Malnutrition in South Africa: Public Health Policy

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Table of Contents

State of Affairs in South Africa
Determinants and Causes of Malnutrition
Importance of Addressing Malnutrition
Interventions and Policies to Consider
Reference List

The world is currently facing multiple issues ranging from the COVID-19 pandemic to climate change. However, a leading and complex issue that is often the consequence of all other crises combined is malnutrition. The global food systems are highly dysfunctional, creating malnutrition crises in certain parts of the world which are the primary cause of death and disease (Branca, 2019). UNICEF describes malnutrition as an invisible emergency, affecting a variety of populations. It can affect a woman who becomes anaemic in pregnancy, giving premature birth to an underweight child. It can affect a child never reaching full physical potential or worse, going blind, due to vitamin deficiency. Near half of early childhood deaths in the modern world can be attributed to malnutrition resulting in 3 million lives lost annually (UNICEF, 2016). Although South Africa fares better than other countries in Sub-Saharan Africa, malnutrition continues to be a prevalent issue across the different geographical areas and socio-economic classes. This policy memo will explore the situation regarding malnutrition in South Africa, identify causal factors, and propose steps in resolving the issue.

State of Affairs in South Africa

South Africa has a relatively high malnutrition burden among its under-five population. Latest figures in 2016 show 13.3% overweight and 27.4% stunting average which is greater than the average for countries with similar levels of development. Low birth-rate prevalence of 14.2% is recorded which has slightly decreased from 15% in the last 15 years. Adult populations are experiencing malnutrition burdens, with 25.8% women of reproductive age have anaemia and 12.6% are diagnosed with diabetes compared to 9.7% in males. Out of the global nutrition targets, South Africa is on course to fulfil only under-five wasting and under-five overweight while showing no progress or worsening indicators on 6 other major targets including under-five stunting, low birthweight, and adult both male and female diabetes and obesity (Global Nutrition Report, 2019).

Despite improvements in the prevalence of under-five stunting over the two decades since the end apartheid in which government policies aggressively sought to resolve the issue, South Africa’s rate is greatly above most comparable countries. Existing social protection policies are in place to address inequities in nutritional status, but children are at risk. Realistically, the majority of children (53%) are living in households below the poverty line, most in rural areas. High levels of income inequality are present in South Africa, with the bottom 20% of households receiving 5% of the total national income and spending R8,485 per year on food. In comparison, the wealthiest 20% receive 60% of all income and non-poor households spend R14,020 on food per year. Compromising just 10% of their income (May, 2016). The disparity in inequality is evident and grotesque, and as will be demonstrated later, contributes to aspects of food security and malnutrition.

Determinants and Causes of Malnutrition

Malnutrition primarily affects young children as a population, followed by women/mothers. One of the primary reasons why the issue of malnutrition is so difficult to control despite being highly preventable, is the range of determinants for it which include socio-demographic, economic, health, and biological causal factors for both the mother and the child.

Socio-demographic – Certain socio-demographics factors are potential determinants of malnutrition in a country. Children (particularly 6-12 months old) and women are more likely to face malnutrition then men. From a general perspective and closely tied to economic determinants, factors such as education completion, household size and location, and potentially race/ethnicity are critical (Kamiya, 2011). Rural areas are more likely to experience higher rates than urban areas. Racial or social minorities (relevant to South Africa during and post-Apartheid era) are more susceptible.
Economic – Poverty is the primary economic determinant of malnutrition, directly correlated with monthly family income and expenditure on food. Food security can be affected by community or country-wide economic influences such as food prices, agricultural practices, market forces and climate change. Economic crises affect middle and lower classes greatly due to price hikes on critical commodities such as food. Global and national economic downturns are correlated with spikes in malnutrition due to limited food consumption and shifts to less balanced diets (Tette, Sifah and Nartey, 2015).
Behavioural – These can include a wide range of behaviours that directly contribute or are indirectly associated with malnutrition. This includes insufficient access to foods as well as proper water or sanitation. Behavioural determinants also include food practices, ranging from inappropriate maternal feeding practices to the choice of foods. In many developing countries or communities, there is an emphasis on consumption of energy dense foods, but which do not provide sufficient nutrient components for healthy functionality and growth (Tette, Sifah and Nartey, 2015).
Biological & Health – Malnutrition can be caused by a range of infectious diseases such as diarrhoea, malaria, intestinal helminths, among others. Malnourished mothers may experience difficulty with breastfeeding their children, causing malnutrition in them. Access to healthcare systems is a vital factor in addressing any underlying conditions or health status which may make an individual susceptible to malnutrition (Maleta, 2015).

These factors are all inherently interdependent. For example, a child living in an impoverished community is likely facing inadequate dietary intake. This makes the child susceptible to disease, which depresses appetite and inhibits absorption of nutrients resulting in decrease of energy. However, the primary underlying determinants are food security, adequate care for mothers and children, and an adequate health environment – all of which are influenced by elements of resources available to a community and a range of political, social, and cultural factors influencing utilization of said resources (Ijarotimi, 2013).

Another phenomenon that should be noted is the double burden of malnutrition. It is a scenario where undernutrition (underweight, thinness, stunting) and over-nutrition (obesity) coexist with diet-related non-communicable diseases. First seen in more affluent countries, in the late 1990s, the double burden of malnutrition was observed in low-to-middle income countries like South Africa. This phenomenon can arise both at the individual level, such as an obese child demonstrating micronutrient deficiencies, or at the household level where there are contrasting forms of malnutrition among family members. Oftentimes, at the population level, both undernutrition and overweight are seen in the same community or region. A study by Modjadji and Madiba (2019) that South Africa demonstrates high levels of the double burden of malnutrition in households, with undernutrition among children and obesity among mother, particularly in rural settings. Malnutrition is directly associated with a depressed socio-economic status and poverty characterized by high rates of unemployment with low household incomes.

