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SOUTH AFRICAN
EARLY CHILDHOOD
REVIEW 2017
ANC antenatal care
ARV antiretroviral
CSG child support grant
DHIS District Health Information System
EC Eastern Cape
ECD early childhood development
ELOM Early Learning Outcomes Measure
FAS Foetal Alcohol Syndrome
FASD Foetal Alcohol Spectrum Disorder
FS Free State
GHS General Household Survey
GT Gauteng
HAART highly active antiretroviral therapy
HIV human immunodeciency virus
KZN KwaZulu-Natal
LCS Living Conditions Survey
LP Limpopo
MP Mpumalanga
MTCT mother-to-child transmission (of HIV)
MTSF Medium Term Strategic Framework
NC Northern Cape
NDoH National Department of Health
NIDS National Income Dynamics Study
NW North West
PCR polymerase chain reaction
PMTCT prevention of mother-to-child
transmission(of HIV)
RTHB Road to Health Book
SA South Africa
SADHS South Africa Demographic
and Health Survey
SANHANES South African National Health
and Nutrition Survey
VIP ventilated improved pit latrine
WC Western Cape
WHO World Health Organisation
Acronyms
01
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Contents
Introduction
Children under 6 years in South Africa
Primary level maternal and child health
Nutritional support
Support for primary caregivers
Social services and income support
Stimulation for early learning
References
District tables
Notes on the data and data sources
Key indicators for early childhood development in South Africa
Contributors
04
06
12
18
24
30
34
40
42
44
45
46
Acknowledgements
The
South African Early Childhood Review 2017
was developed by Ilifa Labantwana, The Children’s
Institute at the University of Cape Town, the
Department for Planning, Monitoring, and Evaluation
(DPME) in the Presidency, as well as Innovation
Edge.
The editors would like to thank all those who
contributed to this publication: Katharine Hall,
Winnie Sambu and Lizette Berry from the Children’s
Institute at the University of Cape Town; Sonja Giese
from Innovation Edge; as well as Colin Almeleh,
Lovemore Mawere, Rhianah Fredericks and
Svetlana Doneva at Ilifa Labantwana.
Mastoera Sadan at the DPME in the Presidency
for her support, input and guidance on the
development of the 2017 Review and Dr Keloe
Masiteng at the DPME for the foreword.
Linda Biersteker, Andrew Dawes, Elizabeth
Girdwood, and Matthew Snelling from ELOM –
South Africa’s rst population level preschool child
assessment tool. The ndings from ELOM’s eld
test on a random sample of 1300 South African
children aged 50-69 months contributed to this
review. Learn more about ELOM at www.elom.org.
za.
DGMT, the ELMA Foundation, the FirstRand
Foundation and FNB for their support of Ilifa
Labantwana as donors.
Gap Design for layout and design.
Deborah Da Silva and Josh Reid for the
photographs used in this publication.
Cover Photograph: Clare Louise Thomas
(for SmartStart).
Suggested citation:
Hall, K., Sambu, W., Berry L., Giese, S., and Almeleh,
C. (2017). South African Early Childhood Review 2017.
Cape Town: Children’s Institute, University of Cape
Town and Ilifa Labantwana
Copyright: 2017 Children’s Institute, University
of Cape Town and Ilifa Labantwana
Any errors are the responsibility of the authors.
Ilifa Labantwana
Douglas Murray House, 1 Wodin Road, Claremont, Cape Town 7700, South Africa
Tel: +27 (21) 670 9847
Email: info@ilifalabantwana.co.za
Web: www.ilifalabantwana.co.za
03
Foreword
With
commitment
from
government
sectors
to work
together,
this essential
package can
be delivered
to all young
children in
South Africa.
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
The essential package of early childhood
development (ECD) services is needed to
support the overall development of chil-
dren. With commitment from government
sectors to work together, this essential
package can be delivered to all young chil-
dren in South Africa.
The Department of Social Development is
in the process of nalising the National In-
tegrated Plan for ECD, which will follow the
National Integrated Early Childhood De-
velopment Policy, approved by Cabinet in
2015. The National Integrated Plan for ECD
is an important step in realising these com-
prehensive and essential ECD services. We
need to move forward with a sense of ur-
gency to give our children a better future.
This publication presents a set of indicators
to support inter-sectoral planning, delivery
and monitoring of an essential package of
ECD services, from conception to age six.
Many children under age six live in house-
holds facing challenges related to poverty
and lack of service delivery. Young children
are especially vulnerable to poor living con-
ditions as they are still growing, have in-
creased nutritional needs and a greater risk
of infection. We need to improve the ECD
services oered to these children.
While we have survey data and some ad-
ministrative data, we need a management
information system to support collection of
routine administrative data. This is crucial for
both planning and for monitoring delivery of
services.
ECD services must be delivered to all chil-
dren who need them. The size of the pop-
ulation of children who need a particular
service is therefore important. Having pop-
ulation numbers helps with setting appro-
priate targets and obtaining the required
budget and other resources. There will al-
ways be budget constraints, but investing in
our children’s future should be paramount
in realising the objectives of the National
Development Plan.
This
South African Early Childhood Review
is an important contribution, which assists in
planning, implementation and monitoring.
Dr Keloe Masiteng
Deputy Secretary of Planning, Department
of Planning, Monitoring and Evaluation
04 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Introduction
Source: Ilifa Labantwana (2014)
The Essential Package (Second Edition)
Early antenatal
booking, nutritional
support in pregnancy,
mental health services,
prevention of alcohol
and substance use
CONCEPTION TO BIRTH
BIRTH TO 2 YEARS
2 TO 4 YEARS
4 TO END OF AGE 5
Birth registration, early
child support grant
access, immunisation,
breastfeeding,
caregiver psycho-
social support
Early learning
interventions,
parenting programmes,
nutritional support
Formal early learning
interventions (e.g. preschool),
nutritional support
ECD services are urgent and the SA
government has an obligation to
provide them
More than a million children are born
in South Africa every year. All of these
children have rights to survival, health,
protection and development. These
rights are protected in the highest
law of our land, the Constitution, and
also in international law. To make
these rights real, the Children’s
Act 38 (2015), as amended, says a
comprehensive national strategy
must be developed to enable a
properly resourced, coordinated and
managed ECD system. However,
children cannot wait for government
to realise comprehensive ECD
services progressively. Early
childhood, especially the rst 1,000
days of life, is a particularly sensitive
and rapid period of development,
which lays the foundation for all future
health, behaviour and learning. When
children do not receive the necessary
input and support to promote their
development during this critical
period, it is very dicult and costly to
help them catch up later.
Progress at policy level
The South African government led
the development of the National
Integrated Early Childhood Develop-
ment Policy (2015), aimed at provi-
ding a multi-sectoral enabling
framework for ECD services. The
policy gives eect to the provision
of a comprehensive package of ECD
services for young children, and
prioritises the delivery of an essential
package of ECD services.
The essential package of services
includes those that are necessary to
promote young children’s survival
and development and enable the
realisation of their Constitutional
rights, and these should be accessible
with immediate eect. The essential
package covers the period from
conception until children start formal
schooling. Because young children
have a broad range of needs that
are interdependent, multiple role-
players should be involved in service
delivery, and it is important that there
is collaboration and referrals between
health, education and social services.
The illustration below shows examples
of types of essential services needed
at dierent ages.
Early childhood development (ECD) services are needed to support the
development of young children. With commitment from government sectors
to work together, an essential package of ECD services can be delivered to all
South Africa’s young children. This review presents a set of indicators to support
inter-sectoral planning, delivery and monitoring of an essential package of ECD
services, from conception to the age of six.
05
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
INTRODUCTION
Nutritional
support
Maternal and child
health services
Stimulation for
early learning
Social services
Support 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
The components of the essential package are:
Since the policy came into eect,
several national structures now
facilitate multi-sectoral co-
ordination and planning toward
implementation. Since early 2016,
the national Department of Social
Development has been in the process
of developing an implementation
plan, in collaboration with relevant
national departments.
While it is promising that some
provinces are in the process of
developing ECD strategies aligned
with the policy vision and objectives,
it is unclear whether the 2018 target
year for implementation, will be
achieved. Actions needed to reach
this goal include amending existing
legislation, establishing leadership
structures, allocating sucient
budget, as well as establishing
communication, accountability and
coordination mechanisms between
all stakeholders – from national to
district to municipal level.
Delivering an essential package of
ECD services requires collaboration
Service delivery also requires
collaboration and engagement
between government departments
and agencies, and civil society
organisations. One way this is currently
happening is through the National ECD
Inter-Sectoral Forum - a platform for
consultation on major developments
in the ECD sector. These include
policies, infrastructure development,
training and curriculum, nancial and
human resource requirements, as
well as monitoring and evaluation.
One of the primary aims of the
forum is to facilitate planning toward
implementation of the National Policy.
The forum is led by the Department
for Social Development and currently
has six interlinked subcommittees,
performing various roles.
Information is critical
Delivery of ECD services requires an
understanding of the number and
distribution of young children, the
conditions they live in, and the services
they require. Data are also important
because they tell us which areas have
the highest levels of child deprivation.
The
Early Childhood Review 2017
reveals striking inequalities in the
welfare of young children across
the country, and within provinces at
district level. The data also show that
there are districts that consistently
perform poorly when a set of
indicators are examined, showing the
extent of deprivation in these areas.
Regular, timely, and high quality data
are needed to monitor coverage
and quality of ECD services; and
ultimately enable and improve
planning and resourcing.
There are many challenges
around data availability and
accessibility currently
For many of the indicators, data are
collected through national surveys,
which do not allow for district level
analysis. For some indicators, data are
collected too infrequently, collected
but not published, or not collected at
all. This is particularly the case with
data on nutrition, early learning and
caregiver support. Another challenge
is the quality of the data available. It
is also dicult to measure and collect
data for some of the indicators,
especially those that relate to quality
of services.
The ECD policy recognises the
importance of proper and eective
monitoring and evaluation (M&E)
systems to track the implementation
and impact of the policy. However,
progress on the development of data
systems for ECD, especially on service
uptake in early learning, is very slow. In
addition, the policy’s M&E framework
is yet to be released. Much greater
emphasis and attention needs to be
placed on data collection systems if
service delivery is to be monitored
and appropriately planned and
budgeted for, and to ensure that the
relevant government departments
responsible for dierent services can
be held to account.
06 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Children under 6
years in South Africa
Because the essential package is about early childhood services that are
essential
, these services need to reach
all
young children. There are still
vast inequalities in children’s circumstances and opportunities from the
time they are born. Nearly two-thirds of children under 6 in South Africa
live in the poorest 40% of households, where unemployment rates are
high and living conditions are poor. Some children may be more difficult
to reach – they may live in remote areas or may not come into regular
contact with service points like clinics. By ensuring that all children get the
full package of essential early services, we can help to provide them with
a more equal start in life.
Plans for ECD
infrastructure
and age-
appropriate
services have
to dierentiate
between the
needs of urban
and rural
populations.
At present, it is not clear exactly how
many young children live in South Africa.
The last census was in 2011 and counted 6.7
million children under 6 years. The census
takes place every 10 years. In between,
Statistics South Africa undertakes the
Community Survey, which is a similar
household survey with a very big sample.
The Community Survey of 2016 estimated
the number of children under 6 years to be
7.1 million. In the same year, the General
Household Survey (GHS), which is another
big survey conducted by Statistics South
Africa, produced a population of 6.2 million
children under 6.
The reasons for these dierences are
related to the models used to determine
the population weights. The Community
Survey and the GHS use dierent models,
but it seems that both are wrong. An
entirely new model, which will be more
closely linked to the 2011 census, is being
developed and the new weights will be
available in 2018. It is only then that we
will know whether the current under-6
population is closer to six or seven million.
The population numbers in the table at
the end of this chapter are from the
weighted GHS data, and are likely to be
an underestimate.
Over half of South Africa’s young children
live in just three provinces: KwaZulu-
Natal, Gauteng and the Eastern Cape.
Provinces and districts face dierent
challenges delivering services to children.
In densely populated places like Gauteng,
which serves over a million young
children, the challenges may be about
the capacity of the infrastructure and
service providers to cope with demand. In
the Northern Cape, a small population
of only about 150,000 young children
is spread over vast distances; and the
challenges may relate to problems of
physical access and the relatively high cost
of getting services to children.
