Strategies to address acute malnutrition and high mortality rate of children under 5

Health and Wellness (WCPP)

21 July 2023
Chairperson: Mr G Pretorius (DA)
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Meeting Summary


The Standing Committee on Health and Wellness (the Committee) in the Western Cape Provincial Parliament (WCPP) convened in a hybrid setting for briefings by the Western Cape Government’s (WCG) Department of Social Development (DSD) and the Department of Health and Wellness (DH&W) on strategies to address acute malnutrition and the high mortality rate of children under five in the Western Cape province.

A study was commissioned by the DH&W to assess and determine the prevalence and severity of stunting among children in the Western Cape. The Stunting Baseline Survey found a reduction in the prevalence of stunting from 27.4% in 2016 to 17.55% in 2023 amongst children under five. The survey provided a good indication of the prevalence of stunting across the province. The results highlighted that children under two are at higher risk and that a 15% prevalence of obesity existed. The interventions and strategies implemented by the Department are based on the results of the survey.

Although the rate of stunting showed a declining trend, the Committee was not satisfied that the strategies were adequate because children continue to die. The 2023 mortality rate amongst children under five, measured against the live birth rate is 1.3%. The Department acknowledged the challenges in combatting the high mortality rate but emphasised that the solution requires a whole of government approach and the involvement of the entire society considering the dire socioeconomic crisis facing the country.

Meeting report

The Chairperson indicated that Minister Fernandez was attending the meeting in her capacity as MEC for the DSD and as acting MEC for the DH&W. She had requested to leave early to attend to a long-standing prior engagement. The Committee was informed that Prof Matthew of the Child Review Board (CRB) was abroad and no longer held the position as Chairperson of the organisation hence the scheduled briefing on the work of the CRB did not occur.

Minister’s introductory remarks
Minister Sharna Fernandez in her capacity as MEC for the DSD and as acting MEC for the DH&W deemed it fortuitous that both departments were presenting on the serious matter of acute malnutrition and the high mortality rate of children under five in the Western Cape. She thanked both teams for their efforts in compiling the detailed presentations. She stated that acute malnutrition and growth stunting speak to the great socio-economic crisis facing our country. The only way to completely overcome the crisis, besides the measures put in place, is through poverty eradication and social upliftment. This could only be done with the dignity of being socially and economically empowered, which means placing jobs at the front and centre of the solutions. The DSD has the role of identifying and assisting vulnerable groups in society. The role of the DH&W is to capacitate frontline services in order to treat patients. Although these efforts go a long way, it is not enough. The involvement of the whole government and the whole society is needed in this fight which is critical because society should not be losing children between the ages of nought and five. The DH&W team would be providing strategies to alleviate the situation and the DSD team would be indicating measures to assist needy people. She would not be able to stay the full session but hoped that Members would note the work that is being done by both departments.

Ms A Bans (ANC) noted that the Minister would only stay for a few minutes and that the Minister for Health was also absent. She sought clarity on whether no Executive Member would be present for the duration of the meeting because it would be unacceptable.

The Chairperson explained that the Minister has to attend to a prior engagement which she, unfortunately, could not postpone. Until she leaves, there would be an Executive Member present.

DSD Presentation
Mr Mzwandile Hewu, Chief Director: Community and Partnership Development, WC DSD, stated that the Department does not have a specific programme targeting children under five. But children are identified through feeding schemes where the mothers, family members and households receive assistance. To reduce the need of vulnerable households, mostly headed by women with young children, the Department provides food relief services to children of beneficiaries to mitigate acute malnutrition and child mortality.

Community Nutrition and Development Centres (CNDCs) provide a meal, five days a week, to ensure regular access to food for vulnerable mothers and children. Data of beneficiaries are kept at the CNDCs to ensure that vulnerable children are retained in the system. The DH&W quality assures the meals that are provided by the CNDCs. A prescribed and standardised meal plan was developed to prevent the distribution of harmful food to vulnerable people.

