South Africa has persistently high rates of hunger and malnutrition among mothers and children. More than a quarter – 27% – of children under five are stunted and 61% of children are iron-deficient. Sixty-nine percent of women of reproductive age are overweight or obese, and 31% are iron-deficient.
These figures paint a worrying picture. They suggest gaps in the country’s evidence-based nutrition policies and services.
One way to accelerate progress on malnutrition is through engaging with the people who are directly affected by policies.
South Africa’s health system strategy does include public consultation. But public participation is mostly limited to public meetings once a policy has already been drafted. This leaves little opportunity for substantial revisions. The lack of meaningful public engagement is also evident in how funds for mother and child nutrition are allocated. Decisions are left to policy makers and there’s little input from people on the ground.
Only by understanding what communities consider important can policies respond to the actual needs of individuals.
We are a group of social scientists at the University of the Witwatersrand who have been exploring approaches for public engagement. We designed a study that puts communities into the shoes of policy makers. We asked community members which programmes they would prioritise if they were given a limited health budget.
The respondents in Soweto, an urban township in South Africa with constrained resources, didn’t focus much on health system programmes. They put more emphasis on the underlying causes of malnutrition. To help mothers and children be well nourished they proposed: providing school breakfast; paid maternity leave; improved food safety; and establishing community gardens and clubs.
This article presents one approach for public engagement. We suggest policy makers, researchers and funders consider programmes that communities view as essential for improving mother-and-child nutrition.
To engage communities, we modified an exercise called CHAT (Choosing All Together). CHAT is a simulation exercise, something like a board game. It offers a practical way to involve the public in making healthcare decisions. It seeks to show not only which programmes people prioritise, using a limited budget, but the values (assumptions, beliefs or perspectives) those priorities are based on.
Our research team modified CHAT specifically for the context of Soweto. Members of the community were invited to select a package of programmes they saw as priorities to improve mother-and-child nutrition. Fifty-four adult men and women volunteered to part take in the exercise. As with policy makers in real life, they had to make difficult decisions around what to include in their package of programmes, what to leave out (given a limited budget), and why. The volunteers had to discuss and debate their choices to convince one another why one programme would be better for the community than another.
Participants worked together in small groups and they could select from 14 programmes. Five programmes were “nutrition-specific” (directly influenced the immediate causes of malnutrition) and delivered through the healthcare system (pregnancy supplements). Nine programmes were “nutrition-sensitive” (addressed the underlying causes of nutrition), and accessed in non-health sectors (extended paid maternity leave).
Community members’ top three priorities were:
- the provision of school breakfast
- extending paid maternity leave to six months and to those in informal employment
- ensuring that food sold by street vendors and served in schools and creches was prepared in a safe and hygienic way.
Affordable healthy food, help in finding jobs, and community gardens were other programmes the participants considered important to improve their community’s mother-and-child nutrition.
I think community gardens can help everyone. To be able to, if you want to, grow vegetables and sell them to people, to be able to get money and teach children and other older people to do gardening.
The community’s choices reflect the values of fairness, equity, social justice and children’s well-being. Participants showed a willingness to consider other viewpoints and reflect on the consequences of their choices for the entire community.
Programmes that would interrupt the intergenerational cycle of poverty were important. These included freeing up disposable income by growing more of their own food, enhancing their self-reliance overall – which could also uplift the neediest among them – and reducing their dependence on social welfare.
In the South African context of astronomical rates of unemployment (more than 60% among young adults), solutions like establishing community gardens represented paths to livelihoods, socio-economic empowerment, and supporting the neediest in the community.
Translating public engagement into action
Public engagement is entrenched in the constitution and in various policy documents. But there are gaps. Even where public engagement has occurred it has had very little impact on policy making.
For South Africa to uphold its commitment to equity in healthcare, engaging the public on ethical and social values should be part of a systematic process of setting priorities in government.
Addressing malnutrition will also require coordinated actions across many sectors. Our findings show that not all potential solutions (such as community gardens and extended maternity leave) would fall to the already overburdened health system.
The South African National Food and Nutrition Security Plan 2018-2023 already has cross-sectoral coordination as an objective, via the establishment of a multisectoral advisory council to oversee alignment of policies, and coordinate and implement programmes. Integrating public engagement, through using tools like CHAT, could complement such efforts.
Agnes Erzse, Researcher, SAMRC/Centre for Health Economics and Decision Science- PRICELESS SA, University of the Witwatersrand
Aviva Tugendhaft, Senior Researcher, SA MRC Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, Wits School of Public Health, University of the Witwatersrand