The implementation gap: Cross-sector management of heat-related health risks in Western cape, South Africa.

As temperatures rise due to climate change, so do adverse health effects. In response, many countries, including South Africa, have developed heat health action plans to address these threats to public health. In the Western Cape province, increasing heat events necessitate a well-coordinated response across governance levels and sectors. Understanding how heat risks are governed, particularly at subnational and local levels, is critical for safeguarding public health and building resilience to future climate challenges. This study draws on 31 in-depth interviews and cross-references a previous policy document analysis to examine how South African decision-makers, both within and outside the health sector, at the Western Cape provincial and municipal levels, manage heat-related health risks. Using an adapted Multiple Governance Framework, the analysis investigates how subnational and local stakeholders work to manage heat-related health risks, some of which are aligned with South Africa's 2020 Heat-Health Action Guidelines. The findings reveal that despite the existence of the Action Guidelines and recognition among Western Cape decision-makers of the urgency of heat-related health risks, implementation remains fragmented. While provincial and municipal stakeholders are actively working to mitigate the health impacts of extreme heat, subnational and local actors were not involved in developing the Heat-Health Action Guidelines limiting their applicability at the local level. The analysis further highlights governance challenges and opportunities that emerge across system, organizational, and individual scales, emphasizing the significant role of decision-makers' perceptions in shaping responses. Strengthening coordination, defining departmental roles, and enabling local adaptation of policy strategies will be essential for improving heat-health action. By addressing these governance gaps, decision-makers in the Western Cape can manage current and future heat-related health risks and communities can be better equipped to withstand the increasing frequency and intensity of extreme heat events.