Chapter 7: Nutrition
White Paper for the Transformation of the Health System in South Africa

1. Background and Introduction

The White Paper contextualises nutrition within the framework of the new Constitution, whose Bill of Rights states that everyone has the right to have access to sufficient food and water. It recognises nutrition as a basic human right, and a prerequisite for the attainment of a person’s physical and intellectual potential. The Department of Health, as a lead agency, must be a key role player within broader governmental policies targetting undernutrition and hunger, led by the Reconstruction and Development Programme (RDP). The White Paper states that nutritional status, especially of young children, should be used to measure the success of the RDP.

The Department of Health is responsible for developing policies, strategies and guidelines for a national integrated nutrition programme. It has developed an Integrated Nutrition Strategy whose objective is to set in motion fundamental processes leading to a sustained improvement in the nutritional status of chidren, especially under the age of five, and an improvement in the quality of life of women. Success of the programmes is perceived to be dependant on political commitment, intersectoral collaboration and community mobilisation and participation. Human resources and institutional capacity are to be developed. Sustainability in terms of processes, resources and impact will be given particular attention.

2. Guiding Principles

• Nutrition for all South Africans should be promoted as a basic human right. Nutritional status, especially of young children, must be the guage to measure the country’s social and economic development.
• Nutrition programmes should be integrated, sustainable, environmentally sound, people and community-driven. Programmes should target the most vulnerable groups, especially women and children.
• Nutritional well-being should be promoted and monitored within nationally-defined goals. There should be a clear nutrition information strategy.

3. Implementation strategies

3.1. Health facility-based programme

This will be established as an integral part of a comprehensive primary health care (PHC) package. It will address:

• undernutrition and micronutrient deficiencies, especially focusing on maternal, child and women’s health;
• prevention of chronic diseases related to lifestyle, such as cardio-vascular diseases and diabetes.

The programme will include:

• nutrition education for caregivers of children and pregnant and lactating women. Emphasis will be on the promotion of breastfeeding, feeding practices during childhood illnesses, and the usage of locally available complementary foods;
• growth monitoring and promotion through universally standardised growth cards;
• nutritional support and counselling for specific diseases;
• provision of counselling and referral services at community level, with regular follow-up and assessment by health staff ;
• food and micronutrient supplementation, especially of targeted vulnerable groups; and
• appropriate nutritional management of diarrhoeal and other infectious diseases.

3.2. Community-based nutrition programme

Communities will be encouraged to identify and solve their own nutrition problems. The mobilisation of various community structures will therefore be a central part of this strategy. Growth monitoring and other initiatives that promote and protect the development of children will be actively supported. The Department of Health aims to do this by building capacity, within communities, in assessment, analysis and operational strategies.

Further, operating within the context of the RDP, the community-based nutrition programme aims to combine other relevant projects such as the Primary School Nutrition Programme (PSNP) and the National Nutrition and Social Development Programme (NNSDP). Links with other departments such as Education and Agriculture, and the NGO sector, including development organisations, will be strengthened so as to assist communities in identifying problem areas and developing appropriate solutions.

The programme aims to:

• provide nutritional services to the most vulnerable individuals and communities;
• mobilise all members of households, as well as community leaders and structures, to take responsibility for improving the nutritional status of their communities;
• become a true community development strategy, with nutrition surveillance as the primary management and monitoring tool.

3.3. Nutrition promotion programme

To combat poverty and put in place a comprehensive and integrated nutrition strategy, a broad cross-sectoral alliance, including high level decision-makers, policy-makers and the general public, should be set up. The aim of such a nutrition promotion strategy will be to raise national awareness about the nutritional situation in South Africa, and to develop an integrated action plan to promote and protect optimal nutrition.

The three main components of the nutrition promotion programme will be:

• Communication and public information, through the mass media and health staff, concerning major aspects of malnutrition such as breast feeding, sound infant and young child feeding practices, diseases which cause childhood undernutrition and the prevention and control of diseases of lifestyle.
• Advocacy, targeting policy-makers and decision-makers at the national, provincial and district levels, to ensure integration of nutrition into broader development policies, plans and programmes. Emphasis will be on the development of a comprehensive nutrition policy; poverty alleviation strategies and linking these to the RDP’s Lead Projects; and the development of land reform measures to reduce the vulnerability of the landless poor;
• Review, implementation and enforcement of legislation relevant to nutrition. This will include the protection of breastfeeding; the control of marketing of infant foods; and the mandatory fortification of staple foods. In addition, the Food Legislation Advisory Group (FLAG) will be reorganised to be representative of all stakeholders.

3.4. Nutrition information strategy

The NIS will be implemented simultaneously at the household, community, district, provincial and national levels to identify the trends, nature, extent and severity of different types of nutrition problems and their causes. It should be closely linked to the health information system and other relevant information systems, for example, the Central Statistical Service (CSS). Information provided by an integrated nutrition information system will be used to:

• improve decision-making, with a view to solving the problems of malnutrition through better targetting of vulnerable groups and allocation of resources;
• monitor and evaluate nutrition programmes and outcomes of the RDP.

To be effective, the NIS must address the following five critical and strategic factors:

• increase the perceptions and knowledge, particularly of politicians and other decision-makers, to recognise nutrition as a ‘priority social problem’;
• effective action plans based on nutrition-relevant information;
• improve the capacity to assess, analyse and design better action plans;
• ensure adequate resources for the maintenance of the NIS in the medium to long term; and
• ensure adequate resources for action.

4. Indicators of success

The succesful implementation of an integrated nutrition strategy will be evaluated according to:

• increased breastfeeding;
• decreased prevalence of underweight, stunted and severely malnourished children under 5 years;
• decreased micronutrient deficiency disorder rate;
• decreased mortality for diseases of lifestyle related to nutrition;
• increased regular growth monitoring to reach 75% of children under 2 years.

5. Some Issues Raised in this Chapter

• The active and sustained involvement of communities is critical to the successful implementation of a sound nutrition strategy. It is unclear how communities would be mobilised and how this involvement would be sustained. What are the specific roles and functions of community structures, for example, the RDP Forums?
• What are the timeframes envisaged for the implementation of the nutrition strategy? Are there available resources to ensure the simultaneous implementation of this plan at the national, provincial and community levels? What are the specific strategies envisaged to identify and involve NGOs in capacity building programmes, especially at the community level?
• This chapter is not specific on the respective roles of the Nutrition Directorate and other directorates within the Department, other departments, provincial authorities and districts.When, where and how will activities be co-ordinated?
• One of the nutrition promotion strategies is the development of policy that will ensure the empowerment of women. What are the timeframes envisioned for the implementation of such a policy? What are the interim strategies to ensure the optimal involvement of women in the INS? Where and how does the empowerment of women fit into a human resource development plan?

For more information, please contact Jane Mathieson or Bea Abrahams by telephone @ 021 - 6964954 or by fax @ 021 - 6969308 or by e-mail at philaw@wn.apc.org . The PHILA programme is funded by a grant from the Henry J. Kaiser Family Foundation.

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