in RSA is secure since the country has political instability.

Knowledge sharing platforms

As part of celebrating world EH day, annual EH conferences are held in September and various governmental and non-governmental organisations such as the South African Local Government Association, labour departments, research entities, community forums, and academic institutions are invited. The conferences discuss the challenges faced by EH professionals and departments across the country and seek solutions. The conference also provides an opportunity for discussion forums, networking, and the cross-fertilisation of ideas.

Continuous professional development

In South Africa, any professional personnel register is mandated to have continuous professional development (CPD) commonly referred to as lifelong learning. Section 26 of the Health Professions Act (56 of 1974) endorses CPD to maintain and update professional competence, thus ensuring that public health is promoted through quality service delivery (Health Professions Council of South Africa 2017). The objective of the CPD is to help EHPs maintain and gain relevant knowledge, skills and ethical attitudes while enhancing and promoting professional integrity.

EHPs must have a minimum of 30 continuing education units per year which are valid for two years, from the 30 continuing education units, five must be for ethics, human rights, or health law (Health Professions Council of South Africa 2020a). Continuing education units can be obtained from two categories, the first category comprises learning activities with non-measurable outcomes such as education, training, research, and publications (Health Professions Council of South Africa 2020a). The second category comprises learning activities with measurable outcomes such as formal structure learning programmes (Health Professions Council of South Africa 2020a). For example, the main author of a peer-reviewed publication or book chapter will receive 15 continuing education units, whereas the co-authors will receive five.

Weaknesses

The weaknesses refer to the internal factors that must be avoided and responded to sufficiently for the profession to achieve its goals and objectives (Nikolaou et al. 2011). Numerous constraints such as funding, community backlog, lack of specialised services, relevant developmental training, buy-in from communities, and visibility of EHS professionals still affect EH in RSA.

Shortage of human resource

The WHO recommends an EHP ratio of 1:10000 people in both developed and developing countries, however, RSA adopted a national ratio of 1:15000 (Agenbag and Balfour-kaipa 2008; Department of Health). According to Statistics South Africa (2020), the RSA mid-year population estimate is 59.62 million and as of September 2020, the HPCSA has a total of 3 565 registered EHPs on its database (Health Professions Council of South Africa 2020a). The division of the total population by the number of registered EHPs shows that RSA does not comply with both the World Health Organization and national EHP ratio. When using the WHO 1:10000 ratio standard, based on the RSA’s population statistics, there is a shortage of 2 397 (40.2%) EHPs, and 410 (10.3%) when using the national standard of 1:15000. Therefore, there is a shortage of EHPs in the country, a challenge that has existed for years.

The shortage of EHPs in RSA is mostly in rural areas where their services are needed the most (Agenbag and Gouws 2004; Reid 2005). For example, during the cholera outbreak that occurred in the Eastern Cape, KwaZulu-Natal and Mpumalanga Province, there was a significant shortage of EHPs, subsequently, EHPs were brought from other provinces (Eales et al. 2002). The shortage of human resources may force EHPs to abandon their core responsibilities which are integral to public health, which also creates a gap in the provision of EHS. Indeed, the shortage of human resources in RSA has forced EHPs to focus on reactive checklist inspections and compliance monitoring rather than a proactive preventative approach (Eales et al. 2002). This approach subsequently gives a perception that EH is less impactful and a relatively low priority profession that requires limited resources (Eales et al. 2002).

Community service backlog

Community service (CS) was introduced in 2003 as a part of training aimed at strengthening the workforce while improving service delivery (Reid et al. 2018). Subsequently, EHP graduates must complete a full 1-year uninterrupted compulsory CS before they can practice independently (Mbola et al. 2019). The purpose of community service was to accelerate career growth and development by ensuring skill transfer of graduates within the public sector. Although CS was seen as a good initiative, the systems and funding were not always in place to facilitate the placement of graduates, resulting in a backlog (Wright et al. 2014; Reid et al. 2018; Mbola et al. 2019). Moreover, the EH CS only accommodates indigenous university graduates, and foreign graduates who qualified in the country are excluded.

