Case Study on DWQ Ukhahlamba District Municipality What can we learn from this incident? Draft Response Strategy Presentation to the MCC 25 February 2010

Case Study on DWQCase Study on DWQUkhahlamba District MunicipalityUkhahlamba District Municipality

What can we learn from this incident? Draft Response Strategy

Presentation to the MCC

25 February 2010

Case study undertaken byCase study undertaken by

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MapMapUkhahlamba DistrictUkhahlamba District

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Sterkspruit: Deaths occurred in villages of Bebeza, Jozana‘s Hoek and Zinxonondo

Deaths occurred in townships of Lulama, Fairview, Nkululeko, Tierkrans farm

Senqu and Elundini make up ¾ of the DM‘s backlogs. Most of the deaths occurred in Senqu (56%) at Empilisweni Hospital, and 26% in Elundini. 17% of the deaths were in

Maletswai. Maletswai had the highest increase in deaths, 37 in 2008 compared to 14 in 2007

The incidentThe incident::an increase in the an increase in the number of baby number of baby

deathsdeaths

CharacteristicsCharacteristics•Over summerOver summer•Urban and ruralUrban and rural•Not isolatedNot isolated•Various causesVarious causes

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Responses & findingsResponses & findings

Investigations, findings and responses by:

– Department of Heath

– Department of Water Affairs

– Eastern Cape Provincial Government (Social Needs Cluster)

– Eastern Cape Provincial Water Forum

Heath:The health system was directly implicated in the

deaths of the babies due to a number of important failures

in the system

WaterWater::

Poor water quality is likely to have been a contributing

factor

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Status of water in the Status of water in the district district (at the time)(at the time)While there is no direct evidence that poor water quality caused the death of babies, the majority of deaths were related to diarrhoea, and there was ample evidence of high levels of risk associated with the drinking water quality system, including

inadequate infrastructure, poorly maintained and operated treatment works,

lack of quality controls in the management of water quality, and

a weak water quality monitoring and reporting system.

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A case study to learn A case study to learn lessonslessons WIN-SA received a request from the Eastern Cape

Provincial Water Sector Forum to document and share learning arising from the Ukhahlamba District incident and the subsequent responses

WIN-SA commissioned PDG to undertake the case study

Two reports were developed:

– A lessons learned report

– A draft response strategy

Focus of Focus of this presentationthis presentation

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Symptoms versus causesSymptoms versus causes

A lot of the investigations focused on symptoms rather than causes. For example, no chlorine led to the recommendation “procure chlorine”.

It is important to understand the underlying causes - how did it come about that there was no chlorine?

Key system findings: (at time of incident)– Low levels of accountability for performance– Inadequate management attention (not important)– Inadequate capacity at three levels:

• Operators,• Supervisors• Management

– Silo operation within municipality - poor communications– At a political and governance level, water not prioritised

Draft Response Strategy

for the Eastern Cape Provincial Water Sector Forum

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Purpose and audiencePurpose and audience

Purpose:– How can we prevent poor water quality? – How best can we respond to poor quality incidents?

For:– water services authorities and providers– provincial and national government

Prevention is better than responsePrevention is better than response

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Requirements for effective Requirements for effective performanceperformance

1. Sound governance arrangements, with clear allocation of role and responsibilities, and clear lines of accountability for performance

2. Sound management, that harnesses the available human and financial resources for effective performance, paying attention to recruitment, retention, performance management, budgeting etc.

3. The necessary skills and experience to operate the systems effectively

4. Sound and effective systems and processes5. Financial viability and sustainability6. Political leadership, ensuring appropriate allocation of

resources and accountability for performance

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Addressing generic weaknesses Addressing generic weaknesses within the municipal system (1)within the municipal system (1)

Two-tier local government creates conditions that make the development and enforcement of clear accountability relationships difficult where the district is the WSA and the local municipality WSP

– This is a situation that must be urgently addressed at the national level.

– One possibility is to devolve the WSA function to the LM where these municipalities perform WSP functions - this needs more thinking

The management of water services in districts with significant rural populations distributed over large geographic distances is a demanding challenge

– More attention needs to be paid at the national level to the development of the necessary management capacity to succeed.

– The introduction of minimum competency requirements for water services managers is also a national strategy that is being pursued.

– Relook at devolved management through village committees

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The ability of municipalities to recruit and retain people with the necessary skills and experience.

There are various strategies that can (and are) being pursued to address this: Using technically skilled people as effectively as possible,

playing a support and advisory role across a number of municipalities, possible funded by national government.

Specific national and regional skills training initiatives (such as plumbing and other artisan skills).

The consideration of other institutional options, including regional service provision solutions.

