south african early childhood review 2019

1SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2019

SOUTH AFRICANEARLY CHILDHOOD

REVIEW 2019

ANC antenatal care

ART antiretroviral treatment

CHW Community Health Worker

CSG Child Support Grant

DHA DepartmentofHomeAffairs

DHIS DistrictHealthInformationSystem

EC EasternCape

ECD early childhood development

ELOM EarlyLearningOutcomesMeasure

FS Free State

GHS GeneralHouseholdSurvey

GT Gauteng

HAART highly active antiretroviral therapy

HIV HumanImmunodeficiencyVirus

KZN KwaZulu-Natal

LCS LivingConditionsSurvey

LP Limpopo

MNCH maternal, newborn and child health

MP Mpumalanga

MTCT mother-to-childtransmission(ofHIV)

NC Northern Cape

NGO Non-GovernmentalOrganisation

NW NorthWest

PIRLS ProgressinInternationalReadingand

Literacy Study

SA South Africa

SADHS South Africa Demographic and Health

Survey

SAECR SouthAfricanEarlyChildhoodReview

SANHANES South African National Health and

Nutrition Examination Survey

Stats SA StatisticsSouthAfrica

TIMSS TrendsinInternationalMathematicsand

Science Study

VIP ventilated improved pit-latrine

WC WesternCape

Acronyms and abbreviations

YounglearnersintheplaygroundofKopanangCreche,inruralKwaZulu-Natal.Photo:JoshReid,2019.


ContentsOpportunitiesforintegratedECDservicedelivery

Introduction

Childrenunder6yearsinSouthAfrica

Primary level maternal and child health

Nutritionalsupport

Supportforprimarycaregivers

Socialservicesandincomesupport

Stimulation for early learning

Referencesandnotes

Notesonthedataanddatasources

KeyindicatorsforearlychildhooddevelopmentinSouthAfrica

Contributors

04

06

08

12

20

24

30

36

42

46

47

48

02 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2019

AcknowledgementsThe South African Early Childhood Review

2019wasdevelopedbyIlifaLabantwana,TheChildren’sInstituteattheUniversityofCapeTown,InnovationEdge,TheGrowGreatCampaignandtheDepartmentforPlanning,MonitoringandEvaluation(DPME)inthePresidency.Theeditorswouldliketothankallthosewhocontributedtothispublication:ShanaazMathews,KatharineHall,andPaulaProudlockfromtheChildren’sInstituteattheUniversityofCapeTown;SonjaGiesefromInnovationEdge;WinnieSambu;KopanoMabasoatTheGrowGreatCampaign;aswellasColinAlmeleh,LovemoreMawere,LauraBrooks,andSvetlanaDonevaatIlifaLabantwana.

MastoeraSadanattheDPMEinthePresidencyforhersupport,inputandguidanceonthedevelopmentofthe2019Reviewandfortheforeword.

LindaBiersteker,AndrewDawes,ElizabethGirdwood,andMatthewSnellingfromEarlyLearningOutcomesMeasure(ELOM)-SouthAfrica’s

firstpopulationlevelpre-schoolchildassessmenttool.ELOMdatafromseveralstudieshavebeenincludedinthisreview.LearnmoreaboutELOMatwww.elom.org.za.

DGMT,theELMAFoundation,theFirstRandFoundation,andFNBfortheirsupportofIlifaLabantwanaasdonors.

JoshReid(forIlifaLabantwana)andBartLove(forDGMT)forthephotographsusedinthispublication.

Suggestedcitation:HallK,SambuW,AlmelehC,MabasoK,GieseSandProudlockP(2019)SouthAfricanEarlyChildhoodReview2019.CapeTown:Children’sInstitute,UniversityofCapeTownandIlifaLabantwana

Copyright:2019Children’sInstitute,UniversityofCapeTownandIlifaLabantwana

Anyerrorsaretheresponsibilityoftheauthors.

Ilifa Labantwana Douglas Murray House, 1 Wodin Road, Claremont, Cape Town 7700, South Africa Tel: +27 (21) 670 9847Email: [email protected] Web: www.ilifalabantwana.co.za

AnECDpractitionerfeedsasmallchildatZamaniNondoweniECDcentreinruralKwaZulu-Natal.Photo:JoshReid,2019.

mailto:[email protected]


ForewordA hopeful future can

only be realisedby

working together

to improve thelivesofchildren in

SouthAfrica.

The National Development Plan 2030 wasadoptedin2012.Aftereightyearswehavemade some progress on both the policyfrontandonchilddevelopmentoutcomes.For example, the National IntegratedEarly Childhood Development Policy was adopted in 2015, while maternal andchild mortality rates have continued on adownward trend. Many of the elements ofthe Essential Package of early childhooddevelopmentareinplace.

The South African Early Childhood Review provides uswith rich data on childdevelopment and shows us that in themain we have some progress, howevertherearesomeareaswherewehavemadelittle or no progress. The picture paintedbythisyear’sreviewisquitebleak.Despitethenumerousinterventionsacrossdifferentsectors, SouthAfrica’s stunting rate at 27%remains unacceptably high. We have toask the question ‘Why does this situationremain?’

Good quality data is vital for planning,programme implementation, and moni-toring. But data on its own is meaninglessunlesswe use it. Over the last decadewehave put in place a monitoring system,howeverwedonotseemtousedatasuffi-ciently for planning and implementation.Could this be that operational staff do not

have the requisite knowledge and skillsto utilise data? Could it be that many ofthe interventions require more than onedepartment or collaboration between government and NGO’s?There is a dearthof research on the challenges of imple-mentation on these types of complexinterventions. If we were to have a betterunderstanding of these implementationchallengeswecouldplanmorerealisticallyon how to address them. The numerousevaluationsundertakenbytheDepartmentof Planning, Monitoring and Evaluation(DPME) provide some evidence and pointto poor co-ordination and collaboration.Calling for improved co-ordination and collaboration will not change anything, what is required is leadership at all levelsandsomeadditionalresources.

Inelevenyearswewillreach2030,ofwhichthe NDP sketches a hopeful future. Thisfuture can only be realised by workingtogether to improve the lives of childrenin South Africa. Investing in our children’sfutureshouldbeparamountinrealisingtheobjectives of the National DevelopmentPlan. Dr Kefiloe MasitengDeputy Secretary of PlanningNational Planning Commission


Socialservicesandincomesupport

Nutritionalsupport

Support for primary caregivers


Standard of Service Delivery

OPPORTUNITIES FOR INTEGRATED ECD SERVICE DELIVERYThisdiagramshowstheessentialpackageofECDservicesatdifferentpointsintheearlychildhoodlifecycle,aswellastheservicetouchpointsaffordedbytheSouthAfricanhealthsystem.ThesehealthsystemtouchpointsareanopportunitytodeliverallessentialECDservicesinanintegratedandcoordinatedway.

94% of eligible women

are placed on HAART

67% of women visitapublichealthfacility before the

20thweekof pregnancy

Pregnancy

THE ESSENTIAL PACKAGE

TheessentialpackageofECDserviceshasfivedomains.Thestandardofservicedeliveryisindicatedas:good,fair,orpoor.Allfivecomponentsoftheessentialpackageimpactonchilddevelopment.

HEALTH SYSTEM TOUCHPOINTS

HealthsystemtouchpointsarephysicalpointsofcontactbetweentheDepartmentofHealth,caregiversandchildren.Healthsystemtouchpointsarealsoopportunitiesforcaregiversandchildrentoaccessessentialservicesfromothergovernmentdepartmentsandagencies.

1

2

CHILD DEVELOPMENT OUTCOMES

Childdevelopmentisafunctionofthefivecomponentsoftheessentialpackage.CurrentlyinSouthAfrica,healthcareistheonlycomponentdeliveringadecentlevelofservice.Asaresult,childrenaresurvivingbutnotthriving.Currently,thereisnonationaldataonchilddevelopmentoutcomes*.

* EarlyLearningOutcomesMeasure(ELOM)isanewSouthAfricanpopulationbasedchildasasessmenttoolthatdetermineswhetherchildren(aged4-6years)aredevelopmentallyontrackforage.

ANTENATAL VISITS

of social g

rants

Register birth & sign up for social grant at health facility

Intro

duced to early bonding activities

DELIVERY IN A FACILITY

Counselle

d on nutrition & breastfeeding

preventio

n of alcohol & substance abuse

Delivery in a health facility under trained personnel

Labour& birth

Inform

ed about early birth registration & availability

Early antenatal booking, antenatal PMTCT, and

GoodPoor Fair

Breastfeeding support, vitamin/

min

eral

supplementation

Register birth & sign up for social grant

at health facility

Sign up for social grant at health facility

Linked to home visiting programme Linked to hom

e visiting p

rog

ramm

e P

arenting

education

Psycholog

ical support A

ttend

ance of an earl.y learning

pro

gram

me. Id

entifi cation

of d

evelopm

ental delays

Ch

ild n

utritio

n, vitamin/m

ineral

sup

ple

mentation, and dew

orming

Introduced to stimu

lation

activities; Identif cation o

f

developmental d

elays

Introduced to parent support programmes & referral for m

other’s mental w

ellbeing


Pregnancy

ANTENATAL VISITS

of social g

rants

Register birth & sign up for social grant at health facility

Intro

duced to early bonding activities

96%ofdeliveriesoccur in health facilitiesunder

trainedpersonnel

77% of children <1 complete the primary

immunisationcourse

Probability of dying <5is32per1000

livebirths

10.2 inpatient deaths

withinfirstweek,per1000 livebirths

inthesameyear

76% of women birthing in public facilitiesreceived

follow-up care 6daysafterbirth

DELIVERY IN A FACILITY

POST

NA

TAL V

ISIT

S

Breastfeeding support

Counselle

d on nutrition & breastfeeding

preventio

n of alcohol & substance abuse

Delivery in a health facility under trained personnel

Labour& birth

Earlych

ildhood

Neonatal

& infan

cy

27% of children

<5arestunted

32% ofHIV- exposedinfantsaged4-8 weeksareexclusively

breastfed

76% of pregnant women attending

facilitieshadatleast4antenatal

visits

hygiene & safety and imm

unisation course

18% of children arenotregistered

withintheirfirstyear

63% of eligible children <1 are

receiving the CSG

81% of eligible children<6 are

receiving the CSG

Inform

ed about early birth registration & availability

Early antenatal booking, antenatal PMTCT, and

Growth m

onitoring, postnatal PMTC

T, treatment of child

ill nesses, education on hom

e

69% of children aged3-5attendan early learning

group programme

21% of children aged0-2attendan early learning

group programme

Breastfeeding support, vitamin/

min

eral

supplementation

Register birth & sign up for social grant

at health facility

Sign up for social grant at health facility

Linked to home visiting programme Linked to hom

e visiting p

rog

ramm

e P

arenting

education

Psycholog

ical support A

ttend

ance of an earl.y learning

pro

gram

me. Id

entifi cation

of d

evelopm

ental delays

Ch

ild n

utritio

n, vitamin/m

ineral

sup

ple

mentation, and dew

orming

Introduced to stimu

lation

activities; Identif cation o

f

developmental d

elays

IMM

UN

ISA

TIO

N V

ISIT

S

Introduced to parent support programmes & referral for m

other’s mental w

ellbeing


The central role of early childhood development (ECD) to reduce socio-economic inequality is broadly accepted in South Africa. Yet, every year, signifcant numbers of poor children begin school lagging behind their wealthier peers. Half will have dropped out before fnishing secondary school. The numbers are staggering when aggregated over a generation. These children are chronically underpowered to fully participate in the economy and society from the very start. Despite the many successes and achievements of the post-Apartheid period, ECD as a sector lags behind.

Nutritional support

Maternal and child health services


Social servicesSupport for primary caregivers

Including antenatal care, PMTCT, physical & mental health screening, psychosocial support and immunisation

For pregnant women, mothers and children

Including parenting skills and psychosocial support

Including birth registration, access to social grants, responsive child protection services and psychosocial support

Including access to quality, age-appropriate early learning programmes

Thecomponentsoftheessentialpackageare:

Children’s long-term development is a function of a package of interrelated and integrated services covering the period from conception to six years of age: maternal, newborn and child health (MNCH) services; nutritional support; support for primary caregivers; social services and protection; and quality early learning programmes.i Collectively, these are known as theEssential Package of ECD services.In addition to these services, thedevelopment of perceptual, motor,

cognitive,language,socio-emotional,andself-regulationskillsinthehomethrough responsive caregiving is acriticalcomponentofECD.

ThemajorityofSouthAfrica’schildrenarebornintoenvironmentsthatreducetheirchancestorealisetheirpotential–typifiedbyinsufficientaccesstohighquality MNCH services and nutrition;inadequate living environments; lackofsecurityandsocialprotection;andlimitedopportunitiesforqualityearlylearning and stimulation. As a result

children experience malnutrition, toxic stress; and are at an increasedrisk of substance abuse, criminalbehaviour,riskysexualbehaviour,andreduced economic potential when theyareolder.ii

The Essential Package of services is a necessary pre-condition to realise children’s constitutional rights. The annual South African Early Childhood Review (SAECR) is structured tobring together all of the available data sources on the components

Introduction


INTRODUCTION

of the Essential Package, and to actas a gauge of how the country isprogressing towards meeting thegoals that have been defined for anumber of years and in a range ofprogramme, research, and policydocuments,iv most recently theNational Integrated ECD Policy of2015. These goals are aligned withthe United Nations SustainableDevelopmentGoalsandtheNurturingCare Framework of the World Health Assembly(2018).

Earlylearninghasbeenforegroundedin 2019 following PresidentCyril Ramaphosa’s Februaryannouncement that the ECD mandate would shift from the Departmentof Social Development to the Department of Basic Education, andthat the government would make an additional year of schooling (GradeRR)mandatory.

Thesearepositivedevelopments.Theannouncement confirms that ECD isrecognisedbygovernmentascritical;while a closer alignment with BasicEducation should result in increasedbudget for ECD, improved workforce training, and closer alignment ofthe early learning curricula with the needs of foundation phase learning.However, we have more work to do

asacountrytoaddresstheentireagespectrum of ECD, which begins atconceptionandnotatagethree.v

The National Integrated ECD Policyrecognises that young children havea broad range of needs that areinterdependent, and multiple role-playersareinvolvedinservicedeliverytomeetthoseneeds.Inpractice,thismeans that effective systems areneeded for co-ordination, referral and follow-up between the three key sectors that are responsible fordeliveringservicestoyoungchildren– Health, Basic Education and SocialDevelopment – aswell aswith otherdepartments such as Home Affairs,theSouthAfricanPoliceServicesandJustice,andlocalgovernment.