Depending on the financial situation, most EH university graduates who are not placed for CS consider furthering their studies in other fields, while some work in the private sector while waiting for CS placement (Eales et al. 2002; Karamchand and Kistnasamy 2017). Many EH university graduates who are unable to further their studies or find work elsewhere, sit and hope for CS placement while voicing out their frustrations on social media platforms. The CS backlog further creates a shortage of EHPs because EH university graduates who do not complete a full year CS are not allowed to register with the regulatory board as independent practitioners (Karamchand and Kistnasamy 2017). In 2018, EHPs, EHP graduates, and EH students marched to the union buildings demanding recognition and CS placement (Mbola et al. 2019). The march highlighted the severity and frustrations caused by the CS backlog. Nonetheless, the CS backlog continues to date with no solid solutions (Mbola et al. 2019).

Failure to render environmental health services

The most noticeable EHS that is poorly rendered across RSA is solid waste management (Zhou et al. 2016). The mismanagement of solid waste becomes a nuisance during rainy seasons due to the significant production of leachate and infestation of flies and insects (Ferronato and Torretta 2019). The mismanaged solid waste also provides habitat and a conducive breeding environment for rodents, which are a serious problem in RSA, particularly in the Gauteng Province (Froestad 2005; Jassat et al. 2013). The mismanagement of solid waste has also burdened public health facilities in Gauteng Province due to preventable environmental-related diseases such as plague, leptospirosis, rickettsia pox, rat-bite fever, murine typhus, Lassa fever, viral haemorrhagic fever, and Salmonellosis (Meerburg et al. 2009; Strand and Lundkvist 2019).

Lack of public awareness

EHPs are supposed to engage with populations at a community level to understand the dynamics, social and cultural norms of the communities (Morse et al. 2020). Engaging with communities helps build trust and it becomes easy to identify major challenges, the types of interventions needed, where they must be placed to make significant improvements in halting the spread and preventing the occurrence of diseases. However, the presence of EHPs in South African communities is limited even during EH crises, leading to a lack of public awareness (Shonhiwa et al. 2019). The lack of public awareness can be attributed to poor logistics and a shortage of staff. Due to the lack of public awareness, communities do not understand the nature and practice of EHPs, hence the profession subsequently lacks recognition.

The presence of EHPs in communities is important in disseminating information regarding environmental stressors (Eales et al. 2002), the mechanism for stressor release, transmission pathway(s), and exposure event(s). This approach can lead to an effective introduction of a preventative mechanism that focuses on the efficacy (level of protection an intervention provides), efficiency (what end-users can afford), and acceptance (what end-users prefer) (Mboera et al. 2014; Musoke et al. 2016; Masekameni et al. 2020). Greenhalgh et al. (2014), alluded that the success of public health interventions depends on their relevance, affordability, acceptability, and consultation with the end-users.

The awareness of environmental stressors and the implementation of EH interventions can also improve the lifestyle of communities and response to environmental stressors, thus significantly decreasing their susceptibility to preventable diseases (Weis et al. 2005). Disseminating the right and relevant information can also help avoid unpleasant situations that unfolded during the COVID-19 outbreak where misleading information was spread (Morawska and Milton 2020). Furthermore, section 32 of the constitution of RSA states that everyone has the right to information held by the state or person that is required for protecting any rights (Republic of South Africa 1996). Therefore, EHPs are denying the public their right to information, particularly on public health-related issues. Although EHPs have the responsibility to disseminate the correct information to the public to avoid propaganda and conspiracy theories, they are invisible in the mainstream media even during EH crises (Eales et al. 2002; Whiley et al. 2019).

Lack of training

EHPs must be well trained and skilled to evolve with the changing times and EH service delivery approaches. However, the training of EHPs in RSA, particularly on the specific functions in the scope of practice guiding EHS is lacking (Selman and Green 2008). Subsequently, there are knowledge gaps and inconsistencies when rendering certain EHS such as the investigation of communicable disease outbreaks (Mbonane and Naicker 2020). Thus, EH-related issues and risk factors that contribute to the spread of disease are not properly identified and addressed during an outbreak. On the contrary, the EH scope of practice states that EHPs have a responsibility to identify environmental factors that could have contributed to disease outbreaks (Coleman 2016). This implies that EHPs ought to be equipped with the relevant methodologies required to assess and quantify complex and dynamic EH problems (Department of Health). It is therefore necessary to frequently review and adapt the training of EHPs to ensure that it is aligned with the current EH challenges (Health Systems Trust 2015).