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Progress has been made on the development of effective management systems and drinking water quality monitoring systems through the Blue Drop initiative. – These initiatives need to be continued and strengthened.– The effectiveness of these systems is ultimately dependent on

sound management and capable staff at the local level.

Ultimately, municipalities are accountable to their citizens.– Strengthening this accountability will go a long way to

addressing poor performance on the part of municipalities. – The citizen voice initiative is an example of a strategy seeking

to strengthen this accountability.

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Local prevention actionsLocal prevention actions

Pay ongoing and careful attention to water quality information

Put in place early warning systems. These could be health indicators (number of cases of diarrhoea) or other proxy indicators that could indicate that they may be a problem

Improve communications between departments, and between sectors (for example, between health and water services).

Draft response protocol

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PrinciplesPrinciples

Focus on outcomes, not inputs Operational support is most effectively provided by persons with

the necessary operational competencies and experience. Governance and operational roles need to be separated. There needs to be clear accountability for performance The entry point and channeling of support to water services

authorities and water services providers should be the senior managers responsible for the performance of these functions in the organisation.

Support should contribute to the building of a learning culture within organisations.

Support should put the needs of the citizen first. Support should promote the integrated management of the water

services business within the municipal environment.

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Response processResponse process

1. Incident occurrence• Identification and characterisation of the incident• Communications related to the incident

2. Investigation phase• Constitution of an investigating team• Investigations• Recommendations

3. Action phase• Implementation of action plans• Monitoring of implementation of action plans

4. Review phase• Review of the incident and responses• Reporting

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Turn-around interventions for Turn-around interventions for providersproviders

The Joint National Water Services Support Strategy (DWA, 2007) sets out an approach for provide direct operational support to water services providers.

This more intensive approach is aimed at turning around the operational performance of a water services provider where there is systemic failure.

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Checklists for actions and Checklists for actions and assessments (1)assessments (1)

Immediate actions at the local level1) Response manager and team: Assign a competent manager

to oversee emergency response and constitute a local response team

2) Communicate by radio, hold community meetings, distribute leaflets, use community development and community health workers, make use of facilities which people use such as clinics, hospitals, schools, government offices etc.

3) Disseminate bleach and re-hydration solutions.4) Assess risks and monitor drinking water quality (at treatment

works and in the distribution system) more frequently and intensively as necessary.

5) Address physical access to safe water by undertaking emergency repairs and/or shutting down treatment works supplying infected water; tank in safe water etc.

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Institutional assessment Contractual arrangements, accountability and

enforcement Review existing contracts Ensure clear roles and responsibilities and accountability Ensure contracts can be enforced (there must be

consequences to non-compliance and poor performance) Quality of management

Assess ability of management to manage the service effectively

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Competency of staff Assess competency of staff

Soundness of systems Assess water quality monitoring system Assess asset management system (including planning) Assess financial accounting and reporting systems Assess human resources system (recruitment, conditions of

service, performance management etc.) Assess management and operational protocols (capital

investment decisions, procurement, maintenance procedures, treatment works operations etc.)

Assess management information systems Assess systems to interface with customers Assess communication systems

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Adequacy of resources Undertake a financial and economic analysis of the water

services function. Understand the costs and revenue requirements. Determine the tariffs necessary for a sustainable service. Make recommendations.

Leadership Assess the extent to which the political leadership facilitates and

supports the creation of conditions necessary for sound management and effective performance.

This is another sensitive area which needs to be handled with care.

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Recommendations for way Recommendations for way forwardforward Publish and circulate lessons learnt report Sector to address generic and systemic weaknesses in

the system

– Weak accountabilities in certain contexts

– Emphasis on sound management

– Necessary skills and experience Draft response strategy

– Needs an owner and champion

– To be reviewed by sector stakeholders

– Adopted as a national response protocol to water quality incidents

More background on study More background on study and lessons learntand lessons learnt

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The study purposeThe study purpose

Examine the challenges and lessons that can be distilled from the experience in Ukhahlamba District Municipality;

Document the key lessons for district municipalities in the Eastern Cape Provincial Forum and the District Water Services Managers Forum;

Facilitate a strategic conversation among key Eastern Cape Forum members and identified stakeholders; and

Prepare an Intervention Strategy for the Provincial Forum on how to deal with similar challenges in future (through a collaborative approach).

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MethodologyMethodology

The report is a collation of findings from primary and secondary research conducted, including a focus group session that was held with officials from the District.

A systems approach was used to understand and analyse the institutional and operating environments both during and after the incident.

The experiences of the staff in the District during the crisis and following it were important.

The lessons learned from the experience.