While South Africa has made goodprogress from a policy perspective,many of the services defined in thepolicyhavemadelittleornoprogressover the past few years, particularlyin the nutrition, early learning and caregiver-support areas. In additionto severe fiscal constraints, the lackof progress is arguably due to theinadequate institutional mechanismsrequiredtoco-ordinate,manageandmonitor complex integrated ECD servicedelivery.SouthAfricalacks:

• aneffectivecentralmechanismto

mobilise and co-ordinate a nationalprogrammeforyoungchildren;

• the ability and capacity to deliver quality services at scale – inparticular, inimplementingstrategiesfor nutrition support, early learning,caregiver support, child protectionfor all children who need it, and enhanced support for children withdisabilities;and

• systems to routinely monitorservices and measure progress formostchildoutcomes.

The SAECR helps to fill some ofthe monitoring and measurementgap by collating indicators on earlychildhood.The publication estimatesthe extent of need (the size of therelevant population) to provide asense of what would be requiredfor a population-level response atscale; presents data on access toservices to provide an estimate ofprogramme reach and the number of exclusions; and where possible,includesinformationonoutcomesasameasureofprogrammequalityandimpact. Using the Essential Packageasaframework,theSAECRhighlightspoints of intersection betweendifferent sectors and services toshow the opportunities for improvedintegrationoftheservicepackage.

Factorsaffectingearlychildhooddevelopment

Social factors e.g. violence, substance

abuse

Psychosocial Risk Factors (e.g. low

stimulation & responsiveness)

Biological Risk Factors (e.g. Stunting & Low

Birth Weight)

Child’s Brain Development

Poverty e.g. food insecurity, hygeine and

sanitation

SENSORIMOTOR

CHILD PSYCHOLOGICAL DEVELOPMENT DOMAINS

COGNITIONLANGUAGESOCIAL SKILLS

CAREGIVER HEALTH &

WELL BEING

Source: Adapted from Dawes et al (2012)iii


Children under 6 years in South AfricaSouth Africa remains a highly unequal society, and there are vast inequalities

in children’s circumstances and opportunities from the moment they are

born. The first step to giving children an equal start in life is to ensure that

all young children get the full package of essential early services. We

need information about the young child population to plan effectively for

service delivery: the size and distribution of the population, where the child

population is increasing, and the circumstances in which young children live.

Given that the young population issomuchbiggerthanpreviouslyestimated,plans,strategies,andbudgetswillneedto be reviewed andrevisedacrossall government departmentsthatdeliverservicestoyoungchildren.

South Africa has not yet achieved complete birth registration and so the size of the child population is really anestimate,basedonStatisticsSouthAfrica’smid-year population estimates. Theprevious issue of the South African EarlyChildhood Review (SAECR) 2017 gave theunder-6 population of South Africa as 6.2million.Sincethen,StatsSAreviseditsmid-yearpopulationestimatesandupdatedthemodel used to calculate the populationweights for its surveys, because they hadbeenbasedonincorrectassumptions.

The re-weighted data reveal that there are substantially more young children than was previously thought. The under-6 populationwascloseto7millionchildrenin2017,nearlyamillionmorethanexpected.Thisisnottheresultofasuddenincreaseinbirths,butduetotherevisedpopulationmodel.AsshowninFigure1,althoughtheyoungchildpopulation increasedthroughthe 2000s (from 5.6 million in 2002 to 6.8millionin2010)theestimatednumberhasremainedquitestablesince2011.

Given that the young population is somuch bigger than previously estimated,plans, strategies, and budgets will needto be reviewed and revised across allgovernment departments that deliverservices to young children in order toensurethattheadditionalchildrencanbeprovidedfor.

There have been some striking changes in the distribution of young children across the provinces. Historically, the biggestchild populations were in KwaZulu-Natal,Limpopo,andtheEasternCape.However,Gautenghasarapidlygrowingpopulation,andbytheendofthe2000shadthesecondlargestpopulationofyoungchildren.Since2012, the under-6 population in Gautenghas grown by over 100,000, an increaseof 8%, and Gauteng now has moreyoungchildren than any other province. Otherprovinces with growing young childpopulations are Mpumalanga, Limpopo,and the Western Cape. The young childpopulation is falling in the Eastern CapeandFreeState.


FIGURE 1: NUMBER OF CHILDREN AGED 0 – 5 YEARS (2002 – 2017)

Source: Statistics South Africa (2003-2018). General Household Survey (GHS) 2002 – 2017 Previously weighted (2014) and newly weighted (2018). Analysis by Children’s Institute (UCT).

CHILDRENUNDER6YEARSINSOUTHAFRICA

The majority (57%) of young children now live in urban areas. Although adultsare more likely than young children to have urban homes, the child populationis gradually urbanising, through acombinationofurbanbirthsandmigration.Cities and towns need to keep planningand providing for larger populations ofyoungchildren.

Three million children under six years still live in rural areas – mainly in the rural former homelands. This is a challengefor ECD service delivery as dispersedcommunities with lower populationdensities pose challenges to deliveringservices, and young children (and theircaregivers) in remote areas may have totravel far to reach service points for birthregistration, health care, education, andotherservices.

Service infrastructure for households remains a challenge, particularly in rural areas and informal settlements. Poor livingconditionscoupledwith inadequatewater, sanitation, and energy services tohouseholds put young children at riskin multiple ways. Almost a third (29%)of young children live in householdswithout piped water on site. Adequate

infrastructure to deliver clean water isimportant for young children becausethey are particularly vulnerable to water-borne diseases. Access to water on siteis important because it is risky for youngchildren to have to leave their house touseorfetchwaterortobeleftalonewhentheircaregiversdoso.IntheEasternCape,over half of the young children do not have pipedwatertothesitewheretheylive.

Similarly,adequatesanitationisnecessaryfor health, as poor sanitation can lead tothe spread of diarrhoeal diseases andother infections that are among the maincausesofmalnutritionanddeathsinyoungchildren. Currently, 1.5 million children donot have a flush toilet or VIP (ventilatedimproved pit-latrine) at home – these arethe minimal forms of sanitation that areregarded by government as adequate,although a VIP can be risky for youngchildren.

Poverty rates have been falling, but two thirds of young children (65%) still live in households that have per capita incomes below the upper poverty line.Thispovertyline,setbyStatsSA,isequivalenttoR1,138in2017andiscalculatedastheamountofmoney needed to provide for minimum

65% of young children live

in households below the upper

poverty line.

New estimates

Old estimates

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

8,000,000

7,000,000

6,000,000

5,000,000

4,000,000

3,000,000

2,000,000

1,000,000

-

Num

ber o

f chi

ldre

n ag

ed 0

-5 y

ears

in S

A

65%



nutritional needs and other basic needssuchasclothing.Eventhoughmostyoungchildren receive a Child Support Grant, the amountofthegrantisoftennotenoughtobringchildrenoutofpoverty.

In South Africa, 2.5 million young children are living below the food poverty line. This is a great concern because it meansthat these children are in householdswherethereisnotenoughmoneytocoverevenbasicnutritionalneeds.Thisincreasesthe risk of malnutrition and stunting inchildren, and possibly compromises thenutrition of pregnant women before their children are born (see Nutritional Supportchapteronpage20).Foodpovertyamongyoungchildrenishigh(30%ormore) inallprovincesexceptGautengandtheWesternCape.

The highest poverty rates for young children are in Limpopo, KwaZulu-Natal and the Eastern Cape. Thesethree provinces combined are home tonearly half of all young children in South Africa,andtheyalsohavethelargestrural

populations. The National Integrated ECDPolicy,approvedbyCabinetin2015,affirmsthatparentsandfamilieshavethefirstdutytocareforyoungchildrenandensurethatthey access early childhood services, butalso recognises that their ability to do somay be limited by resource and capacityconstraints. Young children growing up inpoor households risk exclusion from ECDservicesasthesehouseholdsarelesslikelyto be able to afford transport to and fromclinics and other government offices, orto be able to pay fees for ECD centres orcrèches.

Income poverty is the result of unemployment or employment with very erratic or low income. Unemploymentrates in South Africa are stubbornly highandhaveincreasedinrecentyears.Over2millionchildrenliveinhouseholdswherenomembersareworking,eitherintheformalsector or in informal employment. Thesehouseholds would be entirely dependenton social grants and remittances fromfamilymemberslivingelsewhere.

FIGURE 2: CHANGES IN THE PROVINCIAL POPULATION OF CHILDREN 0-6 YEARS (2012 AND 2017)

Source: GHS (2012, 2017). Analysis by Children’s Institute (UCT)

The highest poverty rates for young children are in Limpopo,

KwaZulu-Natal and the Eastern Cape.

1,600,000

1,400,000

1,200,000

1,000,000

800,000

600,000

400,000

200,000

-Gauteng KZ-Natal Limpopo E Cape W Cape N CapeMpum N West F State

2012 2017

Num

ber o

f chi

ldre

n un

der 6

yea

rs


Data gaps and challenges

All of the indicators in this section are derived from national General Household Survey (GHS) data collected by Stats SA. It is important to have reliable estimates of the young child population across the country in order ensure that programmes are appropriately budgeted and services can reach all young children. Stats SA’s previous

population models appear to have underestimated the child population. The model was revised in 2018, but it remains to be seen whether it is accurate. The next population census will only take place in 2021.

TABLE 1: THE STATUS OF CHILDREN UNDER SIX LIVING IN SOUTH AFRICA IN 2017, BY PROVINCE

Indicator SA EC FS GT KZN LP MP NW NC WC source

Popu

lati

on

Number of children under 6 years

6 978 000 876 000 326 000 1 501 000 1 408 000 906 000 613 000 497 000 149 000 702 000 a

Households with children under 6

4 667 000 496 000 239 000 1 195 000 849 000 567 000 417 000 335 000 105 000 463 000 a

29% 30% 27% 25% 30% 37% 33% 29% 31% 25%

Are

a ty

pe

Urban Children < 6 in urban areas (formal/informal)

3 974 000 336 000 278 000 1 451 000 556 000 145 000 204 000 246 000 104 000 654 000 a

57% 38% 85% 97% 40% 16% 33% 49% 70% 93%

Rural traditional Children < 6 in rural former homeland areas

2 726 000 516 000 39 000 28 000 751 000 752 000 372 000 229 000 38 000 -

a39% 59% 12% 2% 53% 83% 61% 46% 26% 0%

Rural farmsChildren < 6 in commercial farming areas (old RSA)

278 000 24 000 10 000 22 000 101 000 9 000 36 000 22 000 7 000 48 000

a4% 3% 3% 1% 7% 1% 6% 4% 5% 7%

Serv

ices

Inadequate waterChildren < 6 without piped water on site

2 045 000 484 000 38 000 96 000 595 000 423 000 163 000 161 000 28 000 56 000

a

29% 55% 12% 6% 42% 47% 27% 32% 19% 8%

Poor sanitation Children < 6 without a toilet or VIP on site

1 557 000 138 000 64 000 142 000 343 000 398 000 211 000 175 000 19 000 65 000 a

22% 16% 19% 9% 24% 44% 34% 35% 13% 9%

Pove

rty

Child povertyChildren < 6 living in poor households (< R1138 in 2017)

4 528 000 679 000 232 000 665 000 1 100 000 732 000 412 000 343 000 100 000 264 000 a

65% 77% 71% 44% 78% 81% 67% 69% 67% 38%

Food PovertyChildren < 6 living in food poor households (< R531 in 2017)

2 521 000 439 000 122 000 272 000 678 000 481 000 233 000 170 000 46 000 79 000

a

35% 47% 36% 18% 46% 51% 37% 33% 30% 11%

Workless householdsChildren < 6 in households with no employed adults

2 036 000 376 000 112 000 209 000 497 000 416 000 178 000 149 000 43 000 56 000

a

29% 43% 34% 14% 35% 46% 29% 30% 29% 8%



Primary level maternal and child healthProtecting and nurturing the health of the mother and the child is the foundation on which many child development gains are built. The primary health system, through its massive network of clinic facilities and Community Health Workers, arguably offers the best infrastructure to deliver most components of the Essential Package. However, this will require coordinated service delivery and a shift in the approach of the health system from ‘survive’ to ‘survive and thrive’.

67% of all antenatal visits in public facilities during 2017/8

occurred before 20 weeks, up from 61% during 2015/6.

Despite the challenges experienced by the public health system, many of South Africa’s most significant post-Apartheid developmental gains especially for caregivers and children in the poorest households, have been through the health sector. This is critical for ECDbecause of the health sector’s broadrelevance to achieve the goals of theNational Integrated ECD Policy.1 As theECDcontinuumofcareshows(Figure3),itisnotjustthematernal,newborn,andchildhealth (MNCH) interventions that can bedeliveredviahealthsystemchannels.Otherinterventionsthatcanalsobedeliveredviathese channels, even if they are assignedtoothergovernmentdepartments,includebirthregistration,parentingeducationandsupport,nutrition,earlyaccesstotheChildSupport Grant, identification and referralsfordevelopmentaldelays,amongstothers.

Antenatal care (ANC) is the first gateway to a range of health services for pregnant womenandisnecessarytoensurehealthybirths, improve nutrition for both motherand child, and provide counselling andsupport to pregnant women to ensurepositive pregnancy experiences.2 South Africa has maintained a high rate of ANCattendanceinthelasttwodecades.Inthepast three SouthAfrica Demographic andHealth Surveys (SADHS) since 1998, over92%ofwomenwhohavehadababyinthefiveyearsprecedingeachsurveyreportedreceivingantenatalservices.3 However, the timingofthefirstANCvisitandthenumberofvisitsarealsoimportant.

Multiple visits,4 starting in the firsttrimester (0-3 months), are advised asthese provide opportunities to check onthedevelopmentofthefoetus,to identifyanyphysicalormentalhealthproblemsin

67%


the mother, and to deliver recommended interventions.It isencouragingtoseethat67%ofallantenatalvisitsinpublicfacilitiesduring 2017/8 occurred before 20 weeks,up from 61% during 2015/6. However, notall of these are in the first trimester, asrecommended.JustunderhalfofpregnantwomenbooktheirfirstANCvisitinthefirsttrimester, while the same number havetheir first ANC consultation in the secondtrimesterorevenlater.

The quality of the service (as measured by specific interventions that are delivered during each visit)5 is a necessary condition to ensure good

health outcomes for mothers and their children. The SADHS data shows thatwhenwomenvisitfacilitiesforANC,ahighproportion receive the key services suchas blood pressure measurement, withbloodandurinesamplesalsobeingtaken.While it isclearthatthe initialdiagnosticsare being done, we do not know whether theresultswereconveyedtothepregnantwomanandrelevantfollow-upsmade.

The data on antenatal antiretroviral treatment (ART) indicate some emerging service delivery challenges with ANC even inthecontextofsignificantoverallprogresssince 2010 and South Africa’s highly

PRIMARYLEVELMATERNALANDCHILDHEALTH

ManyofSouthAfrica’smost

significantpost-Apartheiddevelopmental

gainsespeciallyforcaregivers

and children inthepoorest

households,havebeen through the

healthsector.