Lack of standardisation in the EH courses among universities

Initially, the EH course was offered by two universities and five universities of technology as a three-year national diploma with an optional one year of a baccalaureus technologiae which is equivalent to an honours degree. The national diploma and baccalaureus technologiae in EH were recently replaced by a 4-year degree in EH. However, the transition to the 4-year degree was not done simultaneously in all institutions, consequently, two institutions (Mangosuthu University of Technology and the Cape Peninsula University of Technology) began offering the EH at a later stage relative to the other learning institutions. Furthermore, institutions have different names for the new 4-year degree, the Central University of Technology offers a Bachelor of Science degree in EH, the Durban University of Technology offers a bachelor of EH, whereas the remaining institutions offer a B-degree in EH.

The list of learning institutions offering the 4-year degree in EH is shown in Table S1 on the supplementary material sheet. From Table S1, it can be noted that there is no standardisation in the modules offered across the different institutions. Some institutions offer modules that are not offered in other institutions for the same EH course. For example, DUT offers biochemistry as a standalone module, at CUT it is combined with chemistry while the other institutions are not offering it all. Furthermore, some institutions offer the same modules but at different levels, and some modules are semester modules and block modules. The University of Johannesburg offers certain modules as block modules while other institutions offer them as semester modules. The lack of standardization creates an impression that certain institutions provide better and quality EH courses than others and therefore, EH graduates from such universities are more informed.

A misdirected, neglected and misunderstood profession

It is claimed that the EH profession is the most misdirected, misunderstood, overlooked, and under-recognised (Whiley et al. 2019). In RSA, EH seems to have moved from a preventative to a curative approach that is defying the role and function of this profession (Eales et al. 2002). Subsequently, responses to public health crises such as disease outbreaks are often dominated by a clinical approach (Eales et al. 2002; Whiley et al. 2019), with the impact of the EH and its preventative measures overlooked (Morawska and Milton 2020; Yang et al. 2021). A study by Rodrigues et al. (2021) showed how EHPs in Portugal, the United Kingdom, the United States of America and Australia played a vital role in controlling the transmission of the coronavirus in residential and occupational settings. For example, EHPs were involved in contact tracing, risk assessment of public facilities, public spaces and workplaces, risk communication and monitored conditions in temporary shelters (Rodrigues et al. 2021). However, in the context of RSA, the Gauteng Department of Health recruited more nurses to combat the COVID-19 outbreak, with little consideration given to EHPs (Africa Press Office 2020). The invisibility of EHPs in turn diminishes the role and importance of EH, subsequently, other professions and politicians are not aware of the profession, hence it is excluded in decision-making forums (Eales et al. 2002; Dhesi 2019). This leads to EH being given less recognition even during disease outbreaks.

Lack of data science approach

Collecting environmental data is a challenge in a global context (O’ Marley et al. 2009; Biber 2013). In RSA, data collection, particularly scientific-technical datasets such as monitoring or sampling of environmental stressors are lacking (Mathee et al. 2010). The lack of data collection often leads to a paucity of reliable exposure data at the receptor level (Sly et al. 2016). Subsequently, it is challenging to spot trends of exposure to environmental stressors in communities. Data availability can enable the country to develop its exposure handbooks. For example, countries such as Canada, China, Korea, and Japan have developed their exposure handbooks through big data collection and monitoring (Filipsson et al. 2011; Phillips and Moya 2014; Jang et al. 2014). On the other hand, RSA continues to rely on the United States Environmental Protection Agency exposure factors that are not a true representation of the RSA population. Using such data can affect the accuracy of results, particularly when conducting a human health risk assessment (Masekameni et al. 2019).