07
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
21%
11%
2%
8%
7%
19%
5%
12%
14%
FIGURE 1: PROVINCIAL SHARE OF CHILDREN UNDER 6 YEARS IN 2015
Source: GHS 2015, analysis by Children’s Institute
KZN GT EC LP WC MP NW FS NC
CHILDREN UNDER 6 YEARS IN SOUTH AFRICA
FIGURE 2: CHILDREN UNDER 6 YEARS LIVING IN HOUSEHOLDS WITH INADEQUATE SERVICES, 2002-2015
60%
45%
30%
15%
0%
Inadequate water
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Source: GHS 2002 - 2015, analysis by Children’s Institute
Some provinces have growing child
populations, while others are shrinking
slightly. The greatest growth has been in
Gauteng and the Western Cape, while the
young child populations of KwaZulu-Natal,
the Free State, the Eastern Cape, and
Limpopo have declined.
South Africa is becoming more urban,
and slightly more than half of all young
children now live in urban areas. However,
there are still some provinces – such as
the Eastern Cape, Limpopo, KwaZulu-
Natal, and Mpumalanga – where the
majority of children under the age of 6 are
rural. In Limpopo, well over 80% of young
children live in rural households. Plans for
ECD infrastructure and age-appropriate
services have to dierentiate between the
needs of urban and rural populations. ECD
services should be exible and responsive
to the needs of children, families, and
communities – wherever they may be.
Inadequate sanitation
08 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
CHILDREN UNDER 6 YEARS IN SOUTH AFRICA
FIGURE 3: CHILDREN UNDER 6 YEARS LIVING BELOW THE UPPER POVERTY LINE (2003 & 2015)
100%
80%
60%
40%
20%
0%
90%
79% 84%
64% 60%
83%
75%
91%
83%
63%
82%
64%
77%
58% 61%
77%
EC FS GT KZN LP MP NW NC WC SA
2003 2015
62%
38% 37%
Source: GHS 2003 & 2015, analysis by Children’s Institute
Young children are especially vulnerable
to poor living conditions, as they are still
growing and have increased nutritional
needs as well as a greater risk of infection.
Adequate water infrastructure is important
because children are vulnerable to water-
borne diseases and can also be exposed
to risks when fetching water. About a third
of children under 6 live in households
without access to piped water on the site
where they live. In the Eastern Cape, 60%
of young children do not have access to
adequate water.
Despite huge progress in providing
sanitation, South Africa still has more than
1.5 million children under the age of 6 who
do not live in a household with a toilet or
ventilated improved pit latrine (VIP) on the
site where they live. Poor living conditions
aect hygiene, health, and food preparation
in households; they can lead to the spread
of diarrhoeal diseases and other infections,
such as pneumonia. These diseases are
among the main causes of child deaths.
Access to adequate water and sanitation
has improved over the years. Between
2002 and 2015, the number of young
children living in households with poor
sanitation was halved: 24% of young
children lived in households with poor
sanitation in 2015, down from 53% in 2002.
The biggest improvement has been in the
Eastern Cape, where the share of young
children living in households with poor
sanitation reduced from 81% in 2002 to 17%
in 2015.
At a district level, there are stark inequali-
ties across the country and within provinces.
For example, only 12% of young children
in the Eastern Cape district of OR Tambo
have access to running water on site,
compared to 94% in Nelson Mandela Bay,
and 98% in the Central Karoo district in the
Western Cape. In 19 out of the 52 districts
in South Africa, more than half of children
under 6 live in households without piped
water. Districts with the greatest sanitation
challenge are in Limpopo. In the province’s
30% of young
children fall
below the food
poverty line.
Source: GHS 2015, analysis by Children’s Institute
79%
3 0 %
09
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
CHILDREN UNDER 6 YEARS IN SOUTH AFRICA
Sekhukhune district, less than 10% of
young children have an adequate toilet on
site; the rates of inadequate sanitation are
also high (over 70%) in Vhembe, Capricorn,
Mopani, and Ehlanzeni.
Poor households have a disproportio-
nately large burden of care for young
children. About 4 million children under 6
years live in the poorest 40% of households.
This is a relative poverty line, and there has
been no signicant change in the number
of young children living in the poorest 40%
of households since 2003.
Statistics South Africa has proposed
three national poverty lines: an upper-
bound poverty line, a lower-bound line
and a food poverty line. The food poverty
line is the most severe, as people living
below this level of income are unable to
aord sucient food to provide adequate
nutrition. The lower poverty line is based on
there being enough income for people to
be adequately nourished, but only if they
sacrice other essential items. The upper
poverty line is the minimum required to
aord both the minimum adequate food
and basic non-food items. This upper-
bound poverty line should be used as
the line of preference for reducing child
poverty. The poverty lines were set in 2011
prices, and increase each year in line with
ination. Using the headline consumer
price index to inate the poverty lines,
the value of the food poverty line was
equivalent to R415 per person per month
in 2015, the lower line was R621 per person
per month, and the upper poverty line was
R965 per person per month.
The child poverty rates in Figure 3 are
based on the upper poverty line, which
allows for a minimum acceptable standard
of living. Child poverty rates are compared
for the years 2003 and 2015.
The majority of young children (62%) live
in households that fall below the upper
poverty line. The highest rates of child
poverty are in the Eastern Cape, KwaZulu-
Natal and Limpopo; where 79%, 75% and
77% of young children respectively lived
in poor households in 2015. The number
and percentage of young children living in
poverty has decreased since 2003 when
4.9 million (79%) young children lived in
poor households. This is due, in large part,
to the expansion of social grants. This
analysis is based on the GHS, which does
not record very detailed information about
household income. A better source, the
Living Conditions Survey, suggests that
poverty rates may be even higher.1
Thirty per cent of young children fall below
the food poverty line. This is very serious,
as children living in such poverty are likely
to be food insecure and may become
malnourished. In the Eastern Cape, almost
half of young children are below the food
poverty line.
Many children under the age of 6 live in
households where nobody is employed or
engaged in income-generating activities.
Employment is important as a source of
income and may come with other benets
for those employed in the formal sector;
such as health insurance, unemployment
insurance, and maternity leave. Regular
income and other employment benets
contribute to a child’s health, development,
and education. While the percentage of
children living in unemployed households
reduced from 38% in 2003 to 29% in 2015,
there are still more than 1.8 million young
children living in households where
nobody is working.
About a third of
children under 6
live in households
without access
to piped water
on the site where
they live.
32%
10 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
We need to have reliable estimates of the young child population for the years in between censuses,
which take place once every 10 years.
• TheresultsofCensus2011werequestionedatrst
because it seemed to over-count young children and
under-count older children.
• More recently, demographers have thought that
the census may have been right – that there was
an increase in fertility rates in the years preceding
the census. The increase also became evident
through the vital registration (births and deaths) data
collectedbytheDepartmentofHomeAairs.
• A new model, used to calculate population weights
for surveys, will be calibrated to the census and will
reectthisupswinginfertilityrates(andthereforethe
number of infants) around 2009, after which the rates
start to decline again.
• This
Early Childhood Review
could be under-
estimating the population and, as a result, also
underestimating the extent of the challenge in
reaching all young children with ECD services.
Data gaps and challenges
CHILDREN UNDER 6 YEARS IN SOUTH AFRICA
Population
Number
of children
under 6 years
6 235 000 884 000 304 000 1 185 000 1 316 000 756 000 528 000 463 000 144 000 655 000 a
Households with
children under 6
4 785 000 582 000 288 000 1 142 000 874 000 561 000 422 000 354 000 112 000 449 000 a
30% 34% 32% 24% 32% 37% 35% 29% 35% 25%
Area type
Urban
Children
< 6 in urban areas
(formal/informal)
3 528 000 350 000 258 000 1 152 000 515 000 127 000 186 000 224 000 97 000 620 000 a
57% 40% 85% 97% 39% 17% 35% 48% 67% 95%
Rural
traditional
Children
< 6 in rural former
homeland areas
2 439 000 524 000 27 000 19 000 688 000 614 000 305 000 222 000 41 000 -
a
39% 59% 9% 2% 52% 81% 58% 48% 28% 0%
Rural farms
Children < 6 in
commercial farm-
ing areas (old RSA)
267 000 11 000 18 000 14 000 114 000 15 000 36 000 17 000 7 000 35 000
a
4% 1% 6% 1% 9% 2% 7% 4% 5% 5%
Service access
Inadequate
water
Children
< 6 without piped
water on site
1 972 000 529 000 24 000 82 000 539 000 370 000 167 000 159 000 37 000 69 000
a
32% 60% 8% 7% 41% 49% 32% 34% 25% 11%
Poor
sanitation
Children
< 6 without a toilet
or VIP on site
1 504 000 151 000 65 000 97 000 375 000 372 000 196 000 141 000 32 000 75 000
a
24% 17% 21% 8% 28% 49% 37% 30% 22% 11%
Povert y
Child poverty
Children < 6 living
in poor households
(< R965 in 2015)
3 875 000 701 000 195 000 456 000 984 000 581 000 335 000 298 000 83 000 242 000
a
62% 79% 64% 38% 75% 77% 63% 64% 58% 37%
Food Poverty
Children
< 6 living in food
poor households
(< R415 in 2015)
1 855 000 419 000 89 000 161 000 480 000 325 000 152 000 134 000 35 000 60 000
a
30% 47% 29% 14% 37% 43% 29% 29% 24% 9%
Workless
households
Children < 6 in
households with
no employed adults
1 811 000 405 000 99 000 143 000 444 000 331 000 141 000 140 000 42 000 66 000
a
29% 46% 33% 12% 34% 44% 27% 30% 29% 10%
TABLE 1: THE STATUS OF CHILDREN UNDER 6 LIVING IN SOUTH AFRICA IN 2015, BY PROVINCE
Indicator SA EC FS GT KZN LP MP NW NC WC source
Indicator SA EC FS GT KZN LP MP NW NC WC source
Primary level
maternal and
child health
Every visit by a caregiver and their child to a health facility, and every visit by a
health worker to a household, is an opportunity to improve access to essential ECD
services. With a well-integrated package of services, caregivers who attend clinics
could receive health interventions related to pregnancy and childbirth, information
about adequate nutrition, and encouragement to stimulate their children. Caregivers
should also be referred to other assistance where needed, like social grants for
poverty alleviation and integrated psychosocial support services for mental health. In
addition to clinic visits, outreach visits to ECD centres by nurses or community health
workers are important. Referrals from home visiting programmes for vulnerable
households and children aged 0-2 are opportunities for young children to access
critical preventative health services, and treatment when sick.
Protecting the health of a mother and her
child starts with antenatal care (ANC).
This is particularly important in reducing
poor pregnancy outcomes and for the
prevention of stunting and HIV in young
children. Early ANC – before 20 weeks in
pregnancy – is an important gateway to
primary health and nutrition services, for
both mothers and children.
There has been a steady increase in early
antenatal bookings, as shown in Figure 4,
with an overall increase from 54% in 2014
to 61% in 2015. However, around 40% of
rst antenatal visits still take place later
than 20 weeks into pregnancy, and this
is based only on pregnant women who
do actually attend antenatal clinics. The
problem is most acute in South Africa’s
metros: Johannesburg, Ekhurhuleni and
Tshwane are three of the top four districts
with the highest number of households
with children under 6, yet also rank in the
top four districts with the lowest rates of
early ANC visits in the country (52%, 55%
and 55% respectively). Only Alfred Nzo
district in the Eastern Cape has a lower
rate. While the increase in early antenatal
visits is encouraging, at least 400,000
pregnant women each year still only
visit the clinic after 20 weeks. Antenatal
visits during early pregnancy are an
12 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
FIGURE 4: PERCENTAGE OF FIRST ANTENATAL VISITS WITHIN FIRST 20 WEEKS OF PREGNANCY
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
70%
60%
50%
40%
30%
20%
10%
0%
31%
61%
Source: DHIS 2005 - 2015
important opportunity for physical and
mental health screening, for referrals to
counselling services where needed, for
sharing information with pregnant women,
and for signing expectant mothers up
to MomConnect.
The inpatient early neonatal mortality
rate indicates the quality of antenatal,
intrapartum and postnatal care. Neonatal
mortality rates in facilities have not changed
substantially in the past 10 years, and are a
key contributor to South Africa’s high infant
mortality rate, which was estimated to be
27 infant deaths per 1,000 live births in
2015. Capricorn district in Limpopo has the
highest inpatient early neonatal death rate
at 22 per 1,000 live births, with a number
of Eastern Cape metros and Northern
Cape districts reporting high inpatient early
neonatal death rates.
The under-5 mortality rate was 40 per 1,000
in 2015. There was a marked decline in
infant and under-5 mortality rates between
2008 and 2011, driven mainly by a reduction
in HIV-related deaths.2 The reduction
became more gradual after 2011.