FIGURE 3: CONTINUUM OF CARE DURING THE FIRST 1000 DAYS OF LIFE

Maternal and child health services

• Early antenatal booking• >4 antenatal clinic visits• Antenatal PMTCT• Prevention of alcohol and

substance abuse

• Immunisation• Home hygiene + safety• Danger signs of childhood

illnesses

• Growth monitoring + Screening• Postnatal PMTCT

Nutrition

Vitamin/mineral supplementation

Antenatal nutrition support • Breastfeeding education• Post-natal nutrition support• Complementary feeding

education

• Child nutrition• Deworming

Primary Caregiver Support

• Antenatal mental health• Bonding with unborn baby

Postnatal maternal mental health

• Parenting Education• Psychological support

• Positive discipline and parenting

Social Services

• Access to the child support grant• Birth registration

Early Stimulation

• Brain development basics• Techniques for learning through play for parents

Out of home early learning services

Source: Ilifa Labantwana

Pregnancy Birth Age 1 Age 2



successful Human ImmunodeficiencyVirus (HIV) treatment programme. SouthAfrica is home to the largest number ofpeople livingwith HIV globally.Access toantenatalARTiscriticaltopreventmother-to-child transmission of HIV and reducethe incidence of paediatric infection, aswell as to ensure adequate health of themother and reduce overall HIV incidence.While improving steadily between 2010and 2016, coverage of antenatal ARTdecreased from 2016 to 2017 nationally,largely in the provinces of Eastern Cape,FreeState,NorthWestandNorthernCapewherecoveragedropped7%,12%,4%and7% respectively.6 Mpumalanga, on theother hand, has made steady progressin delivering antenatal ART to pregnantwomen.Whilechangeoveroneyearmightnot indicate a long-term trend, further

decreases in coverage over time willimpactonwhetherSouthAfricacansustainits achievement of the near elimination ofmother-to-child transmission of HIV. Only0.9% of infants tested HIV-positive at 10weeksin2017/18.

South Africa continues to maintain a high level of facility-based deliveries (public and private) attended to by trained personnel. In 2016, 96% of all births tookplace in health facilities and the majorityofbirths(85%)occurredinpublicfacilities.These statistics are derived from theSADHS, which collects data on deliveriesin public, private, and home deliveries. Inthe more urban and wealthier provinceslike theWestern Cape and Gauteng, over15% and 10% ofwomen respectively gavebirth in private facilities. Women in these

FIGURE 4: : TIME OF FIRST ANTENATAL CARE (ANC) VISIT

Source: SADHS (2016)

47%42%

5%6%

1%

No antenatal care

0-3 month

4-6 month

7 month or more

don’t know

FIGURE 5: SERVICES DURING ANTENATAL CARE

given or bought iron tablets/syrup

blood sample taken

urine sample taken

blood pressure taken

0% 10% 50%20% 60%30% 70% 90%40% 80% 100% Source: SADHS (2016)

In 2016, 96% of all births took place in health facilities

96%



provincesarelikelytohavegreateraccessto private options through higher incomelevels.

In addition to the important newbornchecks, postnatal visits provide additionalopportunities to reinforce advice given tomothersduringpregnancyandtosupportthem to deal with childcare issues thatconfront them and their families soonafter the birth. The postnatal visits andthe subsequent well-child check-upsshouldbeusedtomakereferralstootherservices. This is especially important forthosewho are poor andvulnerable. If thebaby’s birth was not registered beforebeingdischargedfromthefacility,thefirstpostnatalvisitalsooffersanopportunitytoregister,andcaregiversofeligiblechildrencan begin the process of applying forthe Child Support Grant. This integrationof services is currently only possible atsome service points where the relevantgovernmentdepartmentshaveapresence,andsometimesonlyoncertaindays.

The percentage of women in South Africa visiting the clinic with their newborn within six days of birth has remained

fairly static at around 70% coverage since 2013. This means that, annually, over 300,000 newborns are not examined within six days of being born, as per the guidelines. In 2017, the Western Capereportedthelowestcoverageofpostnatalvisits (58%) and Limpopo reported thehighest (86%). As with many of the otherindicators in this review, the performanceofspecificprovincesisinconsistent.Thereis also variation in the within-provincetrends over time suggesting that theremay be reliability issues with the data. Inadditiontocoverageofpostnatalvisits,itispossible to assess the quality of thevisitsusing some key services as proxies. Over85%ofmother-babypairsreceivedclinicalservicessuchascheckingthetemperatureand umbilical cord of the newborn, while less than 80% received more non-clinicalinterventions such as breastfeedinginformation, breastfeeding observation,and information on newborn dangers.Two thirds of mother-baby pairs werereportedtohavereceivedallfivetypesofservices (baby’s umbilical cord checked,baby’s temperature taken, counselling onnewborn dangers and breastfeeding, andobserved breastfeeding). A further 11%

FIGURE 6: ELIGIBLE ANTENATAL CLIENTS INITIATED ON ANTI-RETROVIRAL THERAPY (2010 – 2017)

Source: DHIS (2017)

100%

90%

80%

70%

60%

50%

40%2010 2011 2012 2013 PMTCT

survey2014 2015 2016 2017

EC FS GT KZN LM MP NW NC WC SA

Thepostnatalvisitandthesubsequent

well-child check-upsshouldbe

usedtomakereferralsto

otherservices.



received four services, while 10% did notreceiveanyofthefiveservices.7

The newly designed Road to Health Book aims to improve the quality of postnatal servicesbyensuringthatallbaby-motherpairs receive the same broad range ofessentialservicesandplacingmuchmoreemphasis on the messaging that healthworkersgiveduringallpostnatalvisits. Reporting immunisation coverage is important for two main reasons. Firstly, immunisation is the bedrock for addressing preventable illnesses in children. Secondly, immunisation coverage is often used as a barometer for how well a health system is functioning. TheSouthAfricanEarlyChildhoodReview2017reportedthatimmunisationcoveragehad increased from less than 70% in2000 to almost 90% in 2015. However,when Stats SA recalibrated the mid-yearpopulation estimates in 2017, the under-1immunisationratewasreviseddownwardsto 79% for 2015 because the DistrictHealthInformationSystem(DHIS)usesthepopulationestimatesasadenominator.

Immunisation rates for infants have since declined slightly across most provinces

and in 2017 only 77% of babies were estimated to be fully immunised by the age of one(Figure8).Thisisaconcernasitsuggeststhatevenifqualityimprovementsin the health service are achieved withthe use of the revised Road to HealthBook,thesewillnotbenefitlargenumbersof children unless there are substantialimprovementstohealthserviceaccess. For many health services interventions, those in the wealthier quintiles have higher levels of coverage because they are more able to access services. In the case of immunisation, however, the richest 20% of children are less likely to be fully immunised than the poorest 20%,8

suggestingthatfailuretoimmunisemaybepartlyamatterofindividualchoice.Despitethefactthatpopulationsinruralprovincesoften have to travel further to the nearestclinic than people living in urban areas,immunisation rates are mostly higher inruralareas.Thegovernmentisundertakinga National Vaccination Coverage Surveyin 2019 to improve understanding ofimmunisation perceptions and behaviour.This will help to inform better strategies to prevent any further decline in immunisationratesandimprovetheoverallperformanceofthesystem.

FIGURE 7: SERVICES RECEIVED AT THE POSTNATAL VISIT

Source: SADHS (2016)

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Umbilical cord of baby checked

Temperature of child checked

Information on breastfeeding

Observed brestfeeding

Information on newborn dangers

FIVE MESSAGE PILLARS OF NEW ROAD TO

HEALTH BOOK

EXTRA CARE

HEALTHCARE

LOVE

NUTRITION

PROTECTION


FIGURE 8: IMMUNISATION COVERAGE FOR CHILDREN UNDER-1 (2015 AND 2017)

Source: DHIS (2017)

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%EC FS GT KZN LM MP NW NC WC SA

2015 74% 72% 89% 74% 75% 85% 76% 94% 84% 79% 2017 69% 71% 77% 82% 71% 90% 69% 85% 81% 77%

In terms of the broader service deliverycontext, any decline in immunisationcoveragealsomeansthattherearefewerpoints where young children can bereachedwithnon-clinicalservicessuchasbirthregistration,socialgrants,identificationand referrals for developmental delays,supporttonewmotherswithpost-partumdepression and breastfeeding, andsupport to caregivers with early learningandstimulation.

The ultimate markers of survival and the performance of the health system are child mortality rates. It is encouragingto see the continued decline of infantand under-5 mortality rates. However,the neonatal mortality rate has remainedunchangedinrecentyears.

FIGURE 9: CHILD MORTALITY RATES (2012 – 2017)

Source: Bradshaw et al (2019) Rapid Mortality Surveillance Report 2017

50

40

30

20

10

02012 20142013 2015 2016 2017

Under-5 mortality rate Infant mortality rate Neonatal mortality rate


Pe

r 10

00

live

bir

ths


TABLE 2: HEALTH INDICATORS FOR PREGNANT WOMEN AND CHILDREN UNDER SIX, BY PROVINCE

Indicator SA EC FS GT KZN LP MP NW NC WCData year

source

Popu

latio

n

Number of infants Children under 1 year 1,118,000 142,000 52,000 248,000 219,000 162,000 86,000 69,000 29,000 110,000 2017 a

Poor access to clinics Children < 6 living more than 30 minutes from the nearest health facility

1,372,000 212,000 59,000 126,000 411,000 215,000 151,000 128,000 21,000 49,000 2017a

20% 24% 18% 8% 29% 24% 25% 26% 14% 7%

HIV prevalence in pregnant women Antenatal clients testing HIV+

31% 30% 30% 30% 44% 22% 35% 29% 19% 19% 2015 b

Serv

ice

acce

ss/d

eliv

ery

Prenatal early booking First visit before 20 weeks, out of all antenatal first visits at public facility

67% 65% 66% 61% 72% 63% 74% 66% 64% 70% 2017 /18 c

Antenatal initiation on HAART Antenatal clients on ART as % of eligible total

94% 87% 83% 95% 97% 95% 99% 92% 89% 92% 2017 /18 c

Delivery rate in facility Percentage of deliveries occurring in health facilities, under trained personnel

96% 91% 96% 97% 95% 98% 95% 95% 97% 99% 2016 d

Postnatal visit in 6 days % mothers giving birth in public facilities who return with baby for postnatal visit within 6 days

71% 63% 64% 71% 77% 86% 63% 75% 62% 58% ` c

Immunisation coverage % of children <1 who complete the primary immunisation course 77% 69% 71% 77% 82% 71% 90% 69% 85% 81% 2017

/18 c

Out

com

e

Paediatric HIV prevalence % infants born to HIV+ mothers who test positive in a PCR test at 10 weeks

0.9% 1.2% 1.1% 1.0% 0.7% 0.8% 1.1% 1.1% 1.4% 0.5% 2017 /18 c

Early neonatal mortality rate Number of inpatient deaths with-in 7 days per 1000 live births

12 2017 e

Infant mortality rate Number of deaths under 1 year, per 1000 live births in same year

23 2017 e

Under-5 mortality rate Probability of dying between birth and fifth birthday, per 1000 live births

32 2017 e

• Data on maternal mental health continues to be lacking despite the increasing evidence of its impact on maternal and child health, and on development outcomes.

• We are unable to report on infant and under-5 mortality rates at a provincial level.

• Quality of care data are difficult to collect,

despite its importance. Focus on service quality across the board is needed.

• There are no data on children with disabilities or developmental delays. There are also no data on the numbers of children screened for disabilities and developmental delays.


Provincial estimates not available





Nutritional supportBreaking the inter-generational cycle of poverty and inequality must begin with improving the health and nutrition of young children. Children who receive adequate nutrition in the frst 1000 days of life, and throughout childhood, are more likely to have better health and educational outcomes in childhood, and higher productivity in adulthood. The United Nations Economic Affairs Commission has shown that the costs of tackling the short and long-term negative effects of malnutrition run into billions of dollars, and these costs are borne by both households and governments.9 Preventing malnutrition, therefore, brings positive returns to households and society as a whole.

South Africa has high levels of child malnutrition, despite its status as a middle-income country with a relatively high per capita income compared to other countries in the region (Figure 10). However, per capita income is anaverage and does not reflect the veryhighratesof inequalityandpoverty inthecountry. Stunting occurs when a child isnot growing optimally compared to the expected average growth rate and is themost common form of malnutrition inSouthAfrica.

Theprevalenceofoverweightandobesityis also on the rise amongyoung children.Anestimated13%ofSouthAfrica’schildrenaged under five years are classified asoverweight.Thishasmainlybeenattributedto increased consumption of processedfoods high in salt, sugar, and fats, whichyoung children are exposed to throughhousehold diets. Statistics from the 2016South Africa Demographic and Health Survey(SADHS)showthat35%ofchildrenaged6-23monthsconsumedsugaryfoods

and 44% consumed salty snacks. Highlevels of inactivity (sedentary lifestyles)alsocontributetooverweightandobesity.

While good nutrition is necessary for basic survival and healthy living for both children and adults, studies have consistently shown that investments in early childhood nutrition yield significant gains in childhood and adulthood. However,thenutritionalstatusofachildisdependentonmanyfactors, includingthehealthandnutritionalstatusofthemother.Pregnant women who have poor nutritional intake are at greater risk for frequentinfections and low pre-pregnancy bodymass index (they are stunted themselves)and are more likely to give birth to an under-weightbaby.

In South Africa, about 15% of infants are born with low birth weight.11 There are no significant differences in low birth weightratesacrossurbanandruralareas,butlowbirthweightswerefoundtobehigher(19%)amongbabiesborntooldermothers(aged

An estimated 13% of South Africa’s

children aged under fve years are overweight.

13%


FIGURE 10: STUNTING RATES AND GROSS NATIONAL INCOME (GNI) PER CAPITA

60%

50%

40%

30%

20%

10%

0%

0 5000 10000 15000 20000 25000 30000 35000 40000 45000GNI ($PPP) per capita

% o

f und

er 5

yea

r old

s stu

nted

Zambia

South AfricaKenya

Ghana

Tunisia

Source: Adapted from Jonah C, Sambu W & May J (2018)10 Data from Human Development Report 2018.

35-49 years) compared to an average of14%forbabiesborntomothersagedunder35years.

Low birth weight babies are at significant risk of neonatal and infant mortality,12

as well as other childhood illnesses like pneumonia and diarrhoea. Some studies have also found an associationbetweenlowbirthweightandriskfornon-communicable diseases such as diabeteslaterinlife.13

The risk of low birth weight can be reduced through good quality care and nutrition for pregnant women, and early uptake of antenatal care. Over 90% ofwomen report receiving antenatal care (ANC) during pregnancy, but only 47%begin receiving this care within the firstthree months of pregnancy.14 Through early and routine ANC at public health facilities, women at risk of giving birth tolowbirthweightinfantscanbeidentified,15

provided with necessary care and dietarysupplements,andthegrowthofthefoetuscanbemonitoredregularly.