It has been widely proven that EH challenges can be controlled using research-based decisions (Briggs 2000; Biber 2013; Couch et al. 2016). For example, EH research can help understand challenges such as climate change, exposure to nanoparticles and persistent chemical pollutants (Couch et al. 2016; Shezi et al. 2019). However, sufficient data must be collected to understand the exposure pathway (Briggs 2000). The source(s), nature of the stressor, transport media, and receptors must be known and it must also be determined whether there is a possibility of the stressor changing from one transport media to another (Bonnefoi et al. 2010).

Information on the receptors is important as it gives an insight into the variability within the community and susceptible groups. For example, in a community that relies on river water for drinking, pregnant women, the elderly, and children under five years, and the sick will be at the highest risk of developing adverse health effects if the water is contaminated (Joubert et al. 2020). The ingestion route is one of many exposure pathways, exposure can also occur through ingestion of vegetables watered with the contaminated water and the dermal route when bathing with the contaminated water (Mathee 2011; Genthe et al. 2018). Moreover, there is evidence (e.g. Khan et al. 2008; Amin et al. 2013; Mehmood et al. 2019) that edible plants can be contaminated with heavy metals that are uptaken through the roots, soil, or during irrigation with contaminated water (Genthe et al. 2018).

With the availability of data, simulations and models can be done to predict future exposure using probabilistic risk assessment approaches (Bonnefoi et al. 2010). Such information can also be used to select effective interventions and whether they should be placed at the source, along the pathway, or the receptor level (Weis et al. 2005). Therefore, data collection and understanding of the exposure pathway are fundamental in protecting the public against environmental stressors (Lioy 2010).

Lack of research and development

EHPs have highlighted the necessity of being actively involved in research to make their work evidence-based (Couch et al. 2016). However, little has been done to achieve this goal, even though the profession provides an opportunity for research and development (Couch et al. 2016). Subsequently, there is a lack of data that impedes EH research and the implementation of evidence-based interventions (Department of Health). The lack of research is also caused by insufficient funding needed to conduct large studies (Briggs 2000).

Exposure to chemical stressors through the environmental media has been identified as a major problem, and most of these chemical stressors are endocrine-disrupting chemicals (World Health Organization 2016b; Bornman et al. 2017). However, Nweke et al. (2009) reported that there is limited research to address the human health impacts of these stressors. Nonetheless, a bibliometric study by Wright et al. (2017) evaluating an 18-year trend of EH research in the RSA concluded that there is a promising steady growth in research output. However, the amount of EH research output is not satisfactory, particularly when compared to other European countries (Wright et al. 2017).

Lack of specialisation

EH offers an opportunity for specialisation due to its holistic approach and multidisciplinary nature that allows EHPs to collaborate with other professionals (Morse et al. 2020). For example, during an outbreak or pandemic, EHPs work closely with epidemiologists during the case investigation. Despite the specialisation opportunity that EH offers, there is a lack of specialisation career paths for EHPs in the RSA public health sector. Most EHPs work for many years after obtaining their national diploma and never advance their studies to grow and develop professionally. Anecdotal information suggests that most EHPs when they further their studies, it is outside of the scope of EH. For example, most EHPs have a postgraduate degree in business administration and environmental management. Growth and development within the EH profession can help improve the profession in the country. The global health dynamics are changing daily and there is a need to ensure that EHPs can handle EH problems effectively and efficiently (Day 2016).

Opportunities

The opportunities refer to the external benefits that EHPs can optimise to improve the delivery of EHSs and grow the profession (Nikolaou et al. 2011). Opportunities have positive effects on the profession and can be optimised through the profession’s strengths (Mbachu and Frei 2011).

Access to higher education

Access to higher education in the country has improved and the number of students enrolled at higher institutions is increasing annually (Statistics South Africa 2019). Based on data from 2002, 10 learning institutions were graduating an average of 350 EH students per year and the numbers have likely increased in recent years (Eales et al. 2002). The EH course in RSA is offered at two universities (University of Johannesburg and Nelson Mandela University) and five universities of technology (Tshwane University of Technology, Durban University of Technology, Mangosuthu University of Technology and Cape Peninsula University of Technology and Central University of Technology) (Health Professions Council of South Africa 2020b). The EH course comprises a blend of theory and practical work whereby students are required to complete certain hours of work-integrated learning to gain experience. For example, during recess, students work with qualified EHPs and also visit the abattoir, hospitals and clinics and they must produce a portfolio of evidence for activities done. The course was initially offered as a 3-year national diploma with one optional year of a baccalaureus technologiae.