Immunisation coverage is an indicator of
how well the health system is functioning.
The share of children who are completely
immunised by their rst birthday has
increased from under 70% in 2002 to 89% in
2015. It is a great achievement that the vast
majority of babies are returning to clinics
during their rst year, or are reached by
mobile services, given that many children
(22% of those under 6 years) live far from
their nearest facility. However, a number
of provinces have experienced measles
cases over the past year showing that some
parents still opt out of immunisation or are
not accessing it all.
Some districts have immunisation rates of
over 100%. This is partly because children
may be immunised in areas that are
dierent from where they are counted in
the population. It has also been suggested
that immunisation rates are overestimated
in the District Health Information System
(DHIS), where the rates tend to be higher
than those recorded in comparable surveys.
PRIMARY LEVEL MATERNAL AND CHILD HEALTH
13
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
14 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
PRIMARY LEVEL MATERNAL AND CHILD HEALTH
ROAD TO
HEALTH BOOK
PRIORITY
AREAS
Extra carE
healthcare
love
nutrition
protection
Deliveries conducted in health facilities
and supervised by health personnel
appear to have stabilised. Nationally, the
delivery rate, which is the percentage of
deliveries carried out by health personnel in
public health facilities, increased from 66%
in 2001 to 85% in 2015.3 The highest facility
delivery rates are in Gauteng and Limpopo
provinces (97% and 91% respectively). The
national average is brought down by the
low rates in KZN (79%) and EC (75%) as
these provinces also have some of the
highest number of deliveries in the country.
However, the provincial averages mask the
vast dierences between districts in service
access and uptake, as is shown in Figure
5. Thus, to increase the overall in-facility
delivery rate, it is also important to target
specic districts with very low in-facility
delivery rates, for example, Amathole in
the Eastern Cape, Harry Gwala in KZN and
Xhariep in the Free State amongst others.
The vast majority of infants who are
HIV exposed receive a PCR test within
the rst six weeks of their life. The
Early
Childhood Review 2016
reported on results
from a 2012/13 survey that covered infants
(4-8 weeks old) attending public health-
care clinics and community health centres
for their 6-week immunisation. More recent
data from the National Health Laboratory
Service report a national intrauterine
transmission rate of 1.1%.4 South Africa is
in the process of introducing PCR testing
within six days after birth in order to identify
and treat HIV early in infants. Data problems
notwithstanding, these estimates indicate
some major successes with South Africa’s
Prevention of Mother to Child Transmission
(PMCT) programme.
FIGURE 5: DELIVERIES WHICH TAKE PLACE IN A PUBLIC HEALTH
FACILITY, BY PROVINCE, DISAGGREGATED BY DISTRICT
Source: DHIS 2015
120
110
100
90
80
70
60
50
40
Ekurhuleni
Bualo City
EC FS GP KZN LP MP NW NC WC
Lejweleputswa
eThekwini
Mopani
Dr K Kaunda
Ehlanzeni 88
Frances Baard
Namakwa
Bojanala
G Sibande
80
Waterberg
Harry Gwala
Johannesburg
Xhariep
Amathole
75
89
96
92
79
75
Cape Town
Overberg
89
Delivery in facility rate
Average rate for province (DHIS 2015)
15
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Early infant HIV test
Immunisation
Delivery rate (facility)
Source: DHIS 2000-2015
FIGURE 6: TRENDS IN PUBLIC FACILITY DELIVERY RATES, EARLY HIV TESTING AND IMMUNISATION
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
100%
80%
60%
40%
20%
0%
PRIMARY LEVEL MATERNAL AND CHILD HEALTH
Over a fth of young children (1.4 million)
live in households with poor access to
clinics. The numbers are highest in the
Eastern Cape and KwaZulu-Natal, where
33% and 30% respectively of young
children live more than 30 minutes from
the nearest health facility. Young children
living in the largely urbanised areas, such
as Gauteng and Western Cape, have better
access to health facilities. This indicator
only measures access (through physical
distance). It tells us nothing about the
quality of service at health facilities. Quality
of service provision is dicult to measure,
but is an important data gap.
The Road to Health Booklet (RTHB) is a
vital tool that enables both caregivers
and health professionals to monitor the
growth of young children and identify
danger signs early. All mothers who
deliver babies, in both the public and
private sectors, should receive a RTHB.
The booklet provides health information
for the caregiver, and is also their record
of perinatal visits, immunisation, child
growth, development, and illness events.
The South Africa Demographic and Health
Survey (SADHS) reports that only 66% of
mothers of children aged 12-23 months had
a RTHB, despite the fact that all mothers
are supposed to receive one. While many
caregivers might have the RTHB, it is often
not fully utilised as not all health workers
have been properly trained in its use. In
order to increase uptake and use, the
National Department of Health (NDoH)
has revised the RTHB to be both more
caregiver and health worker friendly and to
include a much more holistic view of child
development, including a comprehensive
section on child development for the
rst time. The NDoH plans to launch the
revised RTHB in late 2017 or early 2018. The
RTHB now includes ve priority sections,
as illustrated on the facing page. These
are nutrition, love, protection, healthcare,
and extra care.
16 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
PRIMARY LEVEL MATERNAL AND CHILD HEALTH
• HIV-relateddataaregenerallybetterthan
for other health domains. However, there
are a number of outcome level data points
that have not been updated recently. These
include PMTCT transmission rates at 6 weeks,
6 months, and 18 months, which are critical for
understanding the MTCT rate. HIV prevalence
amongst pregnant women has also not been
updated since 2013 as the DoH has not released
any subsequent reports.
• Therearenodataoncoverageofspecichealth
interventions during pregnancy, which means we
don’t know whether the required interventions
are actually being delivered.
• Dataonmaternalmentalhealthcontinueto
be lacking despite the increasing evidence of
its impact on maternal and infant outcomes.
• Weareunabletoreportoninfantmortality
rates by province.
• Qualityofcaredataarediculttocollect,
despite their importance. A focus on service
quality across the board is needed.
• Thereislackofdataondevelopmental
screening for infants to identify disabilities
or developmental delays at 6 weeks,
9 months and 12 months.
• Dataondewormingforchildrenaged
1-5 years are currently not available.
Data gaps and challenges
Indicator SA EC FS GT KZN LP MP NW NC WC source
Population
Number of infants
Children < 1 1 043 000 154 000 51 000 203 000 205 000 142 000 84 000 76 000 22 000 108 000 a
Poor access
to clinics
Children
< 6 living more than
30 mins from nearest
health facility
1 356 000 295 000 49 000 96 000 393 000 169 000 123 000 129 000 36 000 64 000
a
22% 33% 16% 8% 30% 22% 23% 28% 25% 10%
HIV prevalence in
pregnant women
Antenatal clients
testing HIV+
30% 31% 30% 29% 40% 20% 38% 28% 18% 19% b
(2013)
Service access/delivery
Prenatal early
booking
1st visit before 20
weeks, out of all
antenatal 1st
visits at public facility
61% 60% 63% 55% 65% 61% 66% 61% 62% 68% c
Antenatal HAART
Antenatal clients on
ART as % of eligible
total
93% 94% 87% 92% 98% 93% 96% 87% 92% 78% c
Early infant
HIV test
Infants born to HIV+
mothers who receive
PCR test around 6
weeks
101% 95% 91% 99% 108% 94% 106% 100% 91% 97% c
(2014)
Immunisation
Children < 1 who
complete the pri-
mary immunisation
course
89% 87% 86% 106% 85% 79% 87% 83% 83% 89% c
Delivery rate
in facility
Percentage of
deliveries occurring
in health facilities,
under trained
personnel
85% 75% 89% 96% 79% 92% 80% 75% 88% 89% c
Outcome
Early neonatal
mortality
Inpatient infant
deaths within 7 days,
per 1 000 live births
10.5 12.8 10.6 9.5 10.8 12.6 9.3 9.8 14.3 7.3 c
Infant
mortality rate
Number of deaths
under 1 year, per
1 000 live births in
same year
27 Mortalit y rates not currently available at provincial level. d
TABLE 2: HEALTH INDICATORS FOR PREGNANT WOMEN AND CHILDREN UNDER 6, BY PROVINCE
18 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Nutritional
support
Lack of proper nutrition can result in poor health and educational outcomes for
children, which in turn contribute to persistent inequality. To break this cycle, the
starting point is maternal nutrition before and during pregnancy. Interventions
to improve maternal and child nutritional outcomes include micronutrient
supplementation, immunisation, education about breastfeeding and child
nutrition,andincomesupportthroughsocialgrants.Poornutritionaectsmaternal
andchildhealth.Conversely,poorhealthcanaectfoodintakeandresultinpoor
nutritional status. For example, a mother who is depressed may not be able to
adequately address the nutritional needs of herself or her child.
When children are chronically under-
nourished they don’t grow as expected.
This is called “stunting”, a condition where
the child is too short for their age. Nationally,
over a fth of children under 5 years suer
from stunting making this condition the
most prominent form of malnutrition in
SA. Usually stunting is associated with
long-term poverty, inadequate access to
nutritious food, and prolonged exposure
to infections. While Figure 7 shows that
stunting rates have reduced for the poorest
20% of children under 5, much more needs
to be done to combat stunting. The rates
of stunting have remained high in the
country, despite improvements in other
aspects of child welfare, and a reduction in
child poverty rates that has been attributed
to the increase in number of children
receiving the child support grant.
FIGURE 7: STUNTING RATES AMONGST CHILDREN UNDER 5 YEARS
50%
40%
30%
20%
10%
0%
30% 27%
25%
21%
2008 2014/2015
Poorest 20% All income groups
Source: NIDS 2008,
NIDS 2014/2015. SALDRU,
University of Cape Town.
Analysis by Children’s Institute
19
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
In addition to high rates of undernutrition,
there is an increase in overweight and
obesity rates amongst children. Some of
the factors that have contributed to this are
inadequate diets characterised by highly
processed food, fats, and sugar intake, as
well as a lack of physical activity. Compared
with children whose weight is in the normal
range, those who are overweight are more
likely to remain overweight or obese in
adulthood, and are at a greater risk of
suering from cardiovascular diseases and
diabetes – in childhood and adulthood.
Nationally, 13% of children under the age of
5 years are overweight.
There is need for regular monitoring of
children’s growth and development. This
will ensure that poor physical growth is
identied and dealt with early, lowering the
risk of children suering from stunting and
other forms of malnutrition. It is important
that children are regularly measured
at clinics and health facilities, and their
heights and weights recorded in the Road
to Health Booklet are used to monitor their
development.
Anaemia in pregnant women can result
in low birth weight and increase the
risk of maternal illness and death. The
prevalence of anaemia amongst women
of reproductive age is 23% nationally, and
is higher than 30% in some provinces.
Anaemia is a major maternal nutritional
problem caused by dietary iron deciency,
blood loss from menstruation, as well as
parasitic and chronic infections. Information
on anaemia is lacking from some provinces,
as the survey sample is too small to draw
reliable estimates. Iron deciency anaemia
is the most common form of anaemia and
aects 10% of women of reproductive age
in the country.
Infants with low birth weight are at risk
of various health conditions that include
poor physical growth. Nationally, 13% of
infants born in public facilities had low birth
weight in 2015. The proportion of infants
born with low birth weight has remained
fairly consistent since 2005.
The World Health Organisation (WHO)
recommends exclusive breastfeeding
for 6 months after a child is born.
Breastmilk contains all the necessary
nutrients for a baby’s growth during this
time, and protects against illness and
infections. The act of breastfeeding also
strengthens a mother’s bond with her
child. A 2012-13 survey of public health
facilities that covered infants aged 4-8
weeks (irrespective of HIV status) found
that only 58% of all infants were exclusively
breastfed, while 11% did not receive any
NUTRITIONAL SUPPORT
FIGURE 8: FEEDING PRACTICES FOR CHILDREN AGED UNDER 6 MONTHS
0% 10% 20% 30% 40%
Source: SADHS 2016,
Key Indicator Report
Breastfeeding and
consuming complementary
foods
Breastfeeding and
consuming other milk
Breastfeeding and
consuming non milk liquids
Breastfeeding and
consuming plain water only
Exclusively breastfeeding
Not breastfeeding
18%
11%
14%
32%
25%
1%
Stunting is
associated
with long-
term poverty,
inadequate
access to
nutritious food,
and prolonged
exposure to
infections.
20 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
breast milk at all. Exclusive breastfeeding
rates for HIV-exposed infants were slightly
lower than the overall gure, at 54%. Mixed
feeding practices were reported for 20%
of HIV-exposed infants, placing them at
risk of HIV transmission. This survey only
covered infants in public health facilities
and those within the 4-8 weeks age group.