The Community Food Garden initiative was piloted by the DSD with the support of the Department of Agriculture to transition beneficiaries from dependency to self-reliance. The gardens are also implemented by selected CNDCs across the Western Cape.

Beneficiaries are encouraged to start Household Food Gardens in their backyards as a project to plant and grow vegetables for making their own nutritious meals.

Food parcels are allocated to qualifying beneficiaries who have no means of income as a result of unemployment and difficult economic conditions. Individuals in need of food parcels need to make a request at their local DSD office where eligibility is assessed.

(See Presentation)

Ms R Windvogel (ANC) was aware that the DH&W has data on children suffering from malnutrition. She asked if there was a working relationship between the DSD and the DH&W in terms of data sharing.

Mr C Fry (DA) referred to the complex dynamics of malnutrition, involving women- and child-headed households. The obvious missing link is the absence of men. Given the whole of society and whole of government approach, he asked what is being done to address the absence of men in this complex dynamic. Reference is made to household gardens supported by suitable CNDCs. He sought clarity on the specific items that are given to CNDCs for this purpose.

Ms Bans asked how many children and families are being supported with food parcels. She had noticed that food parcels were not sustainable. She wanted to understand what the Department regarded as the entry point and exit point for supplying food parcels and how it was assisting beneficiaries to a point where the intervention is no longer needed.

Ms Bakubaku-Vos noted that kitchens are not operating during school holidays. She asked what is being done to accommodate children from disadvantaged households who do not have access to food during school holidays.

Mr Hewu replied that the Department has a Children and Families programme. One of the goals is to encourage men to participate in the upbringing and development of their children. Good results have been reported in some areas. Fathers are supported through the programme but it requires the willingness of fathers to participate. He explained that the Department works with the DH&W in community centres where there are support programmes for vulnerable patients. In communities where there are no healthcare centres, the DH&W would refer vulnerable beneficiaries to the nearest community and development centre for assistance with food parcels. Unfortunately, the DH&W and the DSD do not have community centres in all areas. He agreed with Ms Bans that food parcels are unsustainable but it provides a stop-gap to families. The food parcel is stopped when the family manages to have an income through one of the family members. He stated that many families apply for food parcels on a monthly basis because the circumstances remain unchanged as nobody in the household is able to find employment. The Department continues to provide food parcels but if the supplies run dry then families suffer. The challenge of children not having access to food during school holidays was more pronounced during Covid-19. The Western Cape Education Department is aware that many children are vulnerable during school holidays. Many children are assisted at CNDCs which are supported by the DSD. No child is turned away.

Ms Nomvuyo Mabusela of the DSD said that based on research conducted, it was found that children who are receiving meals from CNDC kitchens range from between three months and five years old. Mothers are also queuing for food at the CNDCs and so are men. The Sustainable Livelihood programme is supporting projects in six areas in the Western Cape, i.e. Kliprand, Uniondale, Laingsburg, Hout Bay, Murraysburg and Kannaland. The Department had ensured that there are specific key result areas that focus on men, e.g. linking men to sustainable livelihood opportunities to equip them to contribute to their households and the lives of their children. Another key result area is to improve health-seeking behaviour amongst men because men often neglect to seek help. She acknowledged that the Department was at the infancy stage where data collection was concerned but would be able to provide solid data within six months. To ensure that food gardens deliver produce of nutritional value, the Department engaged beneficiaries to understand the specific needs of the communities. It was found that communities value certain types of vegetables which are easier to manage. In this regard, the partnership with the Department of Agriculture and other stakeholders is important for advice on the quality of the soil to produce certain vegetable types. Interventions were implemented to treat the soil in order for communities to plant the vegetables of their choice that would provide the nutritional value needed.

Mr Hewu added that in partnership with the Western Cape Department of Agriculture and the National Department of Land Reform, the beneficiaries of the food gardens are provided with implements and seeds to plant vegetables of nutritional value. In Murraysburg, e.g. the partners helped to repair boreholes to allow for constant water flow to the gardens.

The Chairperson directed Members to the Chatbox where the Minister added some comments. He asked if the Minister wanted to add anything else.