Importance of Addressing Malnutrition

The significant impacts of malnutrition bring up viable concerns and priorities which highlight the importance of addressing this critical issue. First, it is important to discuss the consequences at the individual level. As mentioned previously, malnutrition is the primary risk factor for the burden of disease in developing countries, accounting for more than half of the mortality rate in children. The health consequences of malnutrition are severe and oftentimes permanent, resulting in stunted growth and less physical or intellectual productivity for the rest of the individual’s life. Malnutrition creates disturbances in the morphological and functional development of the central nervous system in children which compromises their health and survival. It causes tremendous human suffering, at both the physical level and emotional, inciting desperation and grief for families (Ijarotimi, 2013).

At the population level, malnutrition has long-lasting effects on a country’s wellbeing and economy based off the individual-level factors. International organizations consider malnutrition a violation of human rights, and populations experiencing the issue are more likely to be unhappy and engage in unrest or potentially criminal behaviour for purposes of survival. From an economic standpoint, malnutrition results in waste of human productivity and huma capital, stagnating the economy. Malnourished adults can work less, contributing less to their economies and unable to provide for families. Furthermore, it creates a perpetuating cycle of poverty as malnourished individuals are stuck in poor living conditions, and families are created in such circumstances resulting in new generations also experiencing poverty and subsequent malnutrition (Food and Agricultural Organization of the United Nations, 2020).

Interventions and Policies to Consider

As identified earlier, the three basic conditions which can contribute to reducing malnutrition in the population are adequate food availability, access to medical care, and appropriate feeding practice. When one or more of these factors are missing in any form, energy malnutrition will occur. Any strategic interventions or policy should focus on promoting the supply of, access to, consumption, and competent utilization of an adequate quantity, quality, and variety of foods for all levels of population in the country. This should be combined with a range of secondary interventions such as public education regarding feeding practices (particularly for caretakers of young children where this issue is prevalent) and shifts in cultural beliefs regarding food utilization and health status (Ijarotimi, 2013).

Multisectoral interventions and policies are necessary to address the issue of malnutrition comprehensively. First, it is necessary to establish food security for the most afflicted regions and populations. Relevant government agencies should stabilize and incentivize the market to ensure supply of food while artificially maintaining low prices through subsidies. With the help of international organizations, direct food deliveries are possible to struggling communities. A study by Langendorf et al. found that a combination of government measures are preventive distribution of supplementary food combined with cash transfers to mitigate the effects of poverty has helped to address some population concerns (2014).

Approaches by the international community which trickles down to national and local policy have been focused on a rights-based approach to food security and nutrition. The right to life and adequate food should be recognized legally, with the understanding that the function is not only to increase the availability of food but to empower populations with means to procure it. Policy efforts are multisectoral and targeted not only at the food security element but general socio-economic stability and growth which will lead to better food and nutritional outcomes in the population. From a social perspective, policy should address gender and wealth inequality, enabling an environment for development and equality. A fair and market-oriented economy should be maintained, one with connections to the world trading system to ensure stable inflows of products, including nutritionally beneficial supplements. Policies should target investments both in sustainable food practices, food production systems, and human resources to work these systems to ensure a flow of income. Physical and economic access to sufficient and nutritionally wholesome food, including to rural communities and vulnerable populations should be ensured. Finally, a long-term development plan should be established for multi-sectoral actions that would improve household security, community safety, healthcare access and quality, improvement of lifestyle, and population safety nets alongside direct assistance and mitigation plans for crises (Food and Agricultural Organization of the United Nations, n.d.).

Reference List

Branca, F. (2019) Malnutrition is a world health crisis. Web.

Food and Agricultural Organization of the United Nations. (2020) Understanding the true cost of malnutrition.Web.

Food and Agricultural Organization of the United Nations. (n.d.) 6. Policies and programmes for improving nutrition. Web.

Global Nutrition Report. (2016) South Africa nutrition profile. Web.

Ijarotimi, O.S. (2013) Determinants of childhood malnutrition and consequences in developing countries.Current Nutrition Reports, 2(3), pp.129–133. Web.

Kamiya, Y. (2011) Socioeconomic determinants of nutritional status of children in Lao PDR: effects of household and community factors.Journal of Health, Population and Nutrition, 29(4). Web.

Langendorf, C., Roederer, T., de Pee, S., Brown, D., Doyon, S., Mamaty, A.-A., Touré, L.W.-M., Manzo, M.L. and Grais, R.F. (2014). Preventing acute malnutrition among young children in crises: a prospective intervention study in Niger.PLoS Medicine, 11 (9), p.e1001714. Web.

Maleta, K. (2006) Undernutrition.Malawi Medical Journal: The Journal of Medical Association of Malawi, 18(4), 189–205. Web.

May, J. (2016) ‘Why child malnutrition is still a problem in South Africa 22 years into democracy’, The Conversation, Web.

Modjadji, P. and Madiba, S. (2019) The double burden of malnutrition in a rural health and demographic surveillance system site in South Africa: a study of primary schoolchildren and their mothers.BMC Public Health, 19(1). Web.

Tette, E.M.A., Sifah, E.K. and Nartey, E.T. (2015) Factors affecting malnutrition in children and the uptake of interventions to prevent the condition.BMC Pediatrics, 15(1). Web.

UNICEF. (2016) The faces of malnutrition. Web.

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