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A systems approach: A systems approach: Proximate versus systemic causes Proximate versus systemic causes (1)(1) An examination of the findings, recommendations and

responses from the various investigations revealed that much of the work was undertaken at the level of symptoms and “proximate causes”. For example:

– The symptom (poor water quality monitoring information) led to the recommendation (improve the water quality monitoring system).

– The symptom (poor water quality) led to the recommendations (upgrade treatment works, train operators, recruit supervisors etc.)

– The symptom (no chlorine available) led to the recommendation (supply chlorine to the treatment works).

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Proximate versus systemic Proximate versus systemic causes (2)causes (2) The analysis did not go to the level of seeking to understand the underlying

systemic causes of these symptoms. For example,

– How did it arise that there was poor monitoring of water quality given the fact that this is a stipulated and well know requirement for the proper and effective management of drinking water systems?

– What underlies the deterioration of the water treatment works infrastructure given that proper maintenance and timely refurbishment of these facilities is essential to ensure consistent meeting of drinking water quality standards?

– How did it come about that the operators operating the system did not have the necessary skills to operate the treatment works in a way which ensure consistent meeting of water quality standards, and that these operators were not adequately supervised?

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Proximate versus systemic Proximate versus systemic causes (3)causes (3) Thus, a systems approach was used to

– understand the underlying systemic causes by looking at the institutional and operational environments as a complete system.

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Lessons learned (1)Lessons learned (1)

Institutional arrangements and operational performance There were a series of gaps in the system, which together resulted

in poor management and performance. These challenges were within the institution, but played out in the

actual provision of water services.– This reinforced the critical link between institutional dynamics

and operational performance. – A poorly functioning institution has greater potential to and

eventually will lead to sub-optimal operational performance. The institutional arrangements and resultant poor operational

performance is viewed at three levels: The regulatory level The provider level The citizen or community level

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At the regulatory level:– The District developed a turn-around strategy and improvement

plan, identifying the need to increase capacity. – Posts were created for three water services authority managers

and one water services provider manager. – Sound systems need to be established so that

• Planning is timely and appropriate;

• Operations and maintenance is understood and carried out;

• Interaction with the service providers and other stakeholders are well managed; and,

• The overall functions of the WSA (as asset holder and regulator) can be carried out effectively and efficiently.

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At the provider level:– The challenge was in the lack of clarity on the roles and responsibilities

between the WSA and the WSPs. – The district was the player and referee. – With no clear service level agreements in place the prospect of

effective enforcement, monitoring and accountability was weak.– Accountability and reporting were almost non-existent with the LM

WSPs.– Responsiveness was ad-hoc.– The district realised during the crisis that the flimsy arrangements that

were in place held almost no weight and as the authority the responsibility was with them.

– Managing the relationship between authority and provider is both critical and sensitive.

– Sound inter-governmental relations have to be applied and political support is important in enabling these relations.

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At the citizen or community level:– There was little accountability for poor performance.– There was no clear communication strategy or customer

charter.– The district did not have an established protocol to guide how

the crisis should be dealt with and accounted to communities. – Lessons learned included the need to ensure political support

where communities and Councillors are involved and consultations take place.

– The District has developed a draft communication strategy.– Establishing platforms as a meeting space for the municipality

and the community to enable ongoing civil society water services monitoring and problem solving.

– Citizens need to be trained about their rights and responsibilities.

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Planning Opportunities were created for the District to access more funding. Water treatment works and other infrastructure need to be

refurbished and upgraded.– However, plans need to be developed to allocate the funding

and to safeguard the sustainability of the investments made. The district realised the capital intensity of water infrastructure and

the importance of sound asset management. There is a need for a complete audit of the District’s water services

function including its infrastructure for short, medium and long term plans to be developed and funds allocated and invested appropriately.

The Water Services Development Plan (WSDP) must be well developed. – The plan is a holistic development plan for water services that is

reviewed annually.

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Powers and functions UkDM needs to own its authority function and to regulate water

services. Roles and responsibilities must be clear and understood. Legislated standards and minimum requirements must be enforced. There are initiatives underway to address this, including:

– Improving clarity in terms of regulatory functions and responsibilities;

– Building capacity to monitor and implement regulations; and,– Signing revised contracts and SLAs with all WSPs.

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Political support The Mayor declared water as a priority for the next five years. Water is a standing agenda item in Council meetings, Standing

Committee meetings and Technical Committee meetings. It is discussed at District Mayoral Forum meetings. Eastern Cape Provincial Water Sector Forum has prioritised the

UkDM experience. Political support is seen as central to collaboration and to the

realisation of sound institutional arrangements between stakeholders.