The Minister referred to the three collaboration workstreams, i.e. safety, jobs for growth and dignity, where these topics are discussed at a political and technical level. If a deep dive is identified, the matter is discussed in a meeting, chaired by the Premier on a specific Cabinet day. She stated that the presentations are not done in isolation but in terms of a whole of government collaboration approach.

Ms Windvogel sought clarity on the comment by Mr Hewu that the DSD does not work in areas where there are no community centres. She asked if the Department could simplify the way of working in terms of collaborations. She wanted to know if the Department would zoom into a specific area where an increase in malnutrition is identified based on the data of the DH&W. She asked what criteria are used to identify a family in need of a food parcel. She wanted to understand the working relationship between the two departments.

Ms Bans also wanted to understand the collaboration process. When a child is diagnosed with malnutrition at the hospital and returns home, it becomes a social development issue. She asked about the collaboration to track the child from the hospital to the community and assist the child out of the malnutrition condition. Hence her previous question about the impact of the food parcel and the role of the DSD in assisting the DH&W in the case of a specific malnourished child.

Ms Bakubaku-Vos was aware that a certain amount of resources is being allocated to cater for children at CNDCs in disadvantaged communities. She asked if provision is being made for a top-up of resources to cater for an increase in the numbers during school holidays. She was made aware during oversight visits at CNDCs of shortages of food parcels because more children arrive than which is budgeted.

Mr Hewu explained that the Department has a solid working relationship with the DH&W in terms of the feeding programme. The DH&W is allowed to manage its own feeding programme but where the DH&W does not have a programme, they refer beneficiaries to the DSD. Responding to the question about identifying beneficiaries, he said that because social workers and community development practitioners cannot reach all vulnerable people, the Department relies on a referral system through agents such as pastors, nurses and NGOs. Vulnerable families are referred to the DSD for support where social workers assess them. Food parcels are given to families who qualify in terms of the criteria. The DH&W has a dedicated programme to help with interventions but patients are referred to the DSD in cases where there are challenges. He agreed with Ms Bakubaku-Vos about the serious challenges at CNDCs. But the Department was unable to top-up resources during school holidays due to budget constraints. During pressure periods, the Department provides food parcels to CNDCs to augment their supplies.

Ms Mabusela said the shortages at CNDCs were happening beyond school holidays because there is often no food at home after school. CNCDs are allowed to be part of the FoodForward programme to supplement the meals which the centres are able to provide. This allows CNDCs to provide two meals instead of one meal per day. The aim is to scale up the programme in collaboration with partners to address food shortage.

Mr T Klaas (EFF) apologised for joining the meeting late and asked the Chairperson’s permission to ask a question. He wanted to understand if municipalities have their own feeding schemes and what process is being followed by municipalities to assess beneficiaries who qualify for assistance.

Mr Hewu replied that the Department collaborates well with municipalities. The community kitchen database was compiled with the support of municipalities. The Department was not competing with municipalities and did not want to duplicate interventions.

The Chairperson requested the DSD officials to remain in the meeting in case of follow-up questions after the DH&W presentation.

Mr Klaas requested a meeting with the Chief Director to better understand the support that municipalities are providing to vulnerable people and which funds are being used for this purpose.

The Chairperson suggested to Mr Klaas to arrange a one-on-one meeting with the Chief Director through the office of the Procedural Officer.

DH&W Presentation
Dr Saadiq Kariem, Chief Operating Officer (COO), DH&W, presented. He explained that malnutrition is multifaceted and can be caused by numerous factors which include food insecurity, inadequate breastfeeding practices, poor dietary diversity, inadequate maternal and child healthcare, water and sanitation challenges, social and economic factors and the prevalence of HIV/AIDS. The First 1 000 days initiative has resulted in a decrease in stunting rates as per the 2023 baseline survey. The Stunting Baseline survey was conducted to assess and determine the prevalence and severity of stunting among children in the province. Results of the 2023 survey reflect an improvement from 27.4% in 2016 to 17.55% in 2023. It also identified stunting of 19.7% in children under the age of two.

