Stories of Challenge in South Africa: changes in the enabling environment for nutrition among young children (1994–2021)

Abstract

Despite important nutrition-related policy and programmatic improvements in South Africa, rates of stunting among young children remain unacceptably high, while rates of overweight and obesity in this same population group are simultaneously on the rise. This study sought to examine the changes in the enabling environment for nutrition aimed at young children in South Africa by drawing on a literature review, policy mapping, and stakeholder interviews, for the time period from the end of apartheid in 1994 to 2021. The study focuses on changes and drivers of change at national level but also in three provinces: Western Cape, North West, and KwaZulu-Natal. The study ultimately seeks to better understand the changes and challenges with regards to policy and commitment to nutrition, coordination structures at various levels, and how these led to or did not lead to implementation and impact in these provinces. The study ends with reflections on what these findings mean for food and nutrition security in South Africa going forward, as well as what they might mean for other countries with similar contexts.

Full text

Vol.:(0123456789)
1 3
Food Security
https://doi.org/10.1007/s12571-023-01396-y
ORIGINALPAPER
Stories ofChallenge inSouth Africa: changes intheenabling
environment fornutrition amongyoung children (1994–2021)
ScottDrimie1 · MaravandenBold2 · LisanneduPlessis1 · LauraCasu3
Received: 30 May 2022 / Accepted: 18 August 2023
© The Author(s) 2023
Abstract
Despite important nutrition-related policy and programmatic improvements in South Africa, rates of stunting among young
children remain unacceptably high, while rates of overweight and obesity in this same population group are simultaneously
on the rise. This study sought to examine the changes in the enabling environment for nutrition aimed at young children in
South Africa by drawing on a literature review, policy mapping, and stakeholder interviews, for the time period from the
end of apartheid in 1994 to 2021. The study focuses on changes and drivers of change at national level but also in three
provinces: Western Cape, North West, and KwaZulu-Natal. The study ultimately seeks to better understand the changes and
challenges with regards to policy and commitment to nutrition, coordination structures at various levels, and how these led
to or did not lead to implementation and impact in these provinces. The study ends with reflections on what these findings
mean for food and nutrition security in South Africa going forward, as well as what they might mean for other countries
with similar contexts.
Keywords Malnutrition· Policy· South Africa· Enabling Environment· Food and Nutrition Security· Children
1 Introduction
Over the past decade or so, nutrition has gained extraordinary
attention on the world stage. In 2012, as part of an
international effort to end malnutrition, the World Health
Assembly (WHA) outlined ten nutrition targets to be achieved
by 2025. Nutrition was subsequently explicitly included in
the Sustainable Development Goals (SDGs) for 2030, and a
plethora of research, funding, initiatives, and events has taken
place since to raise awareness about the issue (Development
Initiatives, 2020; McGuire, 2015). However, despite many
countries having developed nutrition-related policies or
interventions, no country is on track to meet the WHA
targets, stunting rates among young children (defined in this
paper as those under five years old) remain high (particularly
in Africa and Asia), and many countries are starting to
experience multiple malnutrition burdens, i.e. both high rates
of undernutrition along with rising prevalence of overweight
and obesity (Development Initiatives, 2020).
While what is needed to reduce malnutrition is clear
– nutrition-specific and nutrition-sensitive interventions,1
implemented at scale, and sustained over time – less is
known about the “enabling environments” that are founda-
tional for building political momentum and converting this
momentum into results on the ground (Gillespie etal., 2013;
Ruel & Alderman, 2013). Given the disappointing global
progress on malnutrition goals, in addition to the fallout
of the Covid-19 pandemic, it is important to examine how
enabling environments can be improved in contexts where
malnutrition continues to exist.
* Scott Drimie
scottdrimie@mweb.co.za
1 Division ofHuman Nutrition, Department ofGlobal Health,
Faculty ofMedicine andHealth Sciences, Stellenbosch
University, Stellenbosch, SouthAfrica
2 Graduate School ofGeography, Clark University, Worcester,
USA
3 University College London, andResearch Consultant,
Institute ofDevelopment Studies andInternational Food
Policy Research Institute, London, England
1 Nutrition-specific interventions address the immediate causes of
undernutrition, such as inadequate dietary intake or disease, whereas
nutrition-sensitive interventions address the underlying causes of
malnutrition, such as household food insecurity, inadequate care prac-
tices, lack of health services, and unhealthy household conditions
(Ruel & Alderman, 2013).