Lack of access to adequate food for the mother during pregnancy and even

before conception results in poor intake of important nutrients that are necessary for the health of both the mother and the child. There is little informationavailableonthedietandnutritionalstatusof pregnant women in South Africa, but it is well established that high levels ofpoverty and unemployment negatively affectaccesstoadequatefood–leadingtohunger, undernutrition, and micronutrient deficiencies in poor households includingthosewithpregnantwomen.16

A third of women of reproductive age (15-49) suffer from anaemia, while 13% of women in the same age group are vitamin A deficient. On the extreme end, 62% ofwomen in this age group are overweightor obese, putting them at risk of non-communicable diseases such as diabetesand hypertension. Obesity in women ofreproductive age has also been found toincrease the risk of them having pretermbabies.Overconsumptionofpoordietsandlack of physical activity are some of themain leading causes of over-nutrition inadultfemalesinSouthAfrica.Consumptionofpoordiets, includingthosethatarerichin highly processed foods, has increasedamongpoorhouseholdspartlyduetolow

NUTRITIONALSUPPORT

Through early and routine

ANC at public healthfacilities,

women at riskofgiving

birth to low birth weight

infantscanbeidentified


incomes and the higher cost of healthierfoods.Otherstructuralbarrierstoahealthylifestyle include lack of opportunities forphysical exercise, safety concerns whileexercising, aswell as time poverty due tothe triple burden of work, child-care, and longtraveldistancestowork.17

Improving maternal nutrition requires policies and programmes that encourage and support consumption of healthy foods rich in micro and macro nutrients (including calcium, iron, proteins, andvitamins)anddiscouragetheconsumptionof highly processed foods. Mothersattending health facilities for ANC or forchildbirth should be sensitised on theneed for proper nutrition for themselvesandtheirbabies.Nutritioninformationcanalso be channelled through CommunityHealth Workers (CHWs) who conducthome visits. This is particularly importantin rural areas where mothers may havechallenges accessing health services duetotraveloverlongdistancesandtransportcosts.Provisionofinformationonmaternalnutrition,aswellasinfantandchildfeedingandregulargrowthmonitoring,isimportantfor nutritional outcomes. However,information alone is not enough whenmanychildrenliveinpoorhouseholdswithinadequatelivingconditions.

Irrespective of their birth weight, children can become stunted if they do not have access to adequate nutrition or if they suffer from frequent infections such as diarrhoea and pneumonia. Close to a third (31%) of children under two years are stunted. Adequate nutritionin early childhood begins with exclusivebreastfeeding for the first six months of achild’slife.Onlyathird(32%)ofSouthAfrica’sinfants under six months are exclusivelybreastfed. Exclusive breastfeeding ishighest among the youngest infants (0-1months)at44%,afterwhichtheratebeginsto decline rapidly (to 23% at 4-5 months).From6monthsofage,childrenshouldbegradually introduced to complementary foods that are diverse and nutritious.However, the vast majority of youngchildren (6-23 months) consume unvarieddiets,while77%ofthemdonotconsumeaminimumacceptabledietatall.18

Food should also be sufficient in quantity,

in order to prevent children from going hungry. Child hunger rates have declinedin SouthAfrica, but 12% of children undersix years live in households that reportchildren going hungry. The percentage ishighest in KwaZulu-Natal, where almost20% of young children live in householdsthatreportedchildhunger.

Eradicating stunting and other forms of malnutrition requires a multi-sectoral approach across a child’s life course, involving multiple government departments (Agriculture, Social Dev-elopment, Health, and Education) andother stakeholders. The implementationof the National Food and Nutrition Security Plan (2017-2022) needs to be prioritised.19 The plan is based on the country’s foodand nutrition security policy and aims toreduce food insecurity and malnutritionthroughensuringthatthesocialprotectionsystemrespondstothenutritionalneedsofchildren,improvingearlyaccesstotheChildSupportGrant(CSG),andothermethods.Afurtherkeyobjectiveistheidentificationandscalingupofhighimpactinterventionsthatimprovenutritionaloutcomes,forexample,exclusivebreastfeedingandmicronutrientsupplementation for pregnant womenand young children. Other objectivesinclude the development of an integrated communication plan to influence peopleacross the life cycle to make informedfood and nutrition decisions, increasingaccess to nutritious and affordable food,and constituting a multi-sectoral counciltooverseetheimplementationoffoodandnutritionsecuritypoliciesandprogrammes.

Given the established links between poverty and malnutrition, a long-term solution would be the reduction of poverty through increased employment opportunities that generate adequate income. But in the context of highunemployment and low wages, socialassistance programmes such as theCSG should be strengthened to cateradequately to the nutritional needs ofchildren. This can be done by increasingthe value of the grant and ensuring thatyoung children have early access to thegrant.

NUTRITIONALSUPPORT

Close to a third (31%) of children under two years

are stunted

Social assistanceprogrammessuchastheCSGshouldbestrengthenedto cater adequatelytothe nutritional needsofchildren.

31%


NUTRITIONALSUPPORT

TABLE 3: NUTRITION INDICATORS FOR PREGNANT WOMEN AND CHILDREN UNDER SIX, BY PROVINCE

Indicator SA EC FS GT KZN LP MP NW NC WC Data year

source

Popu

lati

on

Vitamin A deficiency in women. Women (16-35 years) below the WHO standard

13% 9% 8% 18% 16% * * 9% * 7% 2012 f

Anaemia in women (15+ years) Women (15-49 years) below the WHO standard for iron deficient

33% 30% 28% 32% 29% 29% 39% 38% 26% 24% 2016 d

Low birth weight % infants born with weight below 2500g

15% 14% 17% 12% 17% 11% 14% 16% 20% 18% 2016 d

Child hungerChildren under 6 years in households where children suffer hunger

823 000 64 000 50 000 155 000 271 000 33 000 82 000 72 000 32 000 64 0002017 a

12% 7% 15% 10% 19% 4% 13% 15% 21% 9%

Serv

ice

acc

ess

Breastfeeding Children aged under 6 months who are exclusively breastfed

32% 20% 28% 29% 33% 43% 15% 31% 65% 46% 2016 d

Vitamin A coverage in children (12 - 59 months)

54% 53% 48% 51% 69% 47% 58% 42% 50% 49% 2017 c

Out

com

e

Vitamin A deficiency in children under 5 44% 2012 f

Iron deficiency anaemiain children under 5 1.9% 2012 f

Anaemia in children (6 - 59 months)Children (6-59 months) suffering from anaemia

61% 59% 54% 74% 42% 59% 70% 68% 48% 61% 2016 d

Stuntingin children under 5 27% 25% 34% 34% 29% 22% 22% 27% 21% 23% 2016 d

Underweight in children under 5 6% 3% 8% 6% 4% 5% 5% 13% 8% 12% 2016 d

Overweightin children under 5 13% 21% 17% 11% 18% 8% 9% 8% 5% 14% 2016 d

Lack of detailed individual-level data on food intake remains the biggest challenge in the assessment of dietary intake, particularly among young children and pregnant women. In addition to the fact that existing data on dietary intake is out-dated, the food consumption surveys that collect such data are carried out irregularly which makes it difficult to monitor trends and evaluate the impacts of policies and programmes designed to improve food security and nutrition.

South Africa also lacks disaggregated data on dietary intake and child nutritional outcomes, making it difficult to produce estimates across various levels of disaggregation such as geographical regions and age groups. Consequently, it is difficult to give an accurate diagnosis of the extent of inequalities in food and nutrition security. This hampers the implementation of programmes targeting the most food insecure and malnourished.





As many as 47% of pregnant women suffer from antenatal depression22 and up to 34% of women suffer from postnatal depression.23 Depression not only limits awoman’scapacitytooffernurturingcaretoher child but also has adverse outcomesfor maternal-infant attachment and bonding, early infant feeding practices,maternal health seeking behaviour, infantbrain development, and the mental health ofthechildlateroninlife.24

Although South Africa has high rates of parental absence,25 most children under six years do live with their biological mothers. This suggests thatinvesting in educating pregnant womenon positive parenting and providing themwith psychosocial support throughoutpregnancy and the postnatal period willcontinuetodirectlybenefitthemajorityofchildrenfortheearlyyearsoftheirlives.

An example of how this kind of supportcouldbeprovidedisthroughcommunity-based antenatal and postnatal supportgroups that provide positive parentingeducation, as well as a community ofaffirmation and encouragement for newmothers and their partners. At presentparenting support and educationprogrammes are not widely available inSouth Africa, and these programmes areparticularly scarce for families living invulnerable communities where the needforparentingsupportisgreatest.

National evaluations have found antenatal breastfeeding education amongst HIV-positive mothers to be high, estimated at 94%.26Morerecentdatashowsthatnationally,82%ofwomenwhoreceivedpostnatalcarewereprovidedwithinformation on breastfeeding.27 However, these statistics do not tell us about thequality of breastfeeding education; nor


For children to thrive and reach their full potential, they require nurturing care from their caregivers. Nurturing care is care that is responsive, encourages early learning, and is emotionally supportive.20 However the capacity of caregivers to offer this form of care can be undermined by the high levels of poverty, domestic violence, and perinatal depression that many of South Africa’s primary caregivers experience.21 Caregivers need supportive services, including clear information about parenting, as well as access to psychosocial services and material support.

47% of pregnant women suffer from antenatal

depression and up to 34% of

women suffer from postnatal

depression.

47%


SUPPORTFORPRIMARYCAREGIVERS

do they seem to translate into improvedexclusive breastfeeding rates for infantsunder six months which are estimated tobeataround32%28 - well below the global exclusivebreastfeedingtargetof50%.29 Clearly breastfeeding education alone isnotenoughtoimprovebreastfeedingrates.Mothers need to be supported in theirhomes and communities with commonchallenges related to breastfeeding.These include mental health challengesthat contribute to women losing theirconfidence in their ability to adequatelynourish their child with breastmilk alone,as well as poor breastfeeding techniquesthat may result in cracked nipples andengorged breasts – resulting in the earlyterminationofbreastfeeding.30

SouthAfrica has an approximately 70,000strong workforce of Community Health

Workers(CHWs)whoifcapacitatedthroughadequate training, necessary resources,and supportive supervision, could play acritical role in providing household-basedbreastfeeding support to caregivers. Notonlywould this improve infant health anddevelopment outcomes, but it could alsohelp to protect caregivers from postnataldepression. The literature suggests thatmothers tend to base infant feedingchoices on information provided to themby a healthcare worker,31soaninvestmentin training CHWs on breastfeedingeducation and support is likely to go alongwayinimprovingbreastfeedingratesin South Africa. There is a range of CHWprogrammes already in place in SouthAfrica’s vulnerable communities thatcould be leveraged to improve caregiver support, as well as maternal and childhealthoutcomes.

Breastfeedingeducation

aloneisnotenough to

improve breastfeedingrates.Mothers

need to be supported

in their homesand

communities.

Mentor Mothers - The Philani Maternal, Child Health and Nutrition TrustThe Philani Maternal, Child Healthand NutritionTrust runs a CHW-ledhome visiting programme in theWesternandEasternCape,withtheaim of improving child health and nutritionoutcomes.Theprogrammeis called Mentor Mothers andit provides support and healtheducationtoat-riskpregnantwomenin the communitieswhere they live.AnumberofevaluationshavefoundPhilani’s home visiting programmeto be effective in improving thenutritional status and wellbeing ofchildren in the communities wherePhilanioperates.A2015randomisedcontrol trial found that even in the face of antenatal depression,Philani’s home-visiting programmewas effective in encouraging and

supporting mothers to continuepositive behaviours that promotefoetal and infant wellbeing. Thetrial found that the interventionwaseffective in protecting the unbornchildfromstuntingwhencomparedto children of depressed motherswho did not benefit from MentorMothers.32

Champions for Children - Grow GreatChampionsforChildrenisaninformalcommunityofpracticethatsupports,empowers, and incentivises CHWstoprovideevidence-basedfirst1000days interventions to mothers andchildren through virtual and face-to-face groups in communities.ChampionsforChildrenisanexampleof how the presence of CHWs incommunities can be leveraged toimprove maternal and child health

Examples of Community Health Worker (CHW) programmes in South Africa



outcomes. The CHWs participatingin Champions for Children’s clubshave to date established over 200community-based, peer-supportedbreastfeedinggroupsinLimpopoandMpumalanga. They have routinelygrowth monitored close to 8,000children under two, with the aim of reaching 600,000 children undertwo at scale. An internal evaluationof the programme, six monthsinto implementation, suggeststhat Champions for Children isstatistically significantly effectivein improving CHWs’ confidence intheir own understanding of issuesrelated to maternal mental health, and in conducting screenings forperinatal depression. In addition,after six months of participatingin Champions for Children, CHWsreported improved knowledge in supportingearlyantenatalbookings,improved confidence in their abilitytoidentifyat-riskbabies(particularlylow birthweight babies), measuringmid-upper arm circumference to screenforsevereacutemalnutrition,assessing the weight-for-age andheight/length-for-age of childrenundertwo,andinfacilitatingreferralsto the Department of Home Affairsforchildrenwithoutbirthcertificates.

Family Community Motivator (FCM) programme33 - ELRU The FCM programme is a homevisiting programme, run by ELRU,targeting the most vulnerablehouseholds with pregnantwomen and children under two.The programme aims to provideeducation and support to pregnantwomen and caregivers throughhome visiting and parentingworkshops with the intent topositively change their caregivingbehaviours. The programme alsolinks beneficiaries to governmentsocial and health services. In 2016,an external evaluation of the FCMprogramme in the North Westassessed whether the programmehad changed caregiver and child outcomes such as hygiene andsafetyinthehome,caregivercoping,parenting,earlylearning,andaccessto services. The external evaluationfound significant improvementsin household hygiene and safety,parenting,andcaregivercoping.Theevaluationalsofoundanincreaseinparent-child stimulation activities.Access to birth certificates andRoadtoHealthBookshadimproved for children under 12 months andsocial grant access for childrenunder 12 months had improvedfrom 49% coverage to 81% over thepreviousyear.

Exclusive breastfeeding rates can also be improved by removing structural barriers to exclusive breastfeeding. Thismay include extending maternity benefitsto six months, legislating and enforcingpaid maternity leave, as well as enablingbreastfeeding in the workplace throughstrengthening related labour laws.34 SouthAfricanlabour lawmakesprovision,through the Code of Good Practice on the

ProtectionofEmployeesduringPregnancyand after the Birth of the Child, for newmothers returning to work to take two30-minute breastfeeding or expressingbreaksperdayduringthefirstsixmonthsof their child’s life. However the code isnot legally enforceable and employersare not obliged to provide breastfeedingor expressing rooms, thus presenting amissedopportunitytoremoveasignificant

The majority of expectant mothers (76%) are making four or more visits to a health facility.

76%


structuralbarriertoexclusivebreastfeedinginthefirstsixmonthsoflife.