Given the rapid changes in environmental stressors, well-trained, competitive, and educated EHS graduates are needed to protect public health effectively and efficiently (Day 2016; Ahonen and Lacey 2017; Arshad et al. 2018). Therefore, the EH course was changed to a 4-year degree to better equip students with the relevant skills, knowledge, and expertise required to evaluate the risks posed by environmental stressors (Health Systems Trust 2015).

Research and development

Research has been considered the centre stone of capacity building and strengthening databases (Couch et al. 2016). As such, the importance of research in EH cannot be overlooked. Moreover, Chapter 9 of the National Health Act (61 of 2003), states that the minister must establish a national health research committee council. The committee must develop the application and implementation of an integrated national strategy for health research, coordinate the research activities of public health authorities and identify health research priorities (Department of Health). The health research priorities must address (i) the burden of diseases, (ii) the cost-effectiveness of interventions aimed at reducing the burden of diseases, (iii) availability of human and institutional resources for the implementation of an intervention at the level close to the affected communities, (iv) health needs of vulnerable groups such as woman, children, people with disabilities and the elderly and (v) health needs of communities (Department of Health).

Through research, knowledge gaps can be identified and closed. This is important given that the dynamics of EH are changing from time to time, thus providing an opportunity to study and better understand the problems (Department of Health). The research will also open discussion platforms and provide an opportunity for collaboration with other professionals (Couch et al. 2016). EH research will further help make informed decisions and implement effective evidence-based interventions and ensure capacity building within the profession (Dhesi and Stewart 2015; Couch et al. 2016)

Specialisation

The nine functions of EH and the range of specialism allow EHPs to develop interdisciplinary skills (Morse et al. 2020). The interdisciplinary skills of EHPs are regarded as a significant strength that can be used to collaborate and enhance specialisation which will help make well-informed decisions (Couch et al. 2016). Mbonane and Naicker (2020) found that the majority (80.3%) of EHPs believed that rendering all functions of EHS is not productive and impairs their performance. Furthermore, 62.3% of EHPs highlighted the need for specialisation to address current EH challenges in poorly-resourced countries (Mbonane and Naicker 2020).

Threats

The threats refer to the external barriers that can inhibit EH to reach its goals and objectives and must be overcome (Nikolaou et al. 2011). The threats have negative effects on the profession because they impact the profession’s weaknesses (Mbachu and Frei 2011).

Risk of outbreaks

The threats related to EH in RSA are a consequence of not addressing the weaknesses within the profession, which often leads to loss of life and disability. The listeriosis outbreak that occurred between January 2017 and March 2018 is a good example. The outbreak resulted in 1 200 confirmed cases and 998 deaths and was recorded as the largest outbreak ever recorded globally (National Institute of Communicable Diseases 2018; World Health Organization 2018; Boatemaa et al. 2019). Shockingly, the involvement of EHPs during the listeriosis outbreak was limited (Shonhiwa et al. 2019).

Similarly, amid the ongoing COVID-19 pandemic there is still a limited involvement of EHPs, despite that the pandemic was officially declared a national disaster. Several studies (e.g. Eldridge and Tenkate 2006; Gamboa-Maldonado et al. 2012; Fafard 2015; Lichtveld et al. 2020) have highlighted the importance of EHPs in disaster management. Importantly, EHPs are responsible for planning, hazard identification, human health risk assessment, communication, and ensuring uninterrupted EHS to reduce the potential health effects of the disaster. During the COVID-19 pandemic, EHPs were supposed to conduct contact tracing to enforce the public health regulations as per the National Disaster Act (57 of 2002). EHPs were also responsible for the identification of environmental risk factors and implement interventions to prevent the spread of the coronavirus (Morse et al. 2020). However, according to anecdote evidence, EHPs were involved with patient care whereby they were conducting contact tracing to check if patients were taking their treatment (National Department of Health 2020).