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Effective leadership and management A common feature in the failures and challenges encountered in

the management and implementation of programmes is the lack of effective leadership and sound management.

A key challenge facing the District is meeting service delivery targets, namely the provision of clean water and sanitation to all communities in the district.

This necessitates having qualified and competent personnel. The MHS unit is working well improving water quality monitoring

and testing.

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It is understood that an effective water manager requires – Sound technical competencies: a solid understanding of the

technical fundamentals of the business;– Sound public management skills: to effectively manage and make

optimal use of the limited human and financial resources;– Effective political skills: to mediate the political-administrative

interface; and– Leadership skills: to take courageous decisions, to create the

enabling environment, and to inspire and mobilise the necessary resources and support to achieve the outcomes sought within a complex environment. (Eberhard 2009: 2)

The challenge for the district in the future will be in its ability to retain staff and to attract and recruit and develop new personnel.

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Openness and honesty In the crisis the district was open, honest and up-front about the

situation of water services and water quality. This enabled the turn-around and improvement of the District. Communication The District protected the water services providers in the crisis.

– The reason for that approach was that the District is the authority, and must assume overall responsibility.

There are challenges with managing relationships and communications due to differences in power and hierarchy across the spheres of government.

In dealing with the media there were no protocols and there were lessons learned on how to deal with the media.

In terms of communication with communities, the District has to inform them about the lines of responsibility.

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Sector collaboration Partnerships coupled with collaborative practice are fundamental to the

efficiency and effectiveness of water services provision. Inter and intra-sector partnerships are needed to overcome challenges

and to provide greater potential for sustainable implementation of programmes and initiatives.

Knowledge management There was little documentation of the District’s own learning and the

District’s institutional memory was weak. The District does not have a comprehensive report on the water quality

crisis and the processes that have followed. The lesson is that information must be documented and stored. While systems are important to enable this, individuals are key in terms

of inputs into the systems and for knowledge management to work.

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Sustainability The factors that would ensure the sustainability of activities in the future will

be the ability of the WSA to carry out operations and maintenance with adequate funding for it.

Systems must be continuously built on, and while they must be responsive, they should identify and flag potential threats.

Factors that could potentially undermine sustainability of activities in the future were identified as the following:– The lack of funding for fundamentals such as plant refurbishments and

upgrades. – A potential crisis is still lurking around the corner, but there is hope that

the improved systems that are in place will help prevent the crisis. – Retention of staff and skills that are there as well as the ability to attract

needed staff that have the relevant skills. – Commitment, the will and the ability of the district to continue to strive

to improve and turn-around water services provision.

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Lessons for other Lessons for other municipalitiesmunicipalities The challenges identified in Ukhahlamba are not unique. DWA facilitates an annual water services authority self-assessment,

the Strategic Gap Analysis, which confirms the presence of common challenges at the local level, including the following: – Water infrastructure is mostly maintained on a crisis management

basis as funding for preventative maintenance has been a major challenge.

– In municipalities with DWQ programmes and systems in place, it was felt that the programmes were inappropriate for proper evaluation and need to be adjusted.

– Inadequate staff numbers and skills were reported amongst the majority of water services authorities, compounded by restructuring and the transfer of powers and functions.

– Support systems are often inadequate.– A large number of water services authorities lacked an appropriate

and adequate budget for operations and maintenance. This resulted in municipalities performing crisis maintenance rather than preventative maintenance.

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What other municipalities can What other municipalities can learn from Ukhahlamba (1)learn from Ukhahlamba (1)

Work as a collective with the water function fully integrated into the functions of the municipality and addressed in a holistic manner.

Brokering collaboration with all stakeholders, understanding and improving the rules of engagements and principles that are critical in sustaining partnerships and promoting IGR.

Installation of appropriate systems and mechanisms for monitoring the performance of WSPs.

Installation of appropriate systems for monitoring water quality and there must be a clear response strategy for challenges that arise.

Signed agreements with roles and responsibilities clearly defined, including adequate measures for performance monitoring and enforcement.

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What other municipalities can What other municipalities can learn from Ukhahlamba (2)learn from Ukhahlamba (2)

Community accountability is essential and care should be taken to ensure that communities are engaged, consulted and informed about water services at regular intervals.

Professionalism in attitude and dealings with stakeholders and the public is important.

Openness and honesty about the water situation is critical. Any potential risks related to water quality should not be ignored

and should be dealt with immediately. The WSA is ultimately accountable to communities even if the

function is contracted to another organisation.

Documents

Case Study on DWQ Ukhahlamba District Municipality What can we learn from this incident? Draft Response Strategy Presentation to the MCC 25 February 2010