Antenatal care visits offer a window of opportunity for a range of support interventions. The majority of expectantmothers (76%) are making four or morevisits to a health facility. All of thesewomen should be screened for antenataldepression,substanceabuse,anddomesticviolence – particularly as pregnancy is atimeofincreasedvulnerabilitytodomesticviolenceandmentalillness.35

In addition to the clinical care received in health facilities, the mental and physical health of poor mothers could be optimised through the introduction of a maternity support grant. Providing vulnerable women with a cash grantin pregnancy would contribute to addressing malnutrition during pregnancywhich adversely impacts the growth of the foetus, as well as maternal health and maternal mental health. It wasestimated that, in 2009, at least one inevery four pregnant women in South Africa suffered from hunger36 threatening the health and wellbeing of the mother, and thephysicalandcognitivedevelopmentoftheunbornchild.37

Pregnancy is often a time of reduced earning potential, increased financial pressure and vulnerability to unem-ployment.38 The provision of income supporttopoorandat-riskwomenduring this period would be aligned to the aspirations of South Africa’s National Development Plan. In developing countrycontexts where similar strategies havebeen implemented, pregnancy and early childhood income support have beenshowntoimprovearangeofmaternalandinfant outcomes.39 In addition, pregnancyincome support would enable women toattend the recommended eight antenatal clinicvisits and participate in community-basedparentingsupportgroups.Thiskind

of policy would also serve to reduce thepoor uptake of the Child Support Grant (CSG) in the first year of life, as eligiblewomen’spregnancygrantscouldbecon-vertedintotheCSGoncethebabyisborn.

Income support after pregnancy is crucial, given the high levels of poverty and unemployment in South African households. Statistics show that over athird (37%) of unemployed mothers withchildrenunderageone,liveinhouseholdswhere no adult is employed.40 The CSG is successful at reaching large numbersof children and reducing the effects ofpoverty, but there are delays in gettingbabies registered.Additionally, the CSG isnotdesignedtosupportmaternalnutritionaswellasthebasicneedsoftheirchildren.

The majority of women, estimated at 71% in 2017, attend public health facilities for postnatal care six days after the birth of their child. These postnatal care visitsprovide a critical opportunity to supportcaregivers at a time of great vulnerabilityand link them to relevant services in theircommunities. Postnatal visits also offeran opportunity to reinforce breastfeedingeducationandprovidesupporttomothersfacingbreastfeedingchallenges.Researchsuggeststhatbreastfeedingeducationandsupport is most effective when receivedbothbeforeandafterthebirthofthebaby.41

This chapter does not address thesupport needed by fathers and othermen who provide a social fathering role.More research is needed in this area,particularly in light of evidence pointing to the important role fathers play in thehealth and psychosocial developmentof a child during the first 1000 days andbeyond.42 Programmes are needed thatprovide parental support and educationto men, who are often a neglected group when caregiver support programmes andpoliciesaredeveloped.43

The mental andphysical

health of poor motherscould

beoptimisedthrough the introduction

of a maternity supportgrant.



• There is a lack of data on the provision of support, information, and advice to pregnant women and mothers.

• Information on the quality of antenatal and postnatal services is lacking.

• There are no routinely collected national data on maternal mental health challenges and screening (including domestic and intimate partner violence, as well as alcohol and substance abuse) during pregnancy and after birth.

• There are no national data on the types of parent support programmes available, their identifed target groups, benefciary access and programme reach.

• Data on the management of primary level mental health problems requiring treatment are lacking.



TABLE 4: INDICATORS OF SUPPORT FOR PRIMARY CAREGIVERS, BY PROVINCE


source

Popu

latio

n

Maternal careChildren under-6 who live with their biological mother

85% 74% 82% 94% 80% 82% 84% 85% 85% 92% 2017 a

Household education Children under-6 living with at least one adult who has passed matric

61% 47% 59% 73% 64% 49% 61% 57% 56% 63% 2017 a

Serv

ice

acce

ss

Breastfeeding education % of mothers (15-49 years) who reported receiving infromation on breastfeeding

82% 86% 88% 72% 92% 94% 70% 79% 88% 86% 2016 d

Follow-up antenatal visits% of pregnant women attending facilities who had at least 4 antenatal visits

76% 82% 78% 62% 77% 82% 73% 89% 75% 89% 2016 d

Postnatal follow up Women birthing in pub-lic facilities who received follow-up care 6 days after birth

71% 63% 64% 71% 77% 86% 63% 75% 62% 58% 2017 c


Youngfather,MosizakheBottomone,comfortshisnewbornaheadofaroutineappointmentatPhilaniClinic, Khayelitsha,WesternCape.Photo:BartLove,2018.


Social services and income support

Socialassistanceisawayofredistributingresourcestothepoorthroughgrants.Socialgrants are widely regarded as the mosteffective poverty alleviation programmein South Africa because of their positiveimpact, effective targeting, and widereach.Socialassistanceprogrammeshaveexpanded from covering just 2.7 millionpeoplein1994to17.5millionin2018.

The CSG has had the highest growth of all social grants in South Africa. It wasintroduced for poor children aged under sevenin1998,andthengraduallyextendedtoallchildrenbelowtheageof18by2012.Its reach has expanded from just under22,000childbeneficiariesin1998toover12millionchildrenin2019.

Access to social grants for young children is lagging behind the targeted uptake levels. TheMediumTermStrategicFramework 2014-2019 set a target thatgrantsshouldreachatleast95%ofeligiblepeopleby2019.In2017,thistargethadnotbeenreached:82%ofpoorchildrenundersix years received a grant and only 64%of poor children44 under a year received a grant.

The relatively urbanised and wealthy provinces (Gauteng and the Western Cape) have the lowest CSG uptake rates. Poorer and more rural provinces performbetter in rolling out the CSG to eligible children.Thisspatialpatterningisstrikinglydifferent from many other indicators,where Gauteng and the Western Capetend to outperform other provinces.Previous studies on the implementationof the CSG have suggested that in verypoor provinces or districts where thepopulationishomogenouslypoor,thereisgreateremphasisonfacilitatingenrolmenton the grant; whereas in wealthier areaswhere there is greater inequality andpopulations are not homogenously poor,social security officials are more inclinedtowards“gatekeeping”andmayevenmakeapplications more difficult by demandingsupporting documents that are notrequiredbylaw.45

The CSG has been shown to have a substantial developmental impact on poor children’s nutrition, health, and educational outcomes, and more can be done to improve its reach and impact. The value of the grant should

Early registration of births is important because a birth certifcate is the gateway to other services and benefts, including the Child Support Grant (CSG). The CSG provides income support for children in poverty and thus targets some of the structural causes of poor early childhood development.

82% of poor children under

six years receive a grant and only 64%

of poor children under a year

receive a grant.

82%

64%


For each cohort of

children born in a year, around

200,000children are

notregisteredwithinthefirst

year of their life.

be increased. The grant amount (R400 in2018) is considerably lower than the foodpovertyline(R547in2018).Itisnotenoughto ensure thatyoung children receive theminimum amount of nutrition, let alone the cost of other essentials such as clothing,bedding, transport to clinics, and feesfor child care services such as crèches.Theeasiestwaytoaddressexclusionsforchildrenistoensurethattheyareenrolledon the grant from birth. This requiresgreater investment in enabling birthregistration at health facilities where themajority of births occur and considerationbeing given to expanding this model toinclude simultaneous CSG registration.Further,healthworkersshouldencourageeligiblecaregiverstoapplyfor theCSG, iftheyarenotalreadyaccessingit.

Early birth registration has increased over the past decade. Births are meant to beregisteredwithinthefirst30daysoflifeandtherehasbeenanotableincreaseinbirthregistrations during this period, as shownin Figure 11. The Department of HomeAffairs(DHA)attributesthisachievementtoa range of outreach programmes and theintensificationofbirthregistrationathealthfacilities.46Thereisacorrespondingdeclineinlateregistrations,butcalculationsusinga combination of birth registration dataand population estimates suggest that

for each cohort of children born in a year, around200,000childrenarenotregisteredwithin the firstyear of their life. Some areregistered even later and some are neverregisteredatall.Birthregistrationafteroneyear is very much more difficult becauseof extra proof required and a verificationprocess involving interviews before apanel.

Only 391 of the 1,445 health facilities where births occur in South Africa have DHA service points.47 These servicepointsenablecaregiverstoapplyforbirthregistration of their new-born child at thehealth facility immediately after giving birth. Many of the service points that doexist are not yet connected digitally tothe DHA mainframe, meaning that the applicationmustbeverifiedandprocessedat a DHA office. The Minister of HomeAffairs has committed to ensuring that251 priority service points, covering 84%of the births in South Africa, are digitallyconnected by March 202148. He has alsocommitted that all health facilities wherebirths take place will have DHA servicepoints by 2023.49 However, the 2019/20BudgetVoteprojectsthatbirthsregisteredwithin30dayswillremainat800,000until2023, indicating little intention to intensifyearlybirthregistrationwithinfacilities.50

SOCIALSERVICESANDINCOMESUPPORT

FIGURE 11: BIRTH REGISTRATION TRENDS (2010/11 – 2017/18)

Source: DHA Annual Report (2017-2018)

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

Early registration (0-30 days) Late registration (31 days - 14 years)

1,000,000

800,000

600,000

400,000

200,000

0



From the moment they are born, all children in South Africa are entitled toanameandnationality.Thestateconfersthisthroughbirthregistrationand,inthecaseofchildrenwhoarecitizens, a South African identitynumber.

Why is it so important that children’s births are registered?Birth certificates are the gatewayto a range of services that arecritical for children to reach their developmental potential. Yet overhalf a million children aged 0-18in South Africa do not have birth certificates and, as a result, havepoorer access to a range of stateservices.51

• Children without birth certificates are likely to come from poor families; yet it is difficult for caregivers to access the CSG without birth certificates. Only 18% of young children without birthcertificates receive a social grant,comparedto74%ofthosewithbirthcertificates.

• Unregistered children are more likely than registered children to be without the state-issued personal health record, the Road to Health Book (7% versus 1%), suggesting that they are less likelyto access the primary health careservices necessary such as growthmonitoringandimmunisation.

• Children without birth certificates are at risk of exclusion from school. An estimated 158,000childrenofcompulsoryschoolgoingage do not have birth certificates.Although the law52 does notrequire learners to provide a birthcertificate in order to attend school,the admission policy53 does; andthe Department of Basic Education

has communicated a new policy ofnot paying schools the per learnerallocation for learners withoutidentitynumbers.54Thereisgrowingevidence that many children without birthcertificatesarebeingexcludedfromschool55 even though education isaconstitutionalentitlementandiscompulsory until a child is 15 yearsold.

• There is a risk that young children without identity numbers will be excluded from funding allocations for pre-school educa-tion and services, particularly asefforts are made to strengthen ECDadministrative data systems stan-dardised with the use of identitynumbers.

What are the obstacles to birth registration?Caregiversfacearangeofobstaclesin birth registration. In addition totravelling distance and cost andlongwaitingtimesatDHAoffices,thelegal requirements, computerisedsystems and procedural protocolsimplemented by the DHA tend to be inflexible, making it difficult forsome children to be registeredwithin the required period. This isespecially the case if parental andcare arrangements do not conformtoanuclearfamily‘norm’.56

The law, regulations and protocolsgoverning birth registration needto be reviewed and reformed to includeallchildren,andthesystemsneed to be sufficiently flexible toaccommodatedifferentscenarios.Rather than being excluded fromservices, unregistered childrenshould be fast-tracked into aresponsive government servicethat pro-actively assists with theirregistration.

Compared to children with birth certificates, those whose births are not registered are…

• More likely to be poor • Less likely to receive a social grant• Less likely to access clinics for immunisation and growth monitoring • More likely to be excluded from school and from the school nutrition programme

The challenge of achieving complete birth registration



There are no reliable data on the number of children who need social services, or on the extent of services delivered and service delivery gaps. Services foryoungchildren as defined in the Children’s Actinclude:

• partialcare(crèchesandECDcentres)andECDprogrammes

• prevention and early intervention ser-vices,suchaschildandfamilycounselling,parenting skills programmes, and supportforyoungmothers

• protection services for childrenwho have been abused, abandoned, or neglected

• provisionofalternativecare,includingfostercareandadoption

Data on child abuse, neglect and on the related service responses remain very poor – in part because child abuse and other violent crimes against children are under-reported. The South African Police Service recorded 43,450 crimes againstchildrenin2017/18,ofwhichoverhalfweresexual assault.57 A national prevalence studyestimatedthatoneinthreechildrenexperiences physical violence and sexualabuse before the age of 18.58The Birth toTwenty(BT20)study,alongitudinalstudyofchildrenborninSoweto,Gauteng,suggeststhat children’s exposure to violence andabusemaybeevenmorecommon:99%ofchildren in its sample had experienced orwitnessedactsofviolenceinchildhood.59

Young children are particularly vulnerable to child abuse and neglect because they are dependent on care-givers and cannot protect themselves. The BT20 study found that half (49.9%)of pre-school children had experiencedphysical punishment by a parent or care-

giver.60 The most severe consequenceof child abuse is infanticide (killing of achild under one year). A national surveyof child homicides found that three quarters of homicides among young children(0-4years)hadbeentheresultofabuse by a caregiver in their own home.61

Thelinebetweenphysicalpunishmentandchild abuse is blurred and it is partly forthis reason that civil society organisationsconcernedabouttherightsandwell-beingof children have argued for a complete ban oncorporalpunishment.

Emerging evidence points to the links between intimate partner violence and violence against children in the home. Theseformsofviolencesharecommonriskfactors, and both have intergenerationaldynamics – the experience of violenceor even witnessing violence in childhoodincreases the likelihood of perpetratingviolence in adulthood or entering into violent relationships.62 This implies theneedforjointstrategiestoaddressviolenceagainstwomenandchildren.

Increased efforts are needed to strengthen the child protection system andtoensurethatthevariousduty-bearers,such as the police services, Departmentof Social Development, Department of Healthandthecriminaljusticesystem,cancollaboratewelltoimprovetheefficiencyofresponsive services and referral systems.A national Child Protection framework has been drafted and once finalised, itcouldinformcurrentlegislativeandpolicyframeworkstostrengthenservicedelivery.

One in three children

experiences physical

violence and sexual abuse

before the age of 18

13


Thereisaneedforregularnationaldataontheprevalenceofchildabuseandneglect.The data would need to come from reported cases to the police and socialservicesbecausetheseissuesaredifficultto determine in general surveys. Goodsystemsneedtobeinplacetoensurethatreporting is encouraged and that recordsare accurately recorded and maintained in local offices and properly compiled atprovincialandnationallevel.

Thereisalsoaneedforgoodadministrativedata on the delivery of responsive childprotection services and psychosocialsupport for children. For example, itwould be useful to track the number andproportion of child protection cases thatare brought before the court within 90days, as stipulated in the Children’s Act.This would involve linked administrativedatasystemsfortheDepartmentofSocialDevelopment and the Department of JusticeandConstitutionalDevelopment.