Lack of funding

There is a global trend of insufficiently funding for public health even though it is on the preventative side (Moran 2016; Sen-Crowe et al. 2020). In RSA, insufficient funds are allocated to EHS yearly, subsequently, it becomes difficult to allocate CS placement for EH graduates and recruit employees to strengthen the workforce (Department of Health). Due to insufficient funding, there are ‘frozen posts’ that cannot be advertised nor filed because there is no money, the situation has created a significant unemployment gap that further adds to the shortage of human resources (Eales et al. 2002). The insufficient funding also leads to a lack of bursaries and scholarships for students who wish to do EH and for qualified EHPs who wish to further their studies in the field (Mbola et al. 2019).

Bursaries and scholarships are a significant source of financial support, particularly for low-income students (Callender 2010). It has been proven that students are likely to select a course where there is financial support either in a form of bursaries or scholarships (Kaye 2020). Therefore, the lack of bursaries can affect the number of enrolments and EH graduates produced. A high enrollment for the EH course will ensure that the profession does not have a shortage of workforce, provided EHP graduates are placed for CS. Couch et al. (2016), highlighted that EH will probably remain a distinctly vulnerable profession until EHPs illustrate the importance and value of their work to decision-makers and funders.

Illegal practising and impersonation of EHPs

To practice as an EHP in the RSA, an individual must register with the HPCSA and pay annual fees to renew the registration. Failure to pay the annual fee will lead to suspension from the register, therefore, an individual must pay an annual fee to remain in the register and practice. Nonetheless, some EHPs are not in good standing with the HPCSA and yet they are practising, meaning that the individuals are practising illegally. Secondly, there is a growing trend of EHP impersonators that is witnessed in the metropolitan municipalities of RSA (Kahla 2018; Writer 2018; Carr 2020). The impersonators produce falsified certification to consumers and if any misconduct is found on the consumers’ side, bribery is demanded to avoid legal measures (Naidoo 2019; Jordaan 2020). The impersonators target areas that seem to be neglected by the official EHPs and take advantage of their absence. Although the HPCSA states that unregistered and or unqualified personnel practising as EHPs are committing a criminal offence (Health Professions Council of South Africa 2019), little is being done to solve this problem. Meanwhile, this trend is destroying the image of the profession in the country. Subsequently, people are losing hope in the profession.

Internal and external factor evaluation matrix analysis

To better understand how the factors identified during the SWOT analysis (Table 3) affect the state of EH in RSA, the IFE, and EFE were conducted. The major internal and external factors are listed and rated in Tables 4 and 5, respectively. From Table 4, it can be noted that the strengths have a lower weighted score relative to the weaknesses. Furthermore, the total weighted score is significantly lower than the required average score of 2.5. The low total weighted score in the IFE is an indication that the profession is weak internally and does not respond effectively to the strengths and weaknesses. Therefore, the profession might be weakened thus not adequately serving its purpose of protecting public health through.

Table 5 presents the EFE, and it can be noted that the opportunities had a lower weighted score relative to the threats. However, the total weighted score was near the required average of 2.5. The low total weighted score in the EFE is an indication that the profession’s strategies are not designed to effectively optimise the opportunities and fight against the threats. Figure 3 presents the internal-external factor matrix results of EH in RSA. The IFE and EFE matrix analysis enable policy and decision-makers to focus on critical factors that might have catastrophic results if not addressed sufficiently. Based on the internal-external factor matrix results, EH in RSA must harvest and divest. This implies that there is a need to restructure and develop EH in RSA so that it can meet its objectives of protecting public health. Failure to harvest and divest means that the profession might be at the risk of being dysfunctional.

Recommendations

Based on the SWOT analysis and internal-external matrix on the state of EH in RSA, the following recommendations are suggested to policy and decision-makers. The recommendations are aimed at improving the state of EH in the country given its value and importance to public health.