Strategies to combat acute malnutrition are included in a framework of action to achieve optimum foetal and child nutrition development. The framework contains:

Nutrition-specific interventions and programmes, i.e. breastfeeding, nutrient-rich foods, eating routine, feeding and caregiving practices, parenting stimulation, and low burden of infectious diseases;

Nutrition-sensitive programmes and approaches, i.e. food security including availability and access to food, feeding and caregiving resources, and access to and use of health services and a safe and hygienic environment; and

Building an enabling environment through knowledge and evidence, politics and governance, leadership and financial resources, and social, economic and political environmental context.

Interventions require intersectoral engagements and transversal projects involving a whole of government and a whole of society approach.

(See Presentation)

The Chairperson thanked the COO for the comprehensive briefing.

Mr Fry asked if the Department was engaging research bodies such as the FAMCRU clinical research centre to investigate the link between HIV/AIDS and malnutrition. He enquired about the correlation between malnutrition and diarrhoea. The Road to Health booklet refers to the prevalence of GBV affecting violence against young children and even babies. He wanted to know what impact the Family Strengthening programme had in combatting GBV. He asked what the correlation was between companies in the literacy space and educating children about combatting malnutrition.

Ms Windvogel requested more detail about the prevalence of the different malnutrition categories, the causes and the health consequences thereof. She enquired about the cultural and social factors that are contributing to malnutrition. She asked if Khayelitsha was a cause of concern and why rural areas had not been included in the report. She wanted to know if the various strategies were helping to improve the social and economic conditions. She sought clarity on whether the City of Cape Town reading campaign was connected to the malnutrition programme or if it was a general reading programme.

Mr D Plato (DA) said despite all the strategies in place, the mortality rate was not declining to an acceptable level. He asked what else could be done to stem the tide.

Ms Bans requested the Department to provide actual figures related to severe malnutrition incidence as she was not familiar with the ratios. She asked if the First 1 000 days initiative was helping to improve malnutrition. The Department reported that rural areas have the highest number of malnutrition cases. She had noted an influx of kids that are provided with milk and packages at clinics and enquired about the qualifying criteria and how the process is being monitored to ensure that the support reaches the intended beneficiaries.

Mr Klaas felt that the Department did not present a resolution to address malnutrition. He asked what was being done to assist people affected by HIV/AIDS through this malnutrition programme. He suggested that clinics should be capacitated, similar to feeding schemes at schools, to help people who are suffering at clinics. He asked if the DSD could assist people to be approved as creche managers in areas where there are no centres for early childhood development. For example in Ward 8 in the Drakenstein Municipality, children are sent to creches far from their residences due to the lack of facilities in their areas.

Ms Bakubaku-Vos wanted to know if the Department and provincial government have targeted programmes to address social and economic disparities. She asked for specific detail if targeted programmes existed. She asked what the prevalence of stunting was in the province and the actual number of children affected.

Dr Kariem said the Department has an active research programme for various areas including HIV/AIDS and the linkages with chronic malnutrition. The collaboration with the DG Murray Trust serves as an example of the work done on the Stunting Baseline Survey. The Department also works actively with non-profit organisations on community-based outreach programmes, including the Healthcare Workers programme. He regarded the issue of gender-based violence as another pandemic, particularly where women and children are concerned. Children often get caught up in family and gang-related violence. Part of the response would lie in the Family Strengthening programme that involves a number of role players. The evidence confirmed that strong families can prevent violence against women and children. He argued that reading stimulates the cognitive development of children. He pointed to the data that tells the story of the prevalence of malnutrition. The Stunting Baseline survey serves as a reference point to evaluate the effectiveness of measures implemented to address stunting. The survey was the first representative sample of children under five including testing obesity. The key finding is the reduction in the prevalence of stunting from 27.4% in 2016 to 17.55% in 2023. The survey revealed that children under two are at higher risk. The Department would be focusing on this subcategory of under-risk children. A 15% prevalence of overweight was reported. Strategies for both malnutrition and obesity have to be developed. The study was commissioned by the DH&W and conducted in collaboration with the DG Murray Trust, and researchers from the Universities of Cape Town and Stellenbosch. The study considered key aspects related to malnutrition and stunting that needed to be addressed. Measures to be implemented were identified in the strategies. Part of resolving stunting and malnutrition includes addressing the underlying socioeconomic factors which require a whole of government and whole-of-society approach. The severe malnutrition incidence data in the presentation represents high-level results. He undertook to make detailed information available to the Committee. Rural areas are more at risk which is linked to the poverty index in those areas. The under-five fatality rate measured against the live birth rate of 2023 is 1.3%. The First 1 000 days initiative is a key focus of the Department. Both children and adults at risk in rural and metropole areas are screened and referred to the DSD for care and support. The initiative has resulted in a decrease in the stunting rate as per the 2023 baseline survey.