Initial results from the 2016 South African
Demographic and Health Survey (SADHS),
which used a nationally representative
sample, show that 32% of infants under
6 months are exclusively breastfed (see
Figure 8), up from 7% in 1998. However, 1
in 4 children aged under 6 months are not
breastfed at all.
The rst two years of life are especially
important for child growth and
development. Children need adequate
diets and conducive living environments
that protect against disease in order to
ensure survival and optimum growth.
According to the 2016 SADHS, only 23%
of children aged 6–23 months are fed a
minimum acceptable diet. This means
that close to 80% of children in that age
group are not consuming adequate diets,
increasing the likelihood of malnutrition
and ill-health.
Child hunger is a proxy for food insecurity
and has decreased over time. While child
hunger is based on subjective reporting
and is not very reliable, it allows for
comparisons across provinces and over
time. Between 2002 and 2015, reported
child hunger reduced from 29% to 13%. The
Eastern Cape, Limpopo and Mpumalanga
saw the biggest improvements over this
14-year period, with child hunger rates
reducing by over 20 percentage points in
all three provinces. The biggest change
was in the Eastern Cape, where child
hunger rates reduced from 48% in 2002 to
11% in 2015. It is important to note that data
on child hunger do not necessarily capture
the more critical aspects of nutrition, which
include dietary diversity. Children can be
well-fed and not hungry, but still be under-
nourished. Under-nutrition can lead to both
stunting and wasting on the one hand, and
obesity on the other hand.
Children with vitamin A deciency have
increased risk of infection and are more
prone to diseases. Vitamin A deciency has
decreased since 2005; however over 40%
of young children still suer from a lack
of it. Vitamin A supplementation coverage
rates have improved: in 2015, over 57% of
children aged 12-59 months received a
vitamin A dose at a public facility; up from
52% in 2014, and a substantial improvement
from a coverage rate of 35% just ve
years before. However, disparities across
districts are striking. Some districts such as
Amathole (Eastern Cape) and Xhariep (Free
State) have coverage rates of over 90%,
others such as Pixley ka Seme (Northen
Cape) and Waterberg (Limpopo) have
lower than 40% coverage rates.
A considerable number of women
continue to suer from vitamin A
deciency. Statistics from a national survey
show that 13% of women of reproductive
age (16-35 years) suered from vitamin
Only 23% of
children aged 6
– 23 months are
fed a minimum
acceptable diet.
NUTRITIONAL SUPPORT
FIGURE 9: REPORTED CHILD HUNGER RATES, 2002 & 2015
60%
50%
40%
30%
20%
10%
0%
48%
11%
26%
20% 19%18%
29%
13%
13%
17%
9%
33%
19%
27%
4%
32%
10%
26%
18%
25%
EC FS GT KZN LP MP NW NC WC SA
2002 2015
Source:
GHS 2002 & 2015,
analysis by
Children’s Institute
23%
21
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
A deciency in 2012. Some provincial
samples were too small to provide reliable
estimates. The risk of vitamin A deciency
is high in pregnant women, especially
in the later stages of pregnancy when
there is increased demand by both the
mother and the unborn child. Pregnant
women should therefore have access to
healthy and diverse diets, including fruits
and vegetables which are rich sources of
vitamin A.
The proportion of children under 5 years
who are anaemic is estimated at 11%.
Some of the causes of anaemia include
micronutrient deciencies (such as vitamin
A), and iron deciency, which aects 8% of
children under the age of 5 years. Causes
of iron deciency include lack of sucient
iron intake and blood loss due to worm
infestations. Approximately 2% of children
under 5 years suer from iron deciency
anaemia, which occurs when both iron
deciency and anaemia are present. Iron
deciency anaemia can increase children’s
susceptibility to infections and aect their
cognitive development, which, in turn,
aects their performance in school.
1 in 4 children
aged under 6
months are not
breastfed at all.
NUTRITIONAL SUPPORT
Indicator SA EC FS GT KZN LP MP NW NC WC source
Population
Vitamin A deficiency in women.
Women (16-35 yrs) below the WHO standard 13% 9% 8% 18% 16% * * 9% * 7% e (2012)
Anaemia in women
Women (16-35 yrs) below the WHO standard
for iron-deficiency
23% 20% 18% 19% 36% * 30% 17% * 16% e (2012)
Low birth weight
Infants born in public facilities weighing
below 2.5kg (2014)
13% 14% 12% 13% 12% 10% 12% 14% 20% 15% c
Child hunger
Children in households where children
suffer from hunger
13% 11% 13% 9% 19% 4% 10% 18% 20% 18% a
Service access
Breastfeeding
HIV-exposed infants 4-8 weeks exclusively
breastfed
54% 47% 56% 58% 54% 53% 52% 62% 76% 42% g
(2012/13)
Vitamin A coverage
in children 12-59 months 57% 64% 59% 59% 64% 50% 51% 52% 47% 47% c
Outcome
Vitamin A deficiency
in children under 5 44% e
Anaemia
in children under 5 10.7% e
Stunting
in children under 5 21.3% f
Wasting
in children under 5 3.6% f
Underweight
in children under 5 5.1% f
Overweight
in children under 5 13.4% f
TABLE 3: NUTRITION INDICATORS FOR PREGNANT WOMEN AND CHILDREN UNDER 6, BY PROVINCE
Sample too small for analysis at provincial level
Sample too small for analysis at provincial level
Sample too small for analysis at provincial level
Sample too small for analysis at provincial level
Sample too small for analysis at provincial level
Sample too small for analysis at provincial level
25%
22 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Data gaps and challenges
• There are two main ways to look at child
and maternal nutrition through survey
data. One is through information about
dietary intake, and the other is through
information about nutritional outcomes
– typically by measuring height and
weight, and sometimes by testing for
vitaminandmineraldeciencies.Both
approaches are used in South Africa,
but both also have limitations.
• Food and nutrition surveys are
expensive and not carried out
regularly,makingitdiculttohavea
comprehensive up-to-date picture of
dietary intake. Some surveys such as
the Income and Expenditure and Living
Conditions Surveys collect data on food
expenditure and consumption, but this
information is typically at household
level.Itisthereforediculttoestimate
children’s dietary intake (quantity and
quality) from such data.
• More recent surveys that could provide
in-depth data on health and nutrition,
are the South African National Health
and Nutrition Survey (SANHANES),
the South African Demographic and
Health Survey (SADHS), and the
National Income Dynamics Study (NIDS).
While these surveys collected data
on various aspects of maternal and
child health, including anthropometric
measurements (heights and weights),
there are limited data on food security
and dietary intake. A further problem
relates to the regularity of these
surveys. While NIDS takes place every
two years, it is a panel survey and
does not remain representative of the
population. SANHANES and the SADHS
are both nationally representative
samples, but they are not regular.
SANHANES (2012) has not been
repeated. The most recent SADHS
was in 2016, but that was after a gap
of 13 years. While in many African
countries, the demographic and health
surveysareconductedeveryveyears,
this is not the case in South Africa. It
would be useful for the SADHS to be
conducted more regularly, the sample
size increased, and more data on
food security and nutrition indicators
collected, in order to allow for a detailed
picture on the situation of child nutrition
in the country.
• Disaggregated data on child nutritional
outcomes are lacking, mainly due to
the small sample sizes of these health
and nutrition surveys that make it
diculttoproducereliableestimates
for provinces, across age groups, and
other levels of disaggregation. It is
thereforediculttoassesstheextent
of stunting, for example, at provincial
and district level, the inequalities that
may exist across geographical locations,
and which areas are in urgent need
of interventions. The 2014/15 Living
Conditions Survey (LCS), a nationally
representative survey with a large
sample, collected data on household
socio-economic characteristics,
including income and food
expenditure, as well as anthropometric
measurements for children under 5
years. These kinds of data are important
for understanding the contexts in which
children live, especially in regards to
money-metric poverty and other forms
of deprivation, and how these relate to
stunting and other forms of malnutrition.
Anthropometric data from the 2014/15
LCS have not been made publicly
available, and neither have those from
the previous LCS in 2008/09.
• In some cases, data on nutrition are
only available for particular child age
groups, overlooking others. The 2012
SANHANES collected data on general
nutrition knowledge and dietary
behaviours among children aged 10-
14 years. The 2016 SADHS collected
data on infant and young child feeding
practices, but only for children aged
6-23 months. For older children (2
yearsandover),itisdiculttohave
a picture of the quality and quantity
of diets consumed. The SADHS also
only collects anthropometric data for
children under 5 years and 15-17 years.
Children aged 6-14 years are excluded.
There are lack
of regular
and detailed
national data
on the quality
and quantity
of foods
consumed by
young children.
NUTRITIONAL SUPPORT
24 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
The National Integrated ECD Policy (2015)
recognises the value of supporting primary
caregivers, and views them as central
to supporting early child development.
It identies parent support as an essential
component of the comprehensive
package of ECD services and prioritises
the delivery of parenting support services.
It also promotes the provision of health
services and other forms of support during
pregnancy, and the provision of social
protection to caregivers.
Young children benet from interventions
and support services targeting mothers.
The vast majority of children under 6 years
live with their biological mother (85%),
although there are striking inequalities
between districts, with co-residence rates
as low as 59% in the Amathole region of
the Eastern Cape. As children get older,
they are more likely to live separately
from their parents due to factors like
death and labour migration. Targeting
mothers of young children is critical
to enable access to support services
for both the mother and child, and to
raise awareness of the importance of
responsive, nurturing care. The quality of
the caregiver-child relationship impacts
not only on the physiological aspects
of child development, but also on socio-
emotional development.6
Support for mothers begins with antenatal
care (ANC). Antenatal visits early in
pregnancy enable the identication of any
problems. When problems are identied
early, suitable interventions and support
can be oered, preventing complications
in late pregnancy. The importance of ANC,
support and early intervention is evident
when we consider that South Africa has
the highest documented rates of Foetal
Alcohol Syndrome (FAS) in the world.
Support
for primary
caregivers
Children need caregivers who are responsive and nurturing. Since many
caregivers in South Africa face extreme conditions and stressors, they
require support. Support should include clear information about parenting,
as well as access to psychosocial services and material support.
MomConnect is a Department of Health
initiative that aims to register every pregnancy
in South Africa and send each mother, through mobile
technology, weekly SMS messages to support her
and provide information on how to take care of her
own and her baby’s health. The message content
is targeted based on the stage of pregnancy and
continues after birth, until the child is 1 year old.
For more information visit:
http://www.health.gov.za/index.php/intro
25
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
SUPPORT FOR PRIMARY CAREGIVERS
Area-specic studies in three provinces
have documented Foetal Alcohol Spectrum
Disorder (FASD) rates ranging from 29 to
290 per 1,000 live births between 2001
and 2011.7 Children born with FASD are
likely to demonstrate a variety of life-long
concentration and behavioural diculties.
There is evidence to suggest that levels of
FAS in South Africa are increasing.8
With near-universal antenatal coverage
nationally, antenatal visits are a prime
opportunity to share information on
risks, detect harmful behaviours and
adverse conditions, and oer practical
support, interventions or referral. These
preventative services can prevent negative
child outcomes.
Repeat antenatal visits provide an
opportunity to prepare pregnant women
for childbirth and parenting, and to
support women experiencing particular
challenges, such as physical or mental
health conditions or domestic violence.
Visits also provide access to HIV testing.
Delayed antenatal care therefore has
serious consequences for both the
mother and child. Women who attended
public antenatal facilities in 2012 visited
an average of three to four times during
pregnancy.9 The 2016 Demographic and
Health Survey indicates that 76% of women
surveyed attended ANC visits four or more
times during their last pregnancy.10 These
gures suggest that most women are
aware of the importance of regular ANC
visits during pregnancy. However, there is
room for improvement in early attendance
– close to 40% of women are only making
their rst ANC visit after 20 weeks of
pregnancy.
Pregnant women should be encouraged
to attend antenatal services as early as
possible, to gain access to the range of
benets attached to this service, and to
visit at least four times during the course
of their pregnancy. Non-attendance, late
attendance, and infrequent attendance
at ANC are among the top ve avoidable
factors in perinatal deaths,11 and amongst
the most common underlying causes of
patient-related maternal mortality.12
Targeting
mothers of
young children
is critical to
enable access
to support
services
for both
the mother
and child,
and to raise
awareness of
the importance
of responsive,
nurturing care.