South Africa does not have a nationallyaccepted tool for measuring theprevalence of disability, especially inchildren. The last dedicated nationaldisabilityprevalencesurveyinSouthAfrica

was conducted in 1999. More recently,StatsSAhasincludedmodulesofdisabilityquestions in the Population Census, theCommunity Survey, and some of theGeneral Household Surveys, but thesecannot be used reliably to determinechild disability rates as the “domains offunctioning”measuresarenotadequatelysensitive to normal developmentprocesses,particularlyinyoungchildren.63 Estimates of disability rates from thesesourcesshowhugediscrepancies,rangingfrom0.9%to27.5%ofyoungchildrenunderfouryears,andbetween0.6%and11.2%ofthe total child population.64 The revisedRoad to Health Book includes a potentialtool to identify young children at risk ofdisability and developmental delays.Certain screening systems for identifyingdisabilityinschool-agechildrenhavebeenintroduced through the education systemin conjunction with the Department ofHealth, including assessments of hearing,speech, and gross motor function. Theeffectivenessofthesetoolswilldependonhowwellandconsistentlytheyareappliedby different assessors across differentsettings.


TABLE 5: SOCIAL PROTECTION ACCESS/DELIVERY INDICATORS FOR CHILDREN UNDER SIX, BY PROVINCE

Indicator SA EC FS GT KZN LP MP NW NC WC source

Serv

ice

acce

ss /

deliv

ery

No birth certificateEstimated number of children under 1 not registered within first year

198 000 35 000 4 000 43 000 33 000 44 000 9 000 13 000 5 000 12 000

g

18% 25% 8% 17% 15% 27% 10% 18% 18% 11%

CSG uptake in children under 6Proportion of poor children < 6 years receiving CSG

81% 86% 83% 67% 83% 84% 82% 79% 84% 70% h

Poor infants without grantsNumber and share of poor children < 1 year not receiving CSG or any grant

401 000 43 000 20 000 129 000 66 000 49 000 33 000 22 000 6 000 58 000

h

36% 30% 39% 52% 30% 30% 38% 32% 20% 53%

Thereisaneed for regular national data on the prevalence ofchildabuseandneglect.



EarlylearningunderwayattheMapukatafamilyhomeinAmajingqi,EasternCape.MotherNopheloMapukata withhertwoyoungdaughters.Photo:BartLove,2018.



Early childhood experiences are particularly important in shaping the

development of the brain. Experiences that matter most in terms of

early learning include everyday interactions between the child and

their primary caregivers, as well as the child’s exposure to formal and

informal group-based learning opportunities with peers.

TheSouthAfricanNationalIntegratedECDPolicy (2015) promotes a broad range ofprogrammes and interventions to supportparenting and to enable the delivery of group-based early learning models in avariety of contexts. These are deliveredthrough a combination of government and non-government providers, withsubstantialvariabilityindesignandquality.

The influence of children’s home environment and parenting practices on early development is well established.65

Interactions between parent and childin the first few years of life are especiallyimportant for early language, cognitive, and socio-emotional development. A recentSouth African study has found that manycaregivers never engage in key activitieslikelyto improveearlylearningoutcomes,such as reading, telling stories, or playingwiththeirchildren.66Thestudyalsofoundthat low income families have very littletime available for these activities, andpossess few resources such as children’sbooksortoys.

While the first two years of life represent an important window of opportunity for

brain development, there is very little in place to support early learning for children under two years. Just over onefifth (21%) of children aged birth to twoyears are enrolled in a group programmefor early learning, such as a crèche orplaygroup.67Another9%arereportedtobein the care of a day mother, childminder, or gogo. The remaining 70% are likely beingcaredforathomebytheirmothersorotherfamilymembers.

Unfortunately, the General HouseholdSurvey’s (GHS) questions regarding childcare arrangements cannot distinguishsufficiently between care settings thatinclude an early learning component and thosethatdonot.Thisisacriticaldatagap.Early learning can and should happen inthe full range of spaces where childrenspendtheirdays.Giventhefactthatmanychildren under two years are cared forat home, it is striking to note that half ofchildren of this age are never read to bytheircaregivers.68

Early learning interventions need to include well designed and contextually appropriate programmes to encourage

Manycaregiversnever engage inkeyactivitieslikely to improve early learning outcomes,suchasreading, telling stories,orplaying with theirchildren.


responsive and interactive parenting. These programmes may be deliveredthrough home visiting interventions andas an extension of some group-basedlearning models. Another way to reachparentsinthefirsttwoyearsisthroughthehealth system, where the child’s growthmonitoring and immunisation scheduleenables regular contact with healthworkersasdescribedinpreviouschapters.Tomaximisethisopportunity,theNationalDepartment of Health has recentlyintegrated messages which promoteearlylearningintotheirmobilemessagingplatform, MomConnect. Early learning isalso includedasoneoftheessentialcarecomponentsintherevisedRoadtoHealthBook and Side-by-Side communicationcampaign.Theseareexcitingexamplesofintegratedservicedelivery.

The GHS data show that 69% of children aged three to five years are enrolled in some form of early learning group programme such as a school (Grade R), preschool, nursery school, crèche, educare centre or playgroup. Access

varies substantially across provinces,from less than 60% in KwaZulu-Natal andNorthern Cape to 81% in the Free State.Unfortunately, we know very little aboutthequalityofservicesthroughthepubliclyavailable data and expect significantvariability in the extent to which thesevarious settings offer age-appropriatelearningprogrammes.

Despite some progress, nearly 1.1 million children aged three to five years still do not have access to any form of early learning programme. Close to one thirdof these children live in Kwazulu-Natal.Childrenwhodonothavethebenefitofanearlylearningprogrammearelikelytostartformalschoolingatadistinctdisadvantage.

Children from lower income groups are less likely to access an early learning programme, highlighting the likely role that cost plays as a barrier to access. Pooraccesstoearlylearningopportunitiesfor the poorest children is a disadvantagethat will likely be carried over into their formal schooling years. Since household

STIMULATIONFOREARLYLEARNING

Over 1 million children aged

three to fve years still do not have

access to any form of early learning

programme.

FIGURE 12: ENROLMENT IN EARLY LEARNING GROUP PROGRAMME, BY INCOME QUINTILE AND AGE.

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: GHS (2017) Analysis by Children’s Institute (UCT)

Age

Quintile 1 (poorest) Quintile 2 Quintile 3 Quintile 4 Quintile 5 (richest)

1.1 millionchildren

0 1 2 3 4 5



incomeisusedtoderiveincomequintiles,the number of children is not evenlydistributed across quintiles. Instead, therearemorechildreninthelowerquintilesaspoor households tend to be larger: 77%ofyoungchildrenareinthepoorestthreequintiles.

The access gap between the richest(quintile 5) and poorest children (quintile1) iswidest among the children aged oneto three. A three-year-old in quintile 5 istwice as likely to attend an early learningprogramme as a child of the same agein quintile 1. The gap between quintilescloses at the point of entry into Grade RwhereQuintile1to3childrenhaveaccesstofreeschooling.

While all poor69 children of school age inSouth Africa can access fully subsidised(no-fee)primaryandsecondaryeducation,onlyaround12%ofpoorchildrenundersixyears have access to partially subsidisedearly learning programmes.70 Even in subsidised programmes, the subsidyamount is not enough to cover the fullcosts, and parents are typically requiredto pay fees to cover the shortfall. Witharoundtwomillionchildrenaged0-5livinginhouseholdswherenobodyisemployed,universal access to early learningprogrammes is not achievable with thecurrentfundingmodelandbudget.

Despite the high rates of poverty and unemployment, reported rates of fee payment for ECD services are high. Of the 2.7 million children under six whoattend some kind of group early learningprogramme (below grade R level) or arein the care of a childminder, 84% havefeespaidforthem.FeesrangefromunderR100/monthtooverR2000/month.Nearlyhalf(45%)payoverR200permonth71 – more than half the value of the Child Support Grantatthetimeofthesurvey.

In his 2019 State of the Nation Address,President Cyril Ramaphosa announcedtheshiftofresponsibilityforearlylearningprogrammes, from the Department ofSocial Development to the Department of Basic Education. It remains to be seenhowthisfunctionshiftwillplayout,buttheproposedchangepresentsanopportunity

tobringfundingmodelsforearlylearninginlinewiththeno-feeschoolspolicysoastoensuremoreequitableprovisionofearlylearningopportunitiesforall.

There are no national data on the quality of early learning programmes in South Africa, although several studies have shown that poorer children are more likely to receive poorer-quality programmes.72 Numerous interventionsto improve the quality of early learningprogramme delivery are offered bothby government, through its NationalCurriculum Framework training, and by NGOs. However, evaluation of impact oftheseinterventionsisminimal.Whilemuchemphasishasbeenplacedonpractitionerqualifications, qualifications alone are notsufficienttomakeadifference.73Oversight,mentoring, and on-site support fromsuitably qualified personnel are centralto quality improvement and successfulprogrammedelivery.74

Whether or not children realise the benefits of enrolment in a high quality early learning programme is heavily dependent on dosage – i.e. the durationandintensityofexposuretotheprogramme.The literature suggests that two or moreyears’ exposure to a programme is morebeneficialthanone,andthatfifteenhoursper week is the minimum recommendedparticipation time.75 In a recent SouthAfrican study, children who had higherlevels of programme exposure hadsignificantlybetterlearningoutcomes,andchildren who were enrolled for at leastthree years showed even greater gains.76 Efforts to support better access to highquality early learning programmes must,therefore, go hand-in-handwith efforts toensureretentionandregularattendance.

The cumulative effect of South Africa’s investments in ECD services, from health and nutrition to early learning, can be determined by measuring the proportion of children who are developmentally ‘on track’ for age. No national data currently existtotrackthisimportantindicator.

In 2018, child outcomes data werecollectedon506children(aged4-6years),enrolled in ten different early learning

Severalstudieshaveshownthat poorer children are more likely to receive poorer-qualityprogrammes



programmes77 across six provinces.78 Only 29% of the children were found tobe developmentally ‘on track’ for age, asmeasuredbytheEarlyLearningOutcomesMeasure(ELOM).79

Thetablebelowprovidesabreakdownofthe2018ELOMdataforeachdevelopmentaldomain.Keygapsareevident incognitiveandexecutivefunctioning,aswellasinfinemotorcontrolandvisualmotorintegration.These are foundational skills necessaryfor focus, self-regulation, problemsolving, working memory, and hand-eyecoordination. A concerted focus on thesedomains in early learning programmesmaybehelpful.

Overall, girls performed better than boys in all domains except gross motor development, where they performed equally. One third (33%) of girls achievedthe expected standard on total ELOMscores,comparedto23%ofboys.

A child’s nutritional status is a key determinant of learning outcomes. As would be expected in line with theliterature,81 children with higher height-for-ageZ-scores82 who participated in the study performed significantly better onall ELOM domains and on the ELOM totalscore.Thisreaffirmsthatinterventionsthatensure adequate health and nutrition, aswell as improved water and sanitation, inthe early years are essential to achievinggood educational and developmental outcomes.

Poor early learning foundations set children on a poor education trajectory. Numerous studies have pointed to SouthAfrica’s poor educational performance inthe formal schooling phase. In the 2016Progress in International Reading and

Literacy Study (PIRLS) which assessedliteracy amongst Grade 4 learners,South Africa was placed last out of 50participatingcountries. In thesamestudy,78%ofSouthAfricanGrade4childrenwerenotabletoreachthelowestbenchmarkinthereadingscores(theycouldnotreadformeaninginanylanguage),comparedto4%internationally.Aswith the ELOM findings,girlsscoredhigherthanboys.

ThePIRLSfindingsconfirmtherelationshipbetween income inequality andeducational outcomes – learners frompoor households fare substantially worsethan those from more affluent settings.A key recommendation arising from thestudy was the initiation of pre-primarycampaigns for parents and teachers, toemphasisetheimportanceofearlyliteracyactivitiesatpre-primarylevel.83

Another international study, Trends in International Mathematics and Science Study (TIMSS),84 which assesses numeracy, placed South Africa second last out of 49 countries and found that three out of five Grade 5 learners did not have the minimum required competencies in mathematics (theydid not even have the skills to do basicaddition and subtraction). Importantly,those who attended pre-school beforeentering primary school scored higherthan those who did not attend, althoughthis advantage was reduced for learnersattendingno-feeschools.

The fact that nearly 90% of learners inGrade 3 are in the correct grade for theiragesuggeststhatmanychildrenarebeingpromoted through the foundation phaseeveniftheydonothavethebasicreadingand numeracy skills that would enablethemtolearnathigherlevels.

Interventionsthatensure

adequatehealth and

nutrition, aswellasimproved water and

sanitation,intheearlyyears

areessentialtoachieving good

educational and developmental

outcomes.

78% of South African Grade 4

children were not able to reach the

lowest benchmark in the reading scores (they

could not read for meaning in any language),

compared to 4% internationally.

78%

PERCENTAGE CHILDREN ACHIEVING THE ELOM STANDARD FOR EACH DEVELOPMENTAL DOMAIN (N=506)80

Gross Motor Development 37%

Fine Motor Control and Visual Motor Integration 21%

Emergent Numeracy and Mathematics 36%

Cognitive and Executive Functioning 27%

Emergent Literacy and Language 38%

ELOM Total 29%



TABLE 6: EARLY LEARNING INDICATORS, BY PROVINCE


source

Popu

latio

n Children aged 0-2 years 3 428 000 424 000 163 000 774 000 641 000 491 000 282 000 245 000 70 000 339 000 2017 a

Children aged 3-5 years 3 550 000 452 000 164 000 727 000 768 000 415 000 331 000 252 000 78 000 363 000 2017 a

Serv

ice

acce

ss/d

eliv

ery

Early learning in 0-2 year oldsChildren 0-2 years reported to attend a preschool, nursery school, crèche, educare centre or playgroup.

21% 16% 28% 30% 14% 18% 21% 18% 8% 29%

2017 a 726 000 67 000 45 000 233 000 88 000 90 000 59 000 44 000 6 000 97 000

Children 0-2 years reported to be in the care of a daymother / childminder / gogo.

9% 7% 9% 13% 4% 11% 8% 3% 17% 10%

2017 a 298 000 30 000 14 000 103 000 26 000 52 000 22 000 6 000 12 000 35 000

Children 0-2 years cared for at home / not with a childminder or in a group environment.

70% 77% 64% 57% 82% 71% 72% 80% 75% 61%

2017 a2 404 000 328 000 104 000 438 000 527 000 349 000 202 000 195 000 53 000 206 000

Early learning enrolment in 3-5 year oldsChildren 3-5 years reported to attend an early learning group programme or Gr R

69% 70% 81% 79% 57% 79% 66% 66% 58% 66%

2017 a2 464 000 319 000 133 000 577 000 435 000 330 000 219 000 168 000 46 000 238 000

Number of children 3-5 not attending any early learning group programme

1 086 000 134 000 30 000 150 000 333 000 85 000 111 000 85 000 33 000 125 000 2017 a

ECD feesFee payment rate for children under 6 receiv-ing childcare or group learning prog below Gr R level.