Ms Nicolette Henney, Service Priority Directorate, DH&W, said there is a definite correlation between malnutrition and diarrhoea. Diarrhoea can result in acute malnutrition and the effect of acute malnutrition is diarrhoea. The focus of the Literacy Reading and Wordless Book programmes is on the development and fostering of relationships. The book with only pictures can be used by caregivers to start conversations and build stories around the pictures. The City of Cape Town Road to Health booklet can be used starting from 26 weeks. Parents and family members are encouraged to start fostering relationship building with the child. The book contains health promotion messages and is used in the healthcare system for 12 years. All the messages are discussed with the mother, starting from feeding, protection and risks. It is found that engagement with the mother improves care for the child. The First 1000 days initiative forms part of the Family Strengthening programme. The Stunting Baseline survey highlighted focus areas in the Western Cape. Patients who require intervention are provided with malnutrition starter packs and referral letters for a further supply of six months when discharged from the hospital. An evaluation is done after three months to assess the impact of the packs. The client is educated on how to use the products. It is a supplement and does not provide 100% nutrients. A monthly follow-up is done through home visits by a community healthcare worker who is linked to a client. A register is in place to track clients in terms of the items supplied and the progress made. The Department is aware of the challenges as the products are sometimes used by the entire family and not only the client. To this end, families are educated on the use of the products during home visits. Adult TB and chronic disease patients are assessed and referred to the DSD for access to community kitchens.

The Chairperson enquired about the possibility of undetected cases. He asked if cases of uncooperative parents had been identified and if the Department would consider removing children from the household in such cases.

Dr Kariem replied that the Department is only able to take care of cases reported to healthcare facilities. The baseline survey provided a good indication of the prevalence of stunting across the province. Therefore the strategies take the results of the baseline survey into account. The response to the survey is crucial to identify the incidence of stunting and to take action.

Ms Henney said the Department had trained community healthcare workers to screen for malnutrition during home visits. Staff is required to report the incidence of malnutrition by completing Form 22 which is then referred to the local social worker for further management.

Dr Kariem said the Department had worked closely with the DSD colleagues on Form 22 which was signed off by the heads of the two departments.

Mr Hewu confirmed the good collaboration on Form 22 between the two departments.

The Chairperson extended his thanks to all officials of both departments. He found it heartening that the Departments and the public were in good hands.

Resolutions and actions
Mr Plato submitted a request for the mortality rate in figures instead of percentages. He needed the Department to report back on the strategies to prevent the high mortality rate. There is a problem in the system if children continue to die. Both departments referred to the prevalence of a socioeconomic problem in the Western Cape. He wanted to know what else was needed to resolve the problem. He was concerned about the high mortality rate despite food parcels being given to vulnerable families.

Mr Klaas advocated for clinics to also provide food parcels on a daily basis, similar to the feeding schemes operating at schools.

The Chairperson informed Members of a letter which he had received from the Department of Health regarding the National Health Insurance (NHI). A briefing by the Minister is scheduled for 4 August 2023, but it has not yet been confirmed. Public hearings on the NHI Bill would follow after the Minister’s briefing.

The meeting was adjourned.


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