FIGURE 10: POSTNATAL FOLLOW-UPS – NATIONAL TREND
2010 2011 2012 2013 2014 2015
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: DHIS 2010-2015
26 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
A qualitative study on barriers to antenatal
services reports the primary challenges
to be poor handling of women and girls’
private and condential information; the
need for accurate and readily accessible
health information; and the cost and
transport implications associated with
visiting clinics, particularly for those living
in rural areas.13
The provision of infant feeding education
and support to mothers is crucial to infant
health. A 2012-13 survey on infants aged
4-8 weeks pointed to improvements in
infant feeding education amongst HIV-
positive mothers. In the majority of the
provinces, more than 90% of HIV-positive
mothers surveyed in public health facilities
received infant feeding counselling. Given
the emphasis on supporting exclusive
breastfeeding amongst HIV-positive
mothers, it is likely that the proportion
of HIV‐-negative mothers who receive
infant feeding counselling will be far
lower. This is a data and likely service gap
that needs addressing, given that a high
percentage of mothers will fall within this
category. Revisions to the Road to Health
Booklet present an important opportunity
to address this service gap, as it now
aims to facilitate a more comprehensive
assessment of child health, nutrition,
including breastfeeding, and development.
This initiative is welcomed as it is aligned
with the
National ECD Policy’s directive for
the Department of Health to adopt a more
developmental approach to maternal and
child health.
The postnatal period is an opportunity
for service providers to pay attention to
the caregiver’s mood and functioning,
and to provide support for issues around
adjustment to motherhood, breastfeeding
and bonding with the infant.
There have been substantial improve-
ments in the coverage of postnatal care
over time. Women who give birth in public
health facilities are meant to have a check-
up after six hours, prior to discharge, and
should visit a healthcare facility for further
follow-up care within six days, and again at
six weeks. Checks for infection and other
complications should be done during
these follow-up visits. The objectives of
routine postnatal care are to respond
to the usual psychological and physical
changes that take place post-delivery; to
support, counsel and advise; and to screen
for problems that threaten the mothers’s
and baby’s health.14 The postnatal period
is also a critical period to encourage and
support breastfeeding. In 2010, only 26% of
women who gave birth in public facilities
were recorded as having received follow-
up care within six days. In 2014, this number
had increased to 74%, and then declined
slightly to 69% in 2015.
Both nationally and provincially, the 6-day
postnatal visit rate fell below the national
target of 85% in 2015.15 The national average
masks large provincial variability, with 2015
rates as low as 53% and 58% in the Northern
Cape and Eastern Cape, respectively.
While there are concerns about maintaining
and extending coverage, there are also
important questions about the quality
of care oered at postnatal visits. These
concerns focus on the balance of attention
between psychological and physical
health within a context where maternal
mental health conditions are considerably
widespread.16 Health system audits have
shown that in general, maternal care
services, including postnatal care, lack
quality and require strengthening.17
Maternal mental health is important
in itself, and is also important for child
outcomes. A child’s physical growth,
immunisation, HIV testing and treatment
adherence, and emotional state can
be aected by the mental health of the
caregiver. There are no reliable national
statistics on maternal mental health but it
is known that both antenatal and postnatal
depression and anxiety are prevalent,
aecting an estimated one third of mothers.
While there have been several studies on
antenatal and postnatal depression, they
have been restricted to specic locations.
There are
no reliable
national
statistics on
maternal
mental health
but it is known
that both
antenatal
and postnatal
depression
and anxiety
are prevalent,
aecting an
estimated
one third of
mothers.
SUPPORT FOR PRIMARY CAREGIVERS
However, there are sucient studies
to indicate that maternal depression is
common, with the prevalence of antenatal
depression ranging from 18% to 47%, and
32% to 35% for postnatal depression.18
Maternal depression is frequently not
identied or treated because maternal
mental health services are currently not
universally integrated into the primary
healthcare system.
There is little information on the provision
of and access to parenting support
services. Parent support programmes
aim to improve parental knowledge,
capacity and practices to support parents
in their role as nurturing, responsive
caregivers. Specialist parental support
for vulnerable caregivers is especially
relevant, as it addresses mental health
concerns, substance abuse, and exposure
to violence and abuse, among other
social problems. Currently, very limited
information is available on the provision or
uptake of parenting programmes across
the country. This is an important data gap.
Currently, MomConnect is the closest
there is to a universal parenting support
programmme available to new parents.
With the near-universal uptake of
antenatal care and well-baby clinic visits,
health facilities are an ideal location for
providing innovative programmes and
materials in clinic waiting areas.
• Data on the provision of support, information,
and advice to pregnant women and mothers
are limited. For example, the only indicator
we have for breastfeeding education is based
on information provided to HIV+ mothers.
We therefore have to assume that this is
generalisable to the entire population of
mothers, which is not necessarily the case.
• Information on the content and quality of
antenatal and postnatal services is lacking.
• There are no data on maternal mental
health prevalence and screening (including
domestic and intimate partner violence, as
well as alcohol and substance abuse) during
pregnancy and postnatally.
• Data on management of primary level mental
health problems for treatment are lacking.
• There are no data on the types of parent
supportprogrammesavailable,theiridentied
targetgroups,andbeneciaryaccessand
programme reach.
Data gaps and challenges
Indicator SA EC FS GT KZN LP MP NW NC WC source
Population
Maternal care
Children < 6 who live
with their biological
mother
85% 77% 84% 91% 81% 82% 85% 86% 85% 95% a
Service access/delivery
Breastfeeding
education
HIV+ mothers
remembering receiving
information during
antenatal visits
94% 94% 85% 97% 97% 88% 95% 92% 95% 95% g
(2012)
Postnatal follow-up
Women birthing in pub-
lic facilities who received
follow-up care 6 days
after birth
68% 58% 71% 77% 70% 67% 63% 69% 53% 68% c
TABLE 4: INDICATORS OF SUPPORT FOR PRIMARY CAREGIVERS, BY PROVINCE
SUPPORT FOR PRIMARY CAREGIVERS
28 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Social services
and income
support
Social assistance is a way of redistributing
resources to the poor through grants.
Social grants are widely regarded as
the most eective poverty alleviation
programme since democracy because of
their positive impact and wide reach. Social
assistance programmes have expanded
from covering just 2.7 million people in
1994 to more than 16 million in 2014. Ten
percent of South Africa’s budget in 2017/18
was allocated to social grants.
The CSG has had the highest growth of
all social grants in South Africa in terms
of numbers. It was introduced for poor
children aged 0-7 years in 1998; it then
gradually extended to all children below the
age of 18 by 2012. Its reach has expanded
from just under 22,000 child beneciaries
in 1998 to over 12 million in 2017. It has been
shown to have a substantial developmental
impact on children and their families living
in poverty. However, more needs to be
done to address income poverty and
inequality, especially in light of new trends
showing that poverty has increased since
2011, after declining in the 2000’s.19
Using the upper-bound poverty line as a
rough proxy for the means test, the CSG
uptake rate among poor children under 6
years is 81%. Uptake rates are highest in
the Eastern Cape, Limpopo and the North
West, and lowest in the Western Cape and
Gauteng. This is a known pattern, which
has been reported elsewhere.20 Possible
reasons include that social security ocials
in wealthier provinces act as gatekeepers,
making it more dicult for people to apply,
or that greater population density results in
long queues that deter applicants.
Figure 11 shows slow uptake of the CSG for
infants under 1 year. The CSG is available
to all children whose caregivers have a
monthly income less than 10 times the
amount of the grant (or double that if
they are married). In 2015, the monthly
amount of the grant was R330 per child.
For children whose births are registered,
the CSG application only takes about three
days to process. Eligible caregivers should
be able to start receiving child support
grants within the rst month of a child’s
life. This is important because early access
to the CSG is associated with improved
nutritional, health and education outcomes
for children. CSG uptake remains the lowest
for infants under a year. Amongst poor
infants (below the upper-bound poverty
Earlyregistrationofbirthsisimportantbecausebirthcerticates
arethegatewaytootherservicesandbenets,suchasthechild
support grant (CSG). The CSG is the main grant for children,
providing income support for children living in poverty.
Early access
to the CSG is
associated
with improved
nutritional,
health and
education
outcomes for
children
30 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
line) only 64% receive the CSG. Once again,
uptake rates are lowest in Gauteng and the
Western Cape.
The relatively urbanised and wealthy
provinces (Gauteng and the Western
Cape) have the lowest CSG uptake rates.
Poorer and more rural provinces perform
better in rolling out the CSG to eligible
children. This spatial patterning is strikingly
dierent from many other indicators. In
2015, 55% of poor infants (below the upper-
bound poverty line) in the Western Cape
and 49% in Gauteng were not receiving
the CSG. Uptake rates for infants were also
low in the Free State (54%). This “error of
exclusion” is of concern because it tends to
be the most vulnerable and needy children
who do not access the grant. The highest
rate of uptake for poor infants was in the
Eastern Cape, where 75% of infants under
the upper poverty line were reported to be
receiving the CSG.
Through the Medium Term Strategic
Framework (MTSF) 2014-2019, the South
African government aims to ensure that at
least 95% of people who qualify for social
assistance benets access these benets
by 2019. This will require ways to resolve
FIGURE 11: CHILD SUPPORT GRANT UPTAKE AMONG POOR CHILDREN
(BELOW UPPER POVERTY LINE), BY AGE
SOCIAL SERVICES AND INCOME SUPPORT
0 1 2 3 4 5
100%
80%
60%
40%
20%
0%
Age of child
Source: GHS 2015; Children’s Institute analysis
Source: Statistics South Africa: Recorded live births, 2006 & 2015
100%
80%
60%
40%
20%
0%
52%
87%
77%
96%
78%
94%
64%
85%
91%
77%
70%
53%
86%
73%
92%
61%
89%
65%
91%
75%
2006 2015
EC FS GT KZN LP MP NW NC WC SA
31
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
FIGURE 12: BIRTH REGISTRATION, BY PROVINCE
SOCIAL SERVICES AND INCOME SUPPORT
a few million exclusions. The easiest way
to address exclusions for children is
to ensure that they are enrolled on the
grant from birth.
Birth registration has increased, but many
children’s births are still being registered
late. Births are meant to be registered
within the rst 30 days, but some are not
even registered within the rst year. Of all
the births registered in 2015, 85% were for
births in current year, while 15% (165,000)
were for earlier births. The provinces
with the largest increases in the birth
registration rates over the last ten years are
Eastern Cape (52% in 2006 to 87% in 2015)
and KwaZulu-Natal (53% in 2006 to 84%
in 2015). Current year birth registrations in
Gauteng have declined slightly over the
same period.
There are no reliable data on the number
of children who need social services, or on
the extent of services delivered. Services
for young children dened in the Children’s
Act (2005) include:
• partial care (crèches and centres) and
ECD programmes
• prevention and early intervention
services, such as child and family
counselling
• parenting skills programmes
• support for young mothers
• protection services for children who
have been abused, abandoned, or
neglected
• provision of alternative care, including
foster care, adoption, and care centres
Data on child abuse, neglect, and on the
service response to abuse remain very
poor. The MTSF target (outcome 3) in this
respect requires review, in that it calls for a
2% reduction per annum in the number of
reported crimes against women, children,
and other vulnerable groups (baseline 2012
was 225 430). Given the known problems of
under-reporting, a more appropriate target
might be one that encourages greater
reporting of child abuse and improvements
in prevention services as well as in services
that respond to reported incidents.
The most common crimes reported
against children involve sexual abuse.
In 2016, a national prevalence study
estimated that one in three children
experience sexual violence abuse before
they reach the age of 18.21 Between 18,000
and 20,000 child sexual abuse cases are
reported to the police every year. Crime
statistics for 2013/14 showed that 29% of
sexual oences reported to the police were
children under 18 years – an average of 51
cases a day.22 The 2015/16 crime statistics
report did not include national data on
crimes against children, but, in the North
West, 35% of rape cases involved victims
aged under 18 years.23 Population-based
studies have also found very high levels of
physical abuse and physical punishment.24
Young children are at more risk of child
abuse and neglect because they are
dependent on caregivers and are unable
to protect themselves. In addition to sexual
abuse, neglect, and physical abuse, some
of the other common forms of violence
aecting children under 5 years are
emotional abuse and abandonment. The
most severe consequence of child abuse
is infanticide, which is not uncommon in
South Africa.25
Increased eorts are needed to strengthen
the child protection system. The various
duty-bearers, such as the police services,
Departments of Social Development and
Health, and the criminal justice system,
should collaborate better to improve the
eciency and eectiveness of responses. A
national Child Protection Policy is currently
being drafted. This policy will inform
current legislative and policy frameworks
to strengthen service delivery.