Efforts must be made to address the CS backlog, it must be ensured that at least 80%–90% of the EH graduates are placed for CS annually to strengthen the EH workforce. Post CS, it must be ensured that the graduates are either retained or given an employment opportunity. EHPs need to be in driving seat and be proactive when it comes to controlling environmental stressors and rendering EHS in the country. A risk-based or preventative approach is recommended to address all the EH issues in the country. EHPs should take the initiative and start being visible on public platforms, particularly during EH crises. EHPs must know that it is their responsibility to ensure that the profession is not overlooked nor misdirected, and that can be achieved by their visibility. Their visibility and adequately doing their job will also close the opportunity for EHP impersonators that are destroying the profession’s integrity.

There must be a solid relationship between higher institutions offering the EH course, municipalities, and regulatory bodies. Municipalities and regulatory bodies must inform universities of the EH challenges they encounter in the field. Learning institutions offering the EH course must prepare the upcoming generation of EHPs by equipping them with the necessary skills required to better understand and solve the identified EH challenges. Furthermore, EHPs must be well trained and skilled and evolve with the times and dynamics of EH. Therefore, it is recommended that the training related to EH must be conducted by higher learning institutions offering the EH course must and inform them of the new trend in environmental exposures. Moreover, the training and content thereof must be informed and directed by emerging EH challenges experienced in the field.

The EH course in the country must be standardised across the different institutions to achieve harmony, despite the different names given to the EH course. Ultimately, the fieldwork gives cognisant to EH despite the nature of the qualification and the aim is to produce quality EHPs that will serve the country and protect public health

In other countries, big studies (e.g. Turpin et al. 2007; Hoek et al. 2008; Borrego et al. 2016) aiming to understand exposure to environmental contaminants have been conducted and were a success, however, the kind of studies requires financial resources. Therefore, to ensure research and development in the field of EH, there must be enough funding allocated to research and development. Students can be incorporated into research projects as part of their masters of honours and doctorate courses. Over time, the students will develop a passion for the research work they are involved in and there are likely to specialise in that field.

The ongoing COVID-19 outbreak is not the first nor the last, therefore, it is important to learn from it and take steps to improve preparedness (Anderson et al. 2020). Early detection and warning systems are fundamental in protecting public health, EHPs must determine how the COVID-19 situation in RSA could have been avoided or minimised and how such situations can be prevented in the future. Given that diseases can rapidly spread globally and transition into lethal pandemics such as the COVID-19, emergency preparedness and response, surveillance, and control of communicable diseases must be strengthened to protect public health (Musoke et al. 2016). Insufficient funding was identified as a root cause of the challenges faced in the country. Therefore, the annual budget allocated to EH must be increased to address the lack of human resources, data collection and research, bursaries and scholarships, and CS backlog. The HPCSA must also start playing its role as a regulatory body that is responsible for protecting the practising space of EHPs and the integrity of EH. The HPCSA must also ensure standardisation in the offering of the EH course across all institutions.

Conclusions

For the first time in the context of RSA, the state of EH was holistically evaluated using the SWOT analysis framework. The study also highlighted the importance of EH in protecting public health and ensuring sustainability. Findings from this study can be used as building blocks to strategies and build a future EH profession that is centred on disease prevention by controlling environmental stressors. The total weighted score of 1.83 for the IFE indicated that EH is not responding positively to the strengths and weaknesses while the total weighted score of EFE indicated that EH is not effectively responding to opportunities and threats. The internal-external matrix analysis indicated that EH in RSA needs urgent restructuring if it is to meet the changing and dynamic needs of communities and achieve its objectives of protecting public health. To ensure that EH remains relevant in RSA, concerted efforts must be made to address the weaknesses, opportunities, and threats highlighted in this paper while improving on the strengths. Failure to address the weaknesses, opportunities, and threats and restructure and align the profession with the current EH challenges in RSA might lead to more catastrophic public health events.

Acknowledgments

The authors would like to thank Yonda “YoYo” Nokhwethu, Boipelo “BloBlo” Bhuda, Nkosinathi Moses Lukhele, Mosima Success “Graduate” Letsoalo, Siyanda Nkosi, Nomsa Duduzile Lina Thabethe, Oscar Rikhotso, Justice Malegodi Thobejane and Dr Phoka Caiphus Rathebe for their valuable insights. We also appreciate the help China Seremi Mooa for his valuable assistance with data presentation and visualisation.

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