Intersectoral (in)activity: towards an understanding of public sector department links between water, sanitation and hygiene (WASH) and childhood undernutrition in South Africa

Policy gaps and food systems optimization: a review of agriculture, environment, and health policies in South Africa

South Africa faces the triple burden of malnutrition, high poverty levels, unemployment, and inequality. "Wicked problems" such as these require innovative and transdisciplinary responses, multi-stakeholder coordination and collaboration, managing complex synergies and trade-offs, and achieving sustainable outcomes. Through qualitative content analysis of national and provincial sector-based policies, we explored the interlinkages between the agriculture, environment, and health sectors in South Africa in the context of sustainable food and nutrition security and the extent to which these interlinkages are integrated into policy and planning. A systemic analysis of the review outcomes was performed to identify its main learning outcome, the status quo in the policy process. The nature of feedback loops was identified, and a leverage point was suggested. The review highlighted that policymakers in the agriculture, environment and health sectors are aware of, and have understood, the relationships among the three sectors. They have also made attempts to address these interlinkages through collaboration and coordination. Unfortunately, this has been met with several challenges due to fragmented sector-specific mandates and targets and a lack of resources for integrated solutions. This creates implementation gaps and unintended duplication of activities, leading to poor service delivery. Transitioning to sustainable and healthy food systems will only be possible after these gaps have been closed and implementation optimization has been achieved. Focusing on meta-level problem-framing, functional collaboration through transdisciplinary approaches, and integrated targets are critical to successful policy implementation and progressive realization of national goals related to sustainable food and nutrition security, unemployment, poverty, and inequality.

Stunting, double orphanhood and unequal access to public services in democratic South Africa

Orphans who lack household or community support face significant socio-economic disadvantages. In particular, they are at greater risk of malnutrition and stunting in developing countries. Children who have no living parents, also called double orphans, are most likely to require support from extended families or public institutions. This paper explores how WASH infrastructure, and public health and social services relate to stunting. It is one of the first studies to analyse these factors with a specific focus on double orphans, who tend to live in under-serviced areas with high stunting rates and poor access to public resources. We collate a cross sectional spatial dataset with local child stunting rates from 2013, rates of double orphanhood, private household resources, and public services from 2011 for South Africa, a country where the HIV/AIDS pandemic has led to high rates of double orphanhood. We estimate spatial econometric models that account for unobserved regional shocks and measurement bias, but which do not address other biases. Our results show that high stunting rates, particularly in areas with high proportions of double orphans, overlap strongly with poor provision of WASH and the availability of household resources. By contrast, other softer services accessed outside the home, such as access to health, social welfare and early childhood development facilities are not correlated with stunting in the same way. WASH is more strongly related to reduced stunting when infrastructure covers larger geographic areas and with the combined use of services from adjacent areas. This occurs because of economies of scale in provision and preventing transmission of disease across regions. Policy makers can explore the option to reduce stunting by expanding geographic networks of WASH service delivery into under-serviced areas where double orphans tend to locate.

Water, sanitation, and hygiene (WASH) factors associated with growth between birth and 1 year of age in children in Soweto, South Africa: results from the Soweto Baby WASH study

Interventions to reduce undernutrition and improve child growth have incorporated improved water, sanitation, and hygiene (WASH) as part of disease transmission prevention strategies. Knowledge gaps still exist, namely, when and which WASH factors are determinants for growth faltering, and when WASH interventions are most effective at improving growth. This study drew cross-sectional data from a longitudinal cohort study and used hierarchical regression analyses to assess associations between WASH factors: water index, sanitation, hygiene index, and growth: height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ) at 1, 6, and 12 months postpartum among infants a priori born healthy in Soweto, Johannesburg. Household access to sanitation facilities that were not safely managed was associated with a decrease in HAZ scores at 1 month (β = -2.24) and 6 months (β = -0.96); a decrease in WAZ at 1 month (β = -1.21), 6 months (β = -1.57), and 12 months (β = -1.92); and finally, with WHZ scores at 12 months (β = -1.94). Counterintuitively, poorer scores on the hygiene index were associated with an increase at 1 month for both HAZ (β = 0.53) and WAZ (β = 0.44). Provision of safely managed sanitation at household and community levels may be required before improvements in growth-related outcomes are obtained.