32 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Only 64% of poor
infants receive
the Child
Support Grant.
64%
Indicator SA EC FS GT KZN LP MP NW NC WC source
Service access / delivery
Birth
registration (2015)
Birth registrations
that are for current
year births (2015)
919 562 109 210 47 473 192 439 184 225 121 973 73 686 66 254 24 310 96 626
h
85% 87% 91% 70% 86% 92% 89% 91% 95% 94%
Access to Child
Support Grant
Children < 6
receiving the CSG
(March 2016)
4 254 186 642 954 232 159 630 872 964 979 671 328 373 174 294 040 107 512 337 168 i
CSG uptake in
children under 6
Proportion of poor
children < 6 years
receiving CSG
81% 86% 83% 67% 83% 84% 82% 79% 84% 70% a
CSG uptake
in infants
Proportion of poor
children < 1 year
receiving CSG
64% 75% 54% 49% 64% 68% 68% 57% 76% 55% a
• While birth registration rates are increasing and the
vital registration data are improving, it is worth noting
that the number of births registered in a particular
year may vary over time as the methods are revised.
For example, in 2014 we reported that 76% of births
were for births that occurred in that current year
(based on 2015 data), but in a later report (2016) the
percentage of current births recorded for 2014 was
revised upwards to 83%. The
Early Childhood Review
will always attempt to source the most reliable and
recent data. Trends cannot necessarily be inferred by
comparing two subsequent issues of this publication.
• There is a need for regular national data on the
incidence and prevalence of child abuse (including
corporal punishment and sexual abuse) and neglect.
These data would need to come from reported cases
to the police and social services because these issues
arediculttodetermineingeneralsurveys.Good
systems need to be in place to ensure that records
arewell-keptinlocalocesandproperlycompiledat
provincial and national level.
• Good administrative data on the delivery of responsive
child protection services and psychosocial support for
children, are needed.
• It would be useful to track the number and proportion
of child protection cases that are brought before the
court within 90 days, as stipulated in the Children’s Act.
This would involve linked administrative data systems
for the Department of Social Development and the
Department of Justice and Constitutional Development
– particularly the Children’s Courts.
Data gaps and challenges
SOCIAL SERVICES AND INCOME SUPPORT
TABLE 5: SOCIAL ACCESS/DELIVERY INDICATORS FOR CHILDREN UNDER 6, BY PROVINCE
33
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Stimulation for
early learning
Babies start learning at birth. Learning takes place through their
relationships with the caring adults in their lives. Programmes, such
as home visiting and parenting support, designed to enrich carer
engagement with young children, are therefore extremely important for a
child’s early development. As children grow, so their need for stimulation
increases. From about the age of 3 years, young children derive great
educational, social, and emotional benets from participation in high
quality group-based early learning programmes. These programmes
maytakedierentformssuchasplaygroups,crèchesandpreschools.
The provision of age appropriate
opportunities for early learning is an
essential component of the National
ECD Policy’s comprehensive package
of services. Monitoring progress of the
provision of early learning services requires
us to review access, dosage, and quality.
Higher dosage of quality services is
typically associated with greater cognitive
gains, particularly for children from
low-income communities. For optimum
cognitive outcomes, the evidence
suggests that two years of high quality
preschool programmes are better than
one; that a minimum of 15-30 hours per
week is needed; and that outcomes are
optimised if children are enrolled before
the age of 4 years.26
In addition to the cognitive gains,
early learning programmes provide an
opportunity to link children to other
services that are important at this life
stage. These include sight and hearing
tests, immunisation, deworming, and
developmental screening to ensure early
identication of learning diculties.
Data on access to early learning
programmes are gathered through the
General Household Survey (GHS). The
survey collects information on the number
of children reported to be attending an early
learning group programme. In 2015, 17% of
0-2 year olds nationally were reported to be
attending such a programme. It is dicult to
interpret these data meaningfully because
many group learning programmes are
inappropriate for children of this age.
Better data are needed on the full range of
early learning programmes targeting 0-2
year old children.
Of the 3.1 million children in South
Africa aged 3-5 years, 63% are reported
to be attending a group programme.
This represents a signicant increase in
34 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
access over the past 15 years27 but access
seems to have stabilised between 2012
and 2015. Reasons for this ‘ceiling’ eect
are likely to include the cost of services.
Unlike health and education services,
there is no provision of free group learning
programmes for children of preschool
age in South Africa. As a result, only those
who can aord to pay for the service have
access to it.
It is only in the North West province that
access rates to early learning group
programmes increased substantially for
3-5 year-olds: from 58% to 65% between
2014 and 2015. Access is lowest in
KwaZulu-Natal, at 49%. This is also the
province with the highest number of young
children living in poverty.
Poor children are less likely than wealthier
children to have access to early learning
programmes. Over a million children aged
3-5 years still do not have access to group
learning programmes and most of these
children are found in the poorest quintiles. A
four-year-old child from quintile 1 (poorest
20% of households) has a 50% chance
of being enrolled in a group learning
programme. In contrast, a child of the same
age in quintile 5 (the wealthiest quintile) has
a 90% chance of enjoying these benets.
This inequality in service access between
income groups only disappears at the
point where education becomes widely
available, free, and compulsory – in Grade 1.
At which point, many poorer children enter
school with a distinct disadvantage, having
missed the benets of quality early learning
programmes. Overall, 83% of 3-5 year-old
children in the richest 20% of households
attend a group learning programme,
while only 58% in the poorest 20% of
households are enrolled in a programme.
Observed increases in access to early
learning services is encouraging, but the
sought after early learning outcomes
for children will only be realised if the
programmes accessed are of good quality.
There are no reliable data that enable
national monitoring of the quality of early
learning programmes for children.
A 4-year-old
from a poor
household has a
50% chance of
being enrolled in
a group learning
programme.
A child of
the same age
from a wealthy
household has
a 90% chance
of enjoying this
benefit.
FIGURE 13: EARLY LEARNING PROGRAMME ATTENDANCE BY INCOME QUINTILES AND AGE
0 1 2 3 4 5 6 7 8 9
100%
80%
60%
40%
20%
0%
Age of child
Quintile 5 (wealthiest)
Quintile 4
Quintile 3
Quintile 2
Quintile 1 (poorest)
Source: GHS 2015;
Children’s Institute
analysis.
STIMULATION FOR EARLY LEARNING
35
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
QUINTILE
GROUP LEARNING
1 5
50%
chance
90%
chance
FIGURE 14: EARLY LEARNING PROGRAMME ATTENDANCE BY 3-5 YEAR OLDS, BY INCOME QUINTILES (2015)
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
(Poorest) (Wealthiest)
100%
80%
60%
40%
20%
0%
58% 60%
67%
71%
83%
Source: GHS 2015; Children’s Institute analysis
Research has shown that performance in these domains predicts later school success.
While learning outcomes may be impacted by many factors (including poor nutrition), you
would expect to see higher ELOM scores at a population level for children attending higher
quality programmes.
Currently, ELOM is being used to collect data on the eectiveness of a range of programmes
designed to improve early learning outcomes in young children. These include home visiting,
playgroups, toy libraries, ECD centres, and targeted add-on services. For more information
on ELOM, visit www.elom.org.za
STIMULATION FOR EARLY LEARNING
Early Learning Outcomes Measure
To help address the gap in information on early learning programme quality, Innovation
EdgecommissionedthedevelopmentofSouthAfrica’srstpopulationlevelpreschool
assessment tool, the Early Learning Outcomes Measure (ELOM). ELOM is designed to
assess the extent to which children aged 50-69 months are able to meet development
standardsinvedevelopmentaldomains:
Emergent
literacy &
language
Gross motor
development
Emergent
numeracy &
mathematics
Cognition &
executive
functioning
Fine motor
coordination
& visual motor
integration
36 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
STIMULATION FOR EARLY LEARNING
Data collected on over 1300 children
across the ve quintiles by ELOM clearly
show that poorer children begin school at
a disadvantage. In all domains, regardless
of age, the performance of the poorest
children tends to be lowest. The most
signicant delays were observed in the
emergent literacy and language domain,
as well as in the cognitive and executive
functioning domain.
Figure 15 shows the total ELOM score for
children, aged 60-69 months at the point
of entry into Grade R, in quintile 1, quintiles
2 and 3 combined, and quintiles 4 and 5
combined.
Children at risk (light green: ) are
well below the expected performance
standard (purple: )and need signicant
assistance to come up to the standard,
while those falling behind (dark green:
)are closer to the standard, and with
support should be able to achieve it. These
results provide a baseline against which
to assess improvements in early learning
programme quality over time.
The introduction, in 2017, of the rst ever
conditional grant for ECD in South Africa
provides an opportunity to enhance the
systems needed to scale high quality
early learning programmes. Multiple
interventions are needed to address the
access, dosage, and quality gaps that aect
young children within quintiles 1-3. These
include greater budget allocation; better
funding administration; development of
routine data systems; national rollout of
high quality early learning programmes;
and much greater support for the ECD
practitioners who engage, inspire and
educate young children on a daily basis.
37
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Source: ELOM Technical Manual, 2016
60-69 Months
Z-Score
Percentile
Standard
Scores
Standard Scores
Standard
Q4/5 (Median)
Q2/3 (Median)
Q1 (Median)
54.38
53.85
49.31
41.99
-3.0 -2.5 -2.0 -1.5 -1.0 -0.5 0 0.5 1.0 1.5 2.0 2.5 3.0
-0.1 1 2 7 16 32 50 68 84 93 98 99 99.9
9.14 16.10 23.06 30.02 36.98 43.94 50.90 57.86 64.82 71.78 78.74 85.70 92.66
Key
ELOM Total
FIGURE 15: TOTAL ELOM SCORE FOR CHILDREN AGED 60-69 MONTHS, AT POINT OF GRADE R ENTRY
TABLE 6: EARLY LEARNING INDICATORS, BY PROVINCE
Indicator SA EC FS GT KZN LP MP NW NC WC source
Population
Children aged 0-2 3 151 000 443 000 145 000 614 000 664 000 381 000 272 000 229 000 72 000 332 000 a
Children aged 3-5 3 083 000 442 000 159 000 572 000 652 000 374 000 256 000 234 000 72 000 323 000 a
Service access/delivery
Early learning
enrolment
Percentage of children
0-2 years old
reported to attend an
early learning group
programme
17% 12% 25% 28% 9% 18% 13% 12% 14% 25% a
Percentage of children
3-5 years old
reported to attend an
early learning group
programme
63% 68% 72% 72% 49% 72% 59% 65% 57% 60% a
No access to early
learning programme
Number of children
3-5 not attending any
early learning group
programme
1 131 000 143 000 44 000 158 000 333 000 105 000 106 000 82 000 31 000 130 000 a
• As reported in 2016’s
Early Childhood Review,
South Africa does not have an administrative
data system for ECD similar to those used by
health and education. There are no data on the
number of registered and funded ECD centres and
programmes and how many children are accessing
these services. As a result, all data on ECD services
are drawn from survey data which are not ideal nor
sustainable for robust programme monitoring
and planning.
• Data on the full range of early learning programmes
targeting 0-2 year old children are lacking. Currently,
data are only collected on group programmes, many
of which are inappropriate for children younger than
3 years.
• Lack of data on the quality of early learning
programmes need to be addressed. This information
is essential to inform programme enhancements
andtodirectresourcesatthemosteective
interventions.
• We do not know exactly how many children are
receiving the per child per day early learning
subsidy. The administration of the ECD conditional
grant calls for vastly improved administrative data
to track the number of children requiring and
accessing subsidised early learning programmes.
• While we have data on service access (which
usually means enrolment), we have no data on
dosage i.e. how many hours of an early learning
programme a child is exposed to per week.
Attendance data are recorded at ECD centres
and,ifappropriatelyveriedandcollated,could
be used as a measure of dosage. In the context of
limited resources, this information is important for
us to understand the minimum dosage required for
improved outcomes.
Data gaps and challenges
STIMULATION FOR EARLY LEARNING
38 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
References
40 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
1 Statistics South Africa (2017) Poverty Trends in South Africa: An examination of absolute poverty between 2006 and
2015. Pretoria: Statistics South Africa.
2 Hall K, Nannan, N & Sambu W (2013) Child Health and Nutrition. In: Berry L, Biersteker L, Dawes A, Lake L & Smith C
(eds) South African Child Gauge 2013. Cape Town: Children’s Institute, University of Cape Town.