84% 70% 87% 88% 78% 82% 94% 93% 75% 88%

2017 a 2 291 000 204 000 137 000 683 000 309 000 263 000 215 000 154 000 40 000 287 000

Out

com

e

Foundation phase through-putPercentage of children aged 10-11 who have passed grade 3

86% 89% 90% 88% 95% 89% 88% 87% 85% 89% 2017 a

Maths competencyGr 5 learners who have achieved minimum competence in nu-meracy

39% 26% 36% 57% 33% 24% 40% 29% 37% 68% 2015 i

Reading competencyGr 4 learners with basic reading skills (low benchmark)

22% 15% 27% 32% 18% 9% 17% 22% 19% 45% 2016 j


• South Africa does not have an administrative data system for early learning similar to those used in the health and education sectors. There are no reliable data on the number of registered and funded ECD centres and programmes and on how many children are accessing these services. As a result, all data on ECD services is drawn from survey data which is neither ideal, nor sustainable for robust programme monitoring and planning.

• There is a lack of data on the full range of early learning programmes targeting 0-2 year old children, including coverage of parenting programmes.

• The lack of data on the quality of early learning programmes needs to be addressed. This information is essential to inform programme enhancements and to direct resources to the most effective interventions.

• We do not know exactly how many children are receiving the Department of Social Development’s early learning subsidy. This is because the existing paper-based administrative system limits the accuracy and timeliness of the information. Efforts are underway by government and partners to design and build a Management Information System for ECD.

• ECD centres are required to keep a record of child attendance, but this data is typically not collected in a way that enables it to be verifed and collated. Improvements to attendance tracking systems could provide a helpful measure of dosage. In the context of limited resources, this information is important for us to understand the minimum dosage required for improved child outcomes in key developmental domains.

• The Sustainable Development Goal 4.2, requires South Africa to report on the proportion of children under fve years of age who are developmentally on track in health, learning and psychosocial well-being, by sex. There is currently no national data on this indicator. Several key government departments (Basic Education; Planning, Monitoring and Evaluation; and Social Development) plus partners are in the process of developing a system to address this gap.

• While the national TIMMS estimates are reliable, the provincial estimates have high standard errors.




References and notesI. RichterLM,DaelmansB,LombardiJ,HeymannJ,BooFL,BehrmanJR,etal(2017)Investinginthefoundationof

sustainabledevelopment:pathwaystoscaleupforearlychildhooddevelopment. Lancet.2017;389:103–18.doi:10.1016/S0140-6736(16)31698-1.

II. AndersonL,ShinnC,FulliloveM,ScrimshawS,FieldingJ,NormandJ,Carande-KulisV,andtheTaskForceonCommunityPreventiveServices(2003)Theeffectivenessofearlychildhooddevelopmentprogrammes.American Journal of Preventive Medicine,200324(3S):32-46.Seealso:HoddinottJ,MaluccioJ,BehrmanJ,FloresR&MartorellR(2008)EffectofanutritioninterventionduringearlychildhoodoneconomicproductivityinGuatemalanadults.Lancet2008:371(9610):411-416

III. DawesA,BierstekerL&HendricksL(2012)TowardsIntegratedEarlyChildhoodDevelopment:AnEvaluationoftheSobambisanaInitiative.CapeTown:IlifaLabantwana

IV. Foundationalpoliciesanddocumentsinclude,butarenotlimitedtotheDepartmentofSocialDevelopment’sNationalIntegratedPlans;TheChildren’sAct,No.38(2005);theDiagnosticReviewonEarlyChildhoodDevelopment(2012);WhitePaperonFamilies(2012),SouthAfricanIntegratedProgrammeofActionforEarlyChildhoodDevelopment–MovingAhead(2013/14–2016/17),andTheEssentialPackage(2014).

V. Grantham-McGregorS,CheungYB,CuetoS,etal(2007)Developmentalpotentialinthefirst5yearsforchildrenindevelopingcountries.Lancet. 2007;369:60–70.

1. RepublicofSouthAfrica(2015)NationalIntegratedEarlyChildhoodDevelopmentPolicy.Pretoria:GovernmentPrinters

2. WorldHealthOrganisation(2016)WHOrecommendationsonantenatalcareforapositivepregnancyexperience.[ONLINE]Availableathttps://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/[Accessedat08/08/2019]

3. DepartmentofHealth,MedicalResearchCouncil,OrcMacro(2007)SouthAfricaDemographicandHealthSurvey2003.Pretoria:DepartmentofHealth.Seealso:DepartmentofHealth/SouthAfricaandMacroInternational(2002)SouthAfricaDemographicandHealthSurvey1998.Pretoria:DepartmentofHealth/SouthAfrica.

4. TheWorldHealthOrganisationrecommendsaminimumofeightcontactsduringpregnancy.

5. TheWorldHealthOrganisationrecommendsarangeofinterventionsincluding:nutritionalinterventions,maternalandfoetalassessments,preventivemeasures,interventionsforcommonphysiologicalsymptoms,andhealthsystemsinterventionstoimprovetheutilisationandqualityofantenatalcare.

6. DistrictHealthInformationSystem(2017)

7. SouthAfricaDemographicandHealthSurvey(2016)

8. ibid.AnalysisbyWSambu.

9. UnitedNationsEconomicCommissionforAfrica(2013)TheCostofHungerinAfrica[ONLINE]Accessedat:https://www.uneca.org/publications/cost-hunger-africa[Accessed08/08/2019]

10. JonahC,SambuW&MayJ(2018)Acomparativeanalysisofsocioeconomicinequitiesinstunting:acaseofthreemiddle-incomeAfricancountries.Arch Public Health.2018;76:77.doi:10.1186/s13690-018-0320-2


12. WorldHealthOrganisation(2014)GlobalNutritionTargets2025:LowBirthWeightPolicyBrief[ONLINE]Accessedat:https://www.who.int/nutrition/publications/globaltargets2025_policybrief_lbw/en/[Accessed08/08/2019]

13. MiD,FangH,ZhaoY,&Zhong,L(2017)Birthweightandtype2diabetes:Ameta-analysis. Experimental and therapeutic medicine, 14(6),5313–5320.doi:10.3892/etm.2017.5234


15. TshotetsiL,etal(2019)MaternalfactorscontributingtolowbirthweightdeliveriesinTshwaneDistrict,SouthAfrica.PLoSONE14(3):e0213058.https://doi.org/10.1371/journal.pone.0213058.Seealso:Gumedeetal(2017)Attendanceatantenatalclinicsininner-cityJohannesburg,SouthAfricaanditsassociationswithbirthoutcomes:analysisofdatafrombirthregistersatthreefacilities.BMC Public Health,17(Suppl3):443.

https://www.uneca.org/publications/cost-hunger-africa

https://www.who.int/nutrition/publications/globaltargets2025_policybrief_lbw/en/


REFERENCESANDNOTES

16. See,forexample:Scorgie,Fetal(2015)“Igethungryallthetime”:experiencesofpovertyandpregnancyinanurbanhealthcaresettinginSouthAfrica.Globalization and Health11:37

17. TheConversation(2019)YoungwomeninSowetosayhealthylivingishard.Here’swhy[ONLINE]Accessedat:http://theconversation.com/young-women-in-soweto-say-healthy-living-is-hard-heres-why-118198[Accessed08/08/2019]


19. ParliamentaryMonitoringGroup(2017)NationalFood&NutritionSecurityPolicyImplementationPlan;OperationPhakisaforAfriculture,RuralDevelopment&LandReform:progressreport[ONLINE]Accessedat:https://pmg.org.za/committee-meeting/25488/[Accessed08/08/2019]

20. WorldHealthOrganization,UnitedNationsChildren’sFund,WorldBankGroup(2018)Nurturingcareforearlychildhooddevelopment:aframeworkforhelpingchildrensurviveandthrivetotransformhealthandhumanpotential.Geneva:WorldHealthOrganization.Licence:CCBY-NC-SA3.0IGO.

21. ibid

22. Rochat,etal(2018)TheprevalenceandclinicalpresentationofantenataldepressioninruralSouthAfrica.The Journal of Affective Disorder;2011;135:362–373

23. Cooper,Jetal(1999)Post-partumdepressionandthemother-infantrelationshipinaSouthAfricanperi-urbansettlement.The British Journal of Psychiatry;1999,175:554-558

24. See22[Rochat,etal].Seealso:Galler,etal.MaternalDepressiveSymptomsAffectInfantCognitiveDevelopmentLaterinLife.The Journal of Child Psychology and Psychiatry;2003,31:6

25. HallK&MokomaneZ(2018)Theshapeofchildren’sfamiliesandhouseholds:Ademographicoverview.In:HallK,RichterL,MokomaneZ&LakeL.South African Child Gauge 2018: Children, Families and the State.CapeTown:Children’sInstitute.

26. MedicalResearchCouncilSAPMTCTEReport2012-2013

27. SouthAfricanDemographicandHealthSurvey(2016)

28. ibid

29. GlobalNutritionTargets2025,WorldHealthOrganization

30. DuPlessisetal(2016)BreastfeedinginSouthAfrica-Arewemakingprogress?In:PadarathA,KingJ,MackieE,CasciolaJ,editors.SouthAfricanHealthReview2016.Durban:HealthSystemsTrust.

31. ibid

32. TomlinsonM,Rotheram-BorusMJ,HarwoodJ,leRouxIM,O’ConnorM&WorthmanC(2015)Communityhealthworkerscanimprovechildgrowthofantenatally-depressedSouthAfricanmothers:aclusterrandomizedcontrolledtrial.BMC Psychiatry;15(1),225.Accessedat:https://doi.org/10.1186/s12888-015-0606-7

33. TheFCMprogrammehasbeenimplementedbyELRUintheNorthWestsince2014aspartofpartnershipbetweenIlifaLabantwanaandNorthWestDepartmentofSocialDevelopment.

34. Martin-WiesnerP(2018)Apolicyreview:SouthAfrica’sprogressinsystematisingitsinternationalandnationalresponsibilitiestoprotect,promoteandsupportbreastfeeding.

35. VandenHeeverA, BlaauwD,ScorgieF&ChersichM(2012) InvestigatingthepotentialimpactofmaternityandearlychildsupportinSouthAfrica:Anoptionsassessment.ReportproducedfortheDepartmentofSocialDevelopment.

36. ibid

37. See20[WorldHealthOrganization,UnitedNationsChildren’sFund,WorldBankGroup]

38. See35[VandenHeeveretal]

39. Ibid

40. GeneralHouseholdSurvey(2017)AnalysisbyWSambu

41. See30[DuPlessisetal]

42. Van den BergW & MakushaT (2018) State of SouthAfrica’s Fathers 2018. CapeTown: Sonke GenderJustice &HumanSciencesResearchCouncil

http://theconversation.com/young-women-in-soweto-say-healthy-living-is-hard-heres-why-118198

https://pmg.org.za/committee-meeting/25488/

https://pmg.org.za/committee-meeting/25488/


43. See42[VandenBergW&MakushaT]

44. ChildrenwhoarebelowtheStatisticsSouthAfricaupperpovertyline.Thisisanindicativemeasureofpovertyandnotadirectanalysisofeligibility.

45. See,forexample:HallK,LeattAandRosaS(2009)TheMeanstoLive:Targetingpovertyalleviationtorealisechildren’srights.CapeTown:Children’sInstitute,UniversityofCapeTown;Seealso:BudlenderD,RosaSandHallK(2005)AtAllCosts?ApplyingthemeanstestfortheChildSupportGrant.CapeTown:Children’sInstituteandCentreforActuarialResearch,UniversityofCapeTown;Seealso:GoldblattB,RosaSandHallK(2006)ImplementationoftheChildSupportGrant:Astudyoffourprovincesandrecommendationsforimprovedservicedelivery.Children’sInstitute,UniversityofCapeTownandCentreforAppliedLegalStudies,UniversityoftheWitwatersrand.

46. DepartmentofHomeAffairs(2018)AnnualReport2017-2018

47. MinisterofHomeAffairs(2019)BudgetSpeechJuly2019,NationalAssembly,ParliamentofRSA.

48. Ibid

49. Ibid

50. DepartmentofHomeAffairs(2019)BudgetVote15inEstimatesofNationalExpenditure2019,Page65

51. NationalIncomeDynamicsStudyWave5(2017)AnalysisbyKHall,Children’sInstitute(UCT)

52. SouthAfricanSchoolsAct(No.84of1996)

53. AdmissionPolicyforOrdinaryPublicSchools(GN2432of1998)

54. Circular:SchoolstoupdateSASAMSwithidentitynumbersoflearners(Circular6of2016dated17March2016,EasternCapeDepartmentofBasicEducation

55. See,forexample:CentreforChildLaw,SchoolGoverningBodyofPhakamisaHighSchooland37ChildrenvMinisterofBasicEducationandothers.CaseNo2480/17.

56. See,forexample:ProudlockP(2018)Acloserlookatbirthcertificates.InHallK,RichterL,MokomaneZ&LakeL(2018)SouthAfricanChildGauge2018:Children,FamiliesandtheState.CapeTown:Children’sInstitute(UCT)

57. SouthAfricanPoliceServices(2018)AnnualCrimeReport2017/2018.

58. ArtzL,BurtonP,WardCL,LeoschutL,PhyfeJ,KassanjeeR,&LeMotteeC(2016)OptimusStudySouthAfrica:Technicalreport.SexualvictimisationofchildreninSouthAfrica.FinalreportoftheOptimusFoundationStudy:SouthAfrica.Zurich:UBSOptimusFoundation.

59. RichterL,MathewsS,KaguraJ&NonterahE(2018)AlongitudinalperspectiveonviolenceinthelivesofSouthAfricanchildrenfromtheBirthtoTwentyPluscohortstudyinJohannesburg-Soweto. South African Medical Journal,108(3):181-186

60. Ibid

61. MathewsS,AbrahamsN,JewkesR,MartinL&LombardC(2013)TheepidemiologyofchildhomicidesinSouthAfrica.Bulletin of the World Health Organization,91:562-568.

62. JamiesonL,MathewsS&RöhrsS(2018)Stoppingfamilyviolence:Integratedapproachestoaddressviolenceagainstwomenandchildren.In:HallK,RichterL,MokomaneZ&LakeL(2018)SouthAfricanChildGauge2018:Children,FamiliesandtheState.CapeTown:Children’sInstitute

63. StatisticsSouthAfrica(2014)Census2011:ProfileofpersonswithdisabilitiesinSouthAfrica.Reportno.03-01-59.Pretoria:StatsSA;Seealso:DSD,DWCPDandUNICEF(2012)ChildrenwithDisabilitiesinSouthAfrica:Asituationanalysis:2001-2011.Pretoria:DepartmentofSocialDevelopment,DepartmentofWomen,ChildrenandPeoplewithDisabilities,andUNICEF

64. VisserM,NelM,BronkhorstC,BrownL,EzendamZ,MackenzieK,vanderMerweD&VenterM(2016)Childhooddisabilitypopulation-basedsurveillance:AssessmentoftheAgesandStagesQuestionnaireThirdEditionandWashingtonGrouponDisabilityStatistics/UNICEFmoduleonchildfunctioninginaruralsettinginSouthAfrica.African Journal of Disability5(1),1-9

REFERENCESANDNOTES


65. MelhuishE,PhanM,SylvaK,SammonsP,Siraj-BlatchfordI&TaggartB(2008)Effectsofthehomelearningenvironmentandpreschoolcenterexperienceuponliteracyandnumeracydevelopmentinearlyprimaryschool.Journal of Social Issues, 64(1),95–114

66. DawesA,BierstekerL,GirdwoodL,SnellingM&HorlerJ(2019)EarlyLearningProgrammeOutcomesStudyTechnicalReport.CapeTown:InnovationEdgeandIlifaLabantwana

67. GeneralHouseholdSurvey(2016)Groupprogrammeisdefinedaspre-school,nurseryschool,crèche,educarecentre,andplaygroupsettings.

68. See66[Dawesetal]

69. Forpurposesofeducationfunding,“poor”isdefinedasbeingthepoorestthreequintiles(thepoorest60%ofhouseholds).

70. Roughcalculationsbasedonanestimated700,000childrenaccessingearlychildhoodeducation(StateoftheNationAddress,7February2019)and5.7millionchildrenunder6yearsinQuintiles1-3(GeneralHouseholdSurvey(2017)analysisbyKHall,Children’sInstitute(UCT)).

71. GeneralHouseholdSurvey(2017)analysisbyKHall,Children’sInstitute(UCT)

72. BierstekerL,DawesA,HendricksL&TredouxC(2016)Center-basedearlychildhoodcareandeducationprogramquality:ASouthAfricanstudy.Early Childhood Research Quarterly,36,334–344;Seealso:RichterLandNaickerS(2012)Areviewofpublishedliteratureonsupportingandstrengtheningchild-caregiverrelationships(parenting).USAID’sAIDSSupportandTechnicalAssistanceResources,AIDSTAR-One,TaskOrder1;Seealso:NationalPlanningCommission(2012)NationalDevelopmentPlan2030OurFuture-makeitwork.Pretoria:DepartmentofthePresidency


74. EarlyDM,MaxwellKL,BurchinalM,AlvaS,BenderRH&BryantD(2007)Teachers’education,classroomquality,andyoungchildren’sacademicskills:Resultsfromsevenstudiesofpreschoolprograms.Child Development, 78(2),558–580

75. UNICEF(2008)Thechildcaretransition:Aleaguetableofearlychildhoodeducationandcareineconomicallyadvancedcountries[ONLINE]Accessedat:https://www.unicef-irc.org/publications/507-the-child-care-transition-a-league-table-of-early-childhood-education-and-care-in.html[Accessedon08/08/2019]


77. Theseprogrammesincludedplaygroups,mobileplaygroups,andinterventionstoenrichECDcentres.

78. TheprovincesassessedwereKwaZulu-Natal,EasternCape,FreeState,WesternCape,Mpumalanga,andGauteng.

79. FormoreinformationonELOMpleasesee:SnellingM,DawesA,BierstekerL,GirdwoodE&TredouxCJ(2019)ThedevelopmentofaSouthAfricanEarlyLearningOutcomesMeasure:ASouthAfricaninstrumentformeasuringearlylearningprogramoutcomes. Child Care Health and Development,45,257–270.

80. InnovationEdge(2019)EarlyLearningOutcomesMeasurebaselinedatasetfrommultipleprogrammeeffectivenessevaluations.AnalysedbyMatthewSnellingandAndrewDawes.Seealso:DawesA,BierstekerL,GirdwoodL,SnellingM&HorlerJ(2019)EarlyLearningProgrammeOutcomesStudyTechnicalReport.ClaremontCapeTown:InnovationEdgeandIlifaLabantwana

81. Boyden,J,Dawes,A,Dornan,P&Tredoux,C(2019) TracingtheConsequencesofChildPoverty:EvidencefromtheYoungLivesstudyinEthiopia,India,PeruandVietnam.Bristol:UniversityofBristolPolicyPress

82. AZ-scoreisastatisticalmeasurementofavalue’srelationshiptothemean(average)ofagroupofvalues,measuredintermsofstandarddeviationsfromthemean.

83. HowieS,CombrinckC,RouxK,TsheleM,MokoenaG&McLeodP(2017)PIRLSLiteracy2016:SouthAfricanHighlightsReport.Pretoria:CentreforEvaluationandAssessment.

84. IsdaleK,ReddyV,JuanA&ArendsF(2017)TIMMS2015Grade5NationalReport:UnderstandingmathematicsachievementamongstGrade5learnersinSouthAfrica.CapeTown:HumanSciencesResearchCouncil.

REFERENCESANDNOTES

https://www.unicef-irc.org/publications/507-the-child-care-transition-a-league-table-of-early-childhood-education-and-care-in.html

https://www.unicef-irc.org/publications/507-the-child-care-transition-a-league-table-of-early-childhood-education-and-care-in.html


Notes on the data and data sources

Key Data source Year reported Frequency Lowest level

aStatistics South Africa: General Household Survey (GHS). Data analysed by Children’s Institute, University of Cape Town. (also see http://childrencount.uct.ac.za/ for more indicators)

2017 Annual Province

bDepartment of Health: National HIV and Syphilis Prevalence Survey (http://www.health.gov.za/index.php/shortcodes/2015-03-29-10-42-47/2015-04-30-08-18-10/2015-04-30-08-21-56?download=2584:2015-national-antenatal-hiv-prevalence-survey-final-23oct17)

2013 Annual Province

c Department of Health: District Health Information System. Published by Health Systems Trust (https://www.hst.org.za/healthindicators) 2017/18 Annual District

d Statistics South Africa: South Africa Demographic and Health Survey. Data analysed by W Sambu. (https://www.dhsprogram.com/what-we-do/survey/survey-display-390.cfm) 2016 - Province

e

Medical Research Council Burden of Disease Unit (2019): Rapid Mortality Surveillance Report 2017(http://www.samrc.ac.za/sites/default/files/files/2019-02-06/RapidMortalitySurveil-lanceReport2017.pdf)

2017 - National

fHSRC (2013). The South African National Health & Nutrition Examination Survey (SAN-HANES-1) (http://www.hsrc.ac.za/en/research-outputs/view/6493)

2012 -National

(some province)

gStatistics South Africa (2018) Recorded Live Births 2017 (numerator), analysed with Stats SA mid-year population estimates derived from General Household Survey 2017 (denominator)

2017 - Province

hSouth African Social Security Agency SOCPEN data extracted by special request (numera-tor), analysed with General Household Survey 2017 (denominator) (see http://childrencount.uct.ac.za/socialgrants.php for grant updates)

2018 - Province

i Trends in International Mathematics and Science Study (TIMMS)(http://www.timss-sa.org.za/download/TIMSS-2015-Grade-5-National-Report.pdf 2015 - National

jProgress in International Reading and Literacy Study (PIRLS)(https://www.up.ac.za/media/shared/164/ZP_Files/pirls-literacy-2016_grade-4_15-dec-2017_low-quality.zp137684.pdf)

2016 - National

The data provided in this review are drawn from a range of sources, many of which can be updated annually. Datasourcesfortheindicatorsareindicatedbytheletterkeystotherightofthestatisticaltables.


Population: • Number of infants• Children < 6 access to clinics• HIV prevalence in pregnant women

Service delivery/access:• Prenatal early booking and HAART• Postnatal visit in 6 days• Immunisation coverage• Delivery rate in facility

Outcome:• Paediatric HIV prevalence• Early neonatal mortality

rate• Infant mortality rate• Under-5 mortality

rate

Nutritional support


Population: • Maternal care• Children <6 years living

with at least one adult with a Matric

Service delivery/access: • Breastfeeding education• Postnatal follow-up

6 days after birth • At least 4 antenatal

follow up visits

Social services and income

support

Service delivery/access: • Birth registration• Child Support Grant uptake in

children <6 years• Child Support Grant uptake in

infants


Population: • Children aged 0-2• Children aged 3-5 Service delivery/access: • Children aged 0-2 reported

to attend an early learning programme

• Children aged 3-5 reported to attend an early learning programme

• Fee payment rate for children <6 years in an early learning programme

Outcome: • Foundation phase through-

put • Maths competancy in Grade

5 learners• Reading competency in

Grade 4 learners

Key indicators for early childhood development in South Africa 2019

Population: • Vitamin A defciency in women• Anaemia in women • Low birth weight• Child hunger

Service delivery/access:• Exclusive breastfeeding <6months• Vitamin A coverage in children

12-59 months

Outcome: • Vitamin A defciency in children

<5 years• Iron defciency anaemia in children

<5 years• Anaemia in children 6-59 months • Stunting• Underweight• Overweight


ContributorsDr Colin Almeleh isthe Executive Director of IlifaLabantwana, a national programme working to secure an equal start forall children living in South Africa, through universal access to qualityearly childhood development. Colinhas extensive experience workingwith governments and developmentagencies, having worked forthe Children’s Investment FundFoundation and Absolute Return forKidsonmaternal,newbornandchildhealth projects throughout Sub-Saharan Africa. He holds a PhD inSociology, a BSoSci Hons in SocialAnthropology,andaBScinElectricalEngineering.ColinisapastFoxFellowatYaleUniversity.

Sonja Giese is the foundingExecutiveDirectorofInnovationEdge(IE), an investment platform with asocial impact agenda. IE acts as acatalytic connector and providesfinancial,strategic,andprogrammaticsupport to entrepreneurs andinnovators from diverse sectors,to positively transform early lifeexperiencesforyoungchildrenlivingin poverty. Since its establishment inmid-2014,SonjahasledIEinbuildingan exciting portfolio of investments,demonstratingitsabilitytotakeideasfrom source to scale. Sonja has adegree in Science, a background in public policy, a passion for systemschange,and25yearsofexperienceinthedevelopmentsector.

Dr Katharine Hall is asenior researcher at the Children’sInstitute, a policy research unit atthe University of Cape Town (UCT).She has a PhD in DevelopmentTheoryandPolicy.Herwork is inthearea of child poverty, inequality, and

social policy. She co-ordinates theInstitute’s Children Count indicatorproject, which analyses nationalhousehold survey data to monitoron a variety of indicators related tochild poverty, development, and well-being. Her work has examinedthe targeting of poverty alleviation programmes, particularly in relationto social assistance. Kath hasworked extensively on householdform and care arrangements forchildren. She has a strong interest inhousing policy and urban migration,and their implications for child careand household formation. She is amember of the standing committeeof the International Society for ChildIndicators and UCT’s Poverty andInequalityInitiative.

Dr Kopano Matlwa Mabaso is a South Africanmedical doctor and novelist whocurrently leads the Grow GreatCampaign - a multi-funder initiative, aimed at galvanising South Africatowards achieving zero stunting by2030. Kopano is a Rhodes Scholarand an alumnus of the University ofOxford where she gained both hermasters in Global Health Scienceand DPhil in Population Health. Sheis an elected board member ofHealth Systems Global, the world’sfirst international society dedicatedto health systems strengthening andknowledgetranslation.Kopanoisthefounder of Transitions Foundation,an organisation that seeks to helpSouth Africa’s youth transition fromhopelessness to personal fulfillmentthrougheducation.Sheisapublishedfiction writer and the winner of the European Literary Award (2007) andjointwinneroftheWoleSoyinkaPrizeforLiteratureinAfrica(2010).

Paula Proudlock holdsa Masters in Constitutional andAdministrative Law from UCTand a LLB from the University ofStellenbosch. Paula specialises inresearch, advocacy, and teachingon human rights, with a focus onchildren’s socio-economic rights.She has authored several peerreviewed publications on child law,law reform, and budget analysis aswell as a comprehensive range ofengaged scholarship products suchas legal submissions, affidavits forcourtcases,andpolicybriefs. Paulahas led civil society networks onlaw reform processes notably theChildren’s Institute and ACESS’s (anational network of 1000 NGO’s)successful campaigns to extend theChild Support Grant to 18 and thecampaign to promote an evidence and participatory approach in the makingoftheChildren’sBill.

Winnie Sambu is aresearcher specialising in foodsecurity and nutrition, as well aspoverty and inequality. Winnie hasextensive experience working withlarge household survey data fromvariouscountriesacrossSub-SaharanAfrica and has been involved invarious projects examining socio-economic issues affecting childrenand the households they live in. Sheholds a Master of Economics fromthe University of the Western Capeand a Master of Arts, specialising indevelopment management, from Ruhr-Universität Bochum. Winnieis currently undertaking doctoralstudies at the University of CapeTown.HerTwitterhandleis@wsambu.


CONTRIBUTORS

AsandiswaMbali,withherdaughterandinfanttwins,atthePhilaniClinicinKhayelitsha,WesternCape. Photo:BartLove,2018.

TheSouthAfricanEarlyChildhoodReview2019isanannualpublication,whichpresentsinformationon the essential components of the comprehensive package of early childhood developmentservices. This review includes data and commentary on over 40 carefully selected indicatorson the status of children under six, as well as service delivery progress across five domains.

The SouthAfrican Early Childhood Review 2019 is a joint publication between Ilifa Labantwana,theChildren’sInstituteattheUniversityofCapeTown,theDepartmentofPlanning,MonitoringandEvaluationinthePresidency,TheGrowGreatCampaign,andInnovationEdge.

A note on this publication

Nutritional support

Primary level maternal and child

health


Social services and income

support


About the organisations:

Ilifa Labantwana is a national ECD programme, working to secure an equal start for all children living in South Africa, through universal access to quality early childhood development.www.ilifalabantwana.co.za

The Children’s Institute aims to contribute to policies, laws, and interventions that promote equality and improve the con-ditions of all children in South Africa through research, education, and technical support. www.ci.uct.ac.zawww.childrencount.org.za

The Department of Planning, Monitoring and Evaluation in the Presidency was created to facilitate, influence and support effective planning, monitoring, and evaluation of government programmes aimed at improving service delivery, outcomes and impact on society. www.dpme.gov.za

Established mid-2014, Innovation Edge is a grant-making and investment fund. Innovation Edge focuses on unconvention-al ideas that fnd solutions to early childhood care and education challenges in under-resourced communities.www.innovationedge.org.za

The Grow Great Campaign seeks to galvanise South Africa towards a national commitment to zero stunting by 2030. Grow Great is achieving that using data to mobilise policy makers, stories to inspire the public, communities of practice to sup-port Community Health Workers and mom & baby classes to support parents. www.growgreat.co.za/

south african early childhood review 2019

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