3 This does not include deliveries in private hospitals. Data on deliveries in private institutions are not publicly available,
making it dicult to construct a delivery rate that represents both public and private health institutions. Survey data can
be used to ll the gap. The 2016 SADHS reports that 96% of live births delivered in the past ve years took place
in health facilities.
4 Mazanderani AH & Sherman G (2016) HIV intrauterine transmission rate. In: Massyn N, Peer N, English R, Padarath A,
Barron P & Day C (eds). District Health Barometer 2015/16. Durban: Health Systems Trust.
5 Cloete I, Daniels L, Jordaan J, Derbyshire C, Volmink L & Schubl C (2013) Knowledge and perception of nursing sta
on the new Road to Health Booklet growth charts in primary healthcare clinics in the Tygerberg subdistrict
of the Cape Town metropole district. S Afr J Clin Nutr 2013; 26 (3):141-146. http://academic.sun.ac.za/Health/Media_
Review/2013/18Nov13/les/Knowlege.pdf
6 Britto RP, Lye JS, Proulx K, Yousafzai KA, Matthews SG, Vaivada T, Perez-Escamilla R, Rao N, Ip P, Fernald CHL,
MacMillan H, Hanson M, Wachs DT, Yao H, Yoshikawa H, Cerezo A, Leckman JF & Bhutta AZ (2017) Nurturing care:
promoting early childhood development. Lancet, 389: 91–102.
7 Olivier l, Curfs L & Viljoen D (2016) Fetal alcohol spectrum disorders: Prevalence rates in South Africa. S Afr Med 2016;
106(6 Suppl 1): S103-S106. DOI:10.7196/SAMJ.2016.v106i6.11009.
8 Chersich M, Urban M, Olivier L, Davies L, Chetty C & Viljoen D (2012) Universal Prevention is Associated with Lower
Prevalence of Fetal Alcohol Spectrum Disorders in Northern Cape, South Africa: A Multicentre Before–After Study.
Alcohol and Alcoholism, Volume 47, Issue 1, Pages 67–74, https://doi.org/10.1093/alcalc/agr145.
9 Department of Health. District Health Information Systems, 2012 data.
10 Statistics South Africa (2017) South Africa Demographic and Health Survey 2016: Key Indicator Report. Pretoria:
Statistics South Africa.
11 Pattinson RC (2009) Saving babies 2006-2007. Sixth perinatal care survey of South Africa. Pretoria: Tshepesa Press.
12 Department of Health (2007) Saving mothers: Third report on condential inquiries into maternal deaths in
South Africa, 2002-04. Pretoria: National Department of Health.
13 Amnesty International (2014) Struggle for maternal health. Barriers to antenatal care in South Africa.
Amnesty International Ltd: London.
14 Department of Health (2015). Guidelines for Maternity Care in South Africa. 4th ed. Pretoria: NDoH.
15 Massyn N, Peer N, English R, Padarath A, Barron P & Day C, editors. District Health Barometer 2015/16.
Durban: Health Systems Trust.
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41
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
16 Schneider M, Docrat S, Onah M, Tomlinson M, Baron E, Honikman S, Skeen S, van der Westhuizen C, Breuer E,
Kagee A, Sorsdahl K & Lund C (2016) Integrating mental health into South Africa’s health system: current status
and way forward. South African Health Review 2015/16. Durban: Health Systems Trust.
17 Bradshaw D, Chopra M, Kerber K, Lawn J, Moodley J, Pattinson R, Patrick M, Stephen C & Velaphi S (2008)
Every death counts: saving the lives of mothers, babies and children in South Africa. National Department of Health,
Medical Research Council, University of Pretoria, Save the Children, UNICEF.
Allanson E & Pattinson R (2015) Quality-of-care audits and perinatal mortality in South Africa. Bull World Health Organ,
93:424–428 doi: http://dx.doi.org/10.2471/BLT.14.144683
18 Schneider M, Docrat S, Onah M, Tomlinson M, Baron E, Honikman S, Skeen S, van der Westhuizen C, Breuer E,
Kagee A, Sorsdahl K & Lund C (2016) Integrating mental health into South Africa’s health system: current status and way
forward. South African Health Review 2015/16. Health Systems Trust: Durban.
19 Statistics South Africa (2017) Poverty Trends in South Africa: An examination of absolute poverty between
2006 and 2016. Pretoria: Stats SA.
20 DSD, SASSA & UNICEF (2016) Removing Barriers to Accessing Child Grants: Progress in reducing exclusion from
South Africa’s Child Support Grant. Pretoria: UNICEF South Africa.
21 Artz L, Burton P, Leoschut L, Ward CL and Lloyd S, Kassanjee R, Fensham R & Lloyd S (2016) Sexual Abuse of Children
and Adolescents in South Africa: Forms, extent and circumstances. UBS Optimus Foundation.
22 South African Police Service (2014) Police Crime Statistics. Pretoria: SAPS.
23 South African Police Service (2016) Annual Crime Report 2015/2016. Addendum to the SAPS Annual Report.
Pretoria: SAPS.
24 Matthews S & Benvenuti P (2014) Violence against children in South Africa: Developing a prevention agenda.
In: Mathews S, Jamieson L, Lake L & Smith C (eds). South African Child Gauge 2014. Cape Town: Children’s Institute,
University of Cape Town.
25 Mathews S, Abrahams N, Jewkes R, Martin L & Lombard C (2013) The epidemiology of child homicides in South Africa.
Bulletin of the World Health Organization, 91:562-568.
26 Loeb S, Bridges M, Bassok D, Fuller B & Rumberger RW (2007) How much is too much? The inuence of
preschool centers on children’s social and cognitive development. Economics of Education review, 26(1), 52-66.
Sylva K, Melhuish E, Sammons P, Siraj-Blatchford I & Taggart B (2004) The eective provision of preschool education
(EPPE) project: Final Report: A longitudinal study funded by the DfES 1997-2004. Institute of Education, University of
London/Department for Education and Skills/Sure Start.
27 Prior to 2009, enrolment in early learning programmes is likely to have been under-reported, as the General
Household Survey asked a general question on attendance at educational institutions. This changed in 2009 when
specic questions on ECD facilities were introduced for children aged 0-4 years. Trends are therefore reported
only for the years 2009 to 2015.
42 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
District Tables
District name Province District code Households with
children under 6
(CS 2016)
Inadequate water
(no piped water
on site)
(CS 2016)
Inadequate sani-
tation (no ush or
VIP on site)
(CS 2016)
IP early neo
death rate
(DHIS 2015)
ANC 1st visit
<20 w rate
(DHIS 2015)
VitA 12-59
mm cov yy
(DHIS 2015)
Imm cov
<1 yy
(DHIS 2015)
Alfred Nzo EC DC44 70 784 87.4 70.9 6.5 42.8 63.1 81.5
Amajuba KZN DC25 40 981 13.7 29.8 10.4 58.5 52.7 80.9
Amathole EC DC12 56 644 79.1 54.9 7.7 67.1 91.5 98.8
Bojanala NW DC37 156 986 35.3 55.2 8.6 56.3 45.4 76.6
Bualo City EC BUF 62 552 29.2 24.2 12.5 59.0 58.9 92.5
Cape Town WC CPT 287 955 11.8 12.5 7.0 63.8 41.7 93.7
Cape Winelands WC DC2 60 501 11.9 13.5 8.0 73.6 54.1 79.0
Capricorn LP DC35 124 737 39.0 72.8 22.0 56.5 48.0 74.0
Central Karoo WC DC5 6 566 2.2 4.5 9.2 73.3 54.9 76.9
Chris Hani EC DC13 51 764 59.4 31.0 9.4 67.3 67.8 85.3
Dr K Kaunda NW DC40 71 241 8.1 4.7 9.0 69.5 57.4 89.8
Eden WC DC4 41 932 6.1 7.9 7.0 76.9 84.9 91.0
Ehlanzeni MP DC32 168 842 41.4 71.4 9.2 71.7 54.1 90.8
Ekurhuleni GT EKU 282 701 9.9 10.3 9.6 54.9 66.7 114.5
eThekwini KZN ETH 209 533 17.1 22.2 12.4 63.8 67.9 97.6
Fezile Dabi KZN DC20 50 834 6.6 19.1 14.7 58.0 55.0 71.3
Frances Baard NC DC9 35 207 13.4 12.4 15.8 62.9 52.8 84.1
Gert Sibande KZN DC30 102 382 19.2 26.1 10.3 56.0 44.1 80.2
Harry Gwala KZN DC43 39 152 73.1 44.1 10.9 64.6 64.2 68.5
iLembe KZN DC29 63 894 64.7 53.7 11.7 65.9 74.3 77.6
Joe Gqabi EC DC14 25 309 56.9 36.0 11.4 57.0 53.1 80.2
Johannesburg GT JHB 420 999 6.4 7.2 9.8 52.1 59.4 105.7
JT Gaetsewe NC DC45 27 853 65.6 58.5 15.6 57.3 50.9 96.7
Lejweleputswa FS DC18 66 441 5.9 14.5 11.9 63.5 82.0 109.1
Mangaung FS MAN 65 001 10.3 22.5 12.5 62.7 41.7 74.6
Mopani LP DC33 125 266 56.6 72.0 10.1 63.3 57.5 88.7
N Mandela Bay EC NMA 85 745 6.2 6.1 13.9 61.5 52.3 80.0
Namakwa NC DC6 9 318 3.9 11.8 9.6 73.9 45.4 61.1
Nkangala MP DC31 121 314 17.0 42.5 8.6 63.9 52.7 87.0
NM Molema NW DC38 88 539 56.1 61.0 10.8 61.2 59.0 88.7
OR Tambo EC DC15 102 110 88.0 46.6 18.1 60.1 59.6 88.9
Overberg WC DC3 22 174 9.5 10.7 10.3 78.7 54.9 86.7
Pixley ka Seme NC DC7 18 894 11.5 14.3 6.9 67.0 37.4 77.7
RS Mompati NW DC39 43 265 64.3 30.3 11.9 62.6 59.8 87.1
S Baartman EC DC10 33 919 12.0 12.6 10.8 69.0 58.2 80.1
Sedibeng GT DC42 87 739 6.6 6.7 7.1 65.3 71.4 112.5
Sekhukhune MP DC47 112 412 69.0 90.6 8.5 59.2 51.1 74.4
T Mofutsanyana FS DC19 76 828 13.4 35.0 5.5 63.0 61.1 88.8
Tshwane GT TSH 277 289 10.2 21.6 10.0 55.0 45.7 97.6
Ugu KZN DC21 51 026 78.3 60.8 8.7 65.8 58.0 82.9
uMgungundlovu KZN DC22 77 559 24.9 35.1 10.3 68.7 56.0 72.9
uMkhanyakude KZN DC27 56 450 73.7 56.9 7.3 66.4 62.4 87.5
uMzinyathi KZN DC24 47 391 69.7 60.5 12.0 68.4 71.2 92.2
uThukela KZN DC23 60 545 52.5 41.1 8.3 61.3 83.6 84.7
uThungulu KZN DC28 76 715 40.2 42.4 14.0 63.1 54.5 81.5
Vhembe LP DC34 146 683 61.5 74.7 9.4 63.5 52.2 88.3
Waterberg LP DC36 62 308 37.2 45.2 13.5 61.0 37.9 66.7
West Coast WC DC1 38 032 5.4 6.4 7.6 72.3 50.1 82.5
West Rand GT DC48 75 537 18.3 14.0 8.3 61.6 64.8 107.2
Xhariep FS DC16 12 886 8.2 8.2 2.7 75.3 94.4 123.2
ZF Mgcawu NC DC8 21 676 11.3 17.8 17.0 61.0 41.8 82.1
Zululand KZN DC26 64 969 54.3 44.3 7.3 67.0 54.7 78.1
District name Province District code PCR test coverage within
7 days of birth (of live
births to HIV+ women)
(DHIS 2015)
Delivery in
facility rate
(DHIS 2015)
Live birth
under 2500g
in facility rate
(DHIS 2015)
Biological
mother is
co-resident
(CS 2016)
Children 0-2 years
attending any ECD
or educational insti-
tution (CS 2016)
Children 3-5 years
attending any ECD
or educational insti-
tution (CS 2016)
Alfred Nzo EC DC44 33.8 55.6 9.7 64.7 5.4 71.4
Amajuba KZN DC25 84.5 69.0 14.9 76.0 11.5 65.0
Amathole EC DC12 63.7 47.4 9.3 58.6 14.4 76.0
Bojanala NW DC37 57.9 60.2 13.2 86.6 14.2 69.2
Bualo City EC BUF 62.1 105.9 14.6 77.6 25.1 86.9
Cape Town WC CPT 30.1 93.5 14.2 90.4 24.1 72.5
Cape Winelands WC DC2 89.4 15.2 90.1 22.1 65.2
Capricorn LP DC35 65.9 84.3 12.5 75.7 22.8 85.5
Central Karoo WC DC5 70.6 21.1 83.9 9.5 64.4
Chris Hani EC DC13 53.6 66.5 13.7 62.1 15.9 75.4
Dr K Kaunda NW DC40 81.9 94.1 15.3 87.5 18.6 73.1
Eden WC DC4 85.4 16.2 89.8 24.2 77.1
Ehlanzeni MP DC32 58.8 87.0 12.0 80.3 12.2 71.4
Ekurhuleni GT EKU 66.0 116.5 12.6 89.3 25.3 75.0
eThekwini KZN ETH 76.6 92.4 11.5 85.0 13.1 63.3
Fezile Dabi KZN DC20 46.2 77.7 11.6 85.3 24.8 76.8
Frances Baard NC DC9 77.9 110.6 21.6 86.5 16.3 75.9
Gert Sibande KZN DC30 56.6 81.8 10.5 79.6 12.0 67.3
Harry Gwala KZN DC43 73.1 61.7 9.5 69.2 6.1 61.3
iLembe KZN DC29 84.6 70.7 11.6 74.2 8.0 60.0
Joe Gqabi EC DC14 55.0 64.3 13.1 67.1 11.7 71.8
Johannesburg GT JHB 70.3 82.4 13.2 89.8 24.8 76.9
JT Gaetsewe NC DC45 42.0 85.5 12.6 82.4 11.3 74.2
Lejweleputswa FS DC18 32.2 102.9 13.0 83.8 20.9 74.5
Mangaung FS MAN 82.2 93.0 12.6 85.6 22.7 78.2
Mopani LP DC33 62.2 104.7 10.2 78.3 15.5 80.2
N Mandela Bay EC NMA 70.0 103.5 16.9 87.1 21.5 74.1
Namakwa NC DC6 61.5 62.9 19.7 86.9 7.7 59.4
Nkangala MP DC31 69.8 84.1 13.7 83.1 15.9 71.3
NM Molema NW DC38 65.0 68.5 13.5 78.8 11.2 69.4
OR Tambo EC DC15 24.5 81.5 14.5 65.6 6.5 67.3
Overberg WC DC3 65.4 12.9 91.4 21.5 66.0
Pixley ka Seme NC DC7 65.4 71.1 24.2 81.8 9.0 61.8
RS Mompati NW DC39 86.2 85.5 16.5 76.4 11.1 70.2
S Baartman EC DC10 81.4 72.8 17.3 82.0 15.7 76.7
Sedibeng GT DC42 71.1 102.1 13.1 88.1 34.0 84.3
Sekhukhune MP DC47 45.8 95.0 9.0 77.1 12.3 79.3
T Mofutsanyana FS DC19 54.8 87.5 11.6 77.4 29.0 84.3
Tshwane GT TSH 78.8 92.1 12.8 91.9 25.2 77.2
Ugu KZN DC21 86.7 73.2 11.9 70.9 9.4 61.4
uMgungundlovu KZN DC22 96.6 83.4 14.8 77.2 13.9 69.2
uMkhanyakude KZN DC27 90.0 81.2 10.3 70.0 13.6 66.8
uMzinyathi KZN DC24 90.6 76.8 9.1 72.0 6.3 60.1
uThukela KZN DC23 92.1 68.3 12.3 73.3 9.7 67.2
uThungulu KZN DC28 73.0 79.8 13.2 68.1 8.2 61.4
Vhembe LP DC34 74.2 93.3 8.8 76.8 14.3 73.9
Waterberg LP DC36 58.3 78.0 12.1 82.1 21.1 77.9
West Coast WC DC1 66.2 13.6 91.9 13.3 62.2
West Rand GT DC48 75.4 107.6 13.4 88.0 22.9 75.0
Xhariep FS DC16 84.4 45.1 13.3 76.4 16.9 76.8
ZF Mgcawu NC DC8 48.0 82.7 19.9 87.4 8.5 50.3
Zululand KZN DC26 81.7 71.4 8.9 66.3 8.1 63.3
DISTRICT TABLES
43
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Notes on the data
and data sources
44 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Key Data source Year
reported Frequency Lowest level
a
Stascs South Africa: General Household Survey (GHS). Data analysed by Children’s
Instute, University of Cape Town. (also see www.childrencount.ci.org.za for more
indicators)
2015 Annual Province
bDepartment of Health: Naonal HIV and Syphilis Prevalence Survey
(hp://www.health.gov.za/docs/reports/2013/report2014.pdf) 2013 Annual Province
c
Department of Health: District Health Informaon System.
Published by Health Systems Trust
(hp://www.hst.org.za/content/health-indicators)
2015/16 Annual District
d
Medical Research Council Burden of Disease Unit (2016):
Rapid Mortality Surveillance Report 2015
(hp://www.mrc.ac.za/bod/RapidMortalitySurveillanceReport2015.pdf)
2015 - Naonal
e
HSRC (2013). The South African Naonal Health & Nutrion Examinaon Survey
(SANHANES-1)
(hp://www.hsrc.ac.za/en/research-outputs/view/6493)
2012 -Naonal
(some prov)
f
SALDRU: Naonal Income Dynamics Study (NIDS) – Wave 1, 2008 and Wave 4, 2014.
Data analysed by Children’s Instute, University of Cape Town
(see hp://www.nids.uct.ac.za/ for more about NIDS)
2008
2014/15
2-yearly
(panel) Naonal
g
Goga, A.E., Jackson, D.J., Singh, M., Lombard, C. for the SAPMTCTE study group (2015).
Early (4-8 weeks postpartum) Populaon-level Eecveness of WHO PMTCT Opon A,
South Africa, 2012-2013. South African Medical Research Council & Naonal Department
of Health
(hp://www.mrc.ac.za/healthsystems/SAPMTCTEReport2012.pdf )
2012/13 - Province
hStascs South Africa: Recorded Live Births
(hp://beta2.statssa.gov.za/publicaons/P0305/P03052015.pdf ) 2015 Annual Naonal
ISouth African Social Security Agency SOCPEN data extracted by special request
(see hp://www.childrencount.ci.org.za/social_grants.php for grant updates) 2016 - Province
The data provided in this review are drawn from a range of sources, many of which can be updated annually.
Data sources for the indicators are indicated by the letter keys to the right of the statistical tables.
Primary level
maternal and
child health
Population:
• Number of infants
• Children <6 access to clinics
• HIV prevalence in pregnant women
Service delivery/access:
• Prenatal early booking and HAART
• Early infant HIV test
• Immunisation
• Delivery rate in facility
Outcome:
• Early neonatal mortality
• Infant mortality rate
Nutritional
support
Support for primary
caregivers
Population:
• Maternal care
Service delivery/
access:
• Breastfeeding
education
• Postnatal
follow-up
Social services
and income
support
Service delivery/access:
• Birth registration
• Access to Child Support Grant
• Child Support Grant uptake
in children <6
• Child Support Grant uptake
in infants
Stimulation for
early learning
Population:
• Children aged 0-2
• Children aged 3-5
Service delivery/access:
• Percentage of children
aged 0-2 reported to attend
an early learning programme
• Percentage of children aged
3-5 reported to attend an
early learning programme
• No access to early
learning programme
Key indicators for
early childhood
development in
South Africa
45
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Population:
• VitaminAdeciencyinwomen
• Anaemia in women
• Low birth weight
• Child hunger
Service delivery/access:
• Breastfeeding
• Vitamin A coverage in children
12-59months
Outcome:
• VitaminAdeciencyinchildren
• Anaemia in children
• Stunting
• Wasting
• Underweight
• Overweight
Contributors
46 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
Lizette Berry is a senior
researcher at the Children’s Institute at
the University of Cape Town. She holds a
Master of Social Science specialising in
social policy and management. Berry has
more than 15 years’ experience in child
policy research and has a background
in social work. She has an interest in
the care and development of children;
and contributed to a Southern African
Development Community education
policy framework, which promotes learner
care and support. She also contributed to
the Department of Social Development’s
White Paper on Families and the National
ECD Policy and Programme. Berry was
the lead editor of the
South African Child
Gauge
2013, focused on ECD services.
Colin Almeleh is the Executive
Director of Ilifa Labantwana, a national
programme working to secure an equal
start for all children living in South Africa,
through universal access to quality
early childhood development. Almeleh
has extensive experience working with
governments and development agencies,
having worked for the Children’s Investment
Fund Foundation and Absolute Return
for Kids on maternal, newborn and child
health projects throughout Sub-Saharan
Africa. He holds a PhD in Sociology, a
BSoSci Hons in Social Anthropology, and a
BSc in Electrical Engineering. Almeleh is a
past Fox Fellow at Yale University.
Sonja Giese is Executive Director
of Innovation Edge, a grant and investment
fund focused on unconventional ideas that
find solutions to early childhood care and
education challenges in under-resourced
communities. Over the past 20 years, Giese
has been involved in a number of successful
start-up ventures in the development
space, all focused on improving child
outcomes through combining practical
service delivery experience with policy
and systems reform. She has a Bachelor
of Science and Honours degrees from the
University of Cape Town.
47
SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
CONTRIBUTORS
Katharine Hall is a senior
researcher at the Children’s Institute, a
policy research unit at the University of Cape
Town (UCT). She has a PhD in Development
Theory and Policy. Her work is in the area of
child poverty, inequality and social policy.
She co-ordinates the Institute’s Children
Count indicator project, which analyses
national household survey data to monitor
a variety of indicators related to child
poverty, development and well-being. Her
work has examined the targeting of poverty
alleviation programmes, particularly in
relation to social assistance. Hall has
worked extensively on household form and
care arrangements for children. She has a
strong interest in housing policy and urban
migration, and their implications for child
care and household formation. She is a
member of the standing committee of the
International Society for Child Indicators
and UCT’s Poverty and Inequality Initiative.
Kefiloe Masiteng is the Deputy
Secretary for National Planning in the
Department of Planning, Monitoring and
Evaluation. Prior, she served as Deputy
Director General at Statistics South Africa for
11 years and was responsible for population
and social statistics. Masiteng has also
worked as Chief Director in the Presidency
Policy Coordination and Advisory Services,
where she was responsible for governance
and administration, and conceptualised
the government-wide monitoring and
evaluation system. She has also worked in
the Departments of Housing and Health,
where she was responsible for monitoring
and evaluation. Dr Masiteng has a PhD
from the School of Governance at Wits, a
Masters in Public Health from University
of Pretoria, and a Batchelor of Science
Honours from Wits.
Winnie Sambu is a researcher
at the Children’s Institute at the University
of Cape Town. She holds a Master of
Economics from the University of the
Western Cape and a Master of Arts,
specialising in development management,
from Ruhr-Universität Bochum. She is
an expert in data analysis, focusing on
large household survey data to produce
statistics for child-centred indicators
used to monitor achievement of socio-
economic rights for children in South
Africa. These indicators are monitored
through the Children Count project (www.
childrencount.net) and are published in the
South African Child Gauge
on an annual
basis. Sambu’s research interests include
poverty and inequality, food security,
and household living conditions. Sambu
has also been involved in other research
projects within the Children’s Institute, co-
authoring publications on early childhood
development (
South Africa Early Childhood
Review
) as well as child protection.
Notes
48 SOUTH AFRICAN EARLY CHILDHOOD REVIEW 2017
The South African Early Childhood Review 2017
is an annual publication, which presents infor-
mation on the essential components of the comprehensive package of early childhood develop-
ment services. This review includes data and commentary on over 40 carefully selected indica-
tors on the status of children under six, as well as service delivery progress across ve domains.
The South African Early Childhood Review 2017
is a joint publication between Ilifa Labantwana,
the Children’s Institute at the University of Cape Town, the Department of Planning, Monitoring and
Evaluation in the Presidency, and Innovation Edge.
A note on this publication
Nutritional
support
Primary level
maternal and child
health
Stimulation for
early learning
Social services
and income
support
Support for primary
caregivers
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.za
www.childrencount.uct.ac.za
TheDepartmentofPlanning,MonitoringandEvaluationinthePresidencywascreatedtofacilitate,inuenceandsupport
eectiveplanning,monitoringandevaluationofgovernmentprogrammesaimedatimprovingservicedelivery,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-
alideasthatndsolutionstoearlychildhoodcareandeducationchallengesinunder-resourcedcommunities.
www.innovationedge.org.za