S.Drimie et al.
1 3
In order to improve nutrition outcomes among young chil-
dren, South Africa has implemented a wide range of nutri-
tion-specific and nutrition-sensitive policies and programmes
since the early 1990s. Despite progress on reducing wasting
and undernutrition, South Africa’s stunting rate has remained
stubbornly high and rates of overweight and obesity have
increased over the past two decades. Stunting among children
under five stands at ~ 27% (30% of boys, 25% of girls) (NDoH
etal., 2017), a rate that is “exceptionally high” for a country
with one of the biggest economies in sub-Saharan Africa, and
falls far short of successes achieved in several other low- and
middle-income nations (May etal., 2020; Micha etal., 2020)
(Table1).2
The position of South Africa’s double burden of malnutri-
tion also reflects poor performance relative to global trends
and other middle-income countries (May etal., 2020). The
South Africa Demographic and Health Survey (SADHS) in
2016 found that 13% of under-five children were overweight
or obese (NDoH etal., 2017). Furthermore, for children
between 5 and 19years of age, overweight and obesity have
steadily increased since the early 2000s and were projected
to be around 35% for girls and 26% for boys in 2019 (Devel-
opment Initiatives, 2022). Overnutrition increased with age
with a strong gender bias emerging in late teens (aged 15–19),
where 8.6% of young men and 26.8% of young women were
overweight or obese. Prevalence of overweight and obesity
among all women increased over time, from 56% in 1998 to
68% in 2016, with the highest rates of overweight and obesity
(81–82%) in women aged 45 – 60years (NDoH etal., 2017).
Obesity and stunting are linked in South Africa and found in
the same households – at least one obese adult is found in 45
percent of households with a stunted child (FAO etal.,2022).
The risk of becoming overweight or obese has been connected
to previous nutritional status, with stunted children having
twice the likelihood of being overweight as children of aver-
age height (Steyn etal., 2005).
An effective response to this situation would have substan-
tial social and economic returns (Ruel & Alderman, 2013).
Yet, little is known about why the numerous policies and
programmes developed to improve nutrition in South Africa
have not resulted in expected impacts on the ground. Using
a mixed qualitative approach, the paper focuses on the ques-
tion of why, despite nearly three decades of nutrition-related
policy development and programme implementation, there has
been insufficient progress on improving nutrition outcomes
among young children in South Africa, particularly in terms of
stunting and overweight and obesity. It does this by examining
changes in the enabling environment for nutrition, focusing
on issues of political commitment, agenda-setting, and policy
coherence with attention to broader political-economic dynam-
ics. The focus is primarily at national-level with in-depth anal-
ysis of the three provinces of KwaZulu-Natal, Western Cape,
and North West to enable specific issues to emerge.
The study is part of the Stories of Challenge in Nutri-
tion research initiative (2019–2021), which was led by the
International Food Policy Research Institute (IFPRI) and
carried out with country partners. The initiative sought to
investigate drivers of political attention to and action on
the multiple burdens in nutrition, in order to foster learning
across contexts and inform policy and programme develop-
ment (Gillespie etal., 2021).3
The paper proceeds as follows. Section 2 discusses
the framework on an enabling environment for nutrition,
which was used to guide the design of the study. Sec-
tion3describes the study setting and the methods used for
this research. Section4examines the findings of the study,
Table 1 Changes in young child
nutrition outcomes (1998 –
2016) (%)
Source: May etal. (2020)
Indicator NFCS 1999
1–9 yrs SADHS 2003
< 5 yrs NFCS-FB 2005
1–9 yrs SANHANES 2012
< 5yrs SADHS 2016
< 5 yrs
Wasting 3.7 5.2 4.5 2.9 2.5
Underweight 10.3 11.5 9.3 5.8 6
Stunting 25.5
(1-3yrs)
27.4 23.4
(1-3yrs)
26.5
(1-3yrs)
27
(< 5yrs)
Overweight 12.4 Not reported 10.6 16.5 (girls)
11.5 (boys)
13.3
Obesity 6.6 Not reported 4.8 7.1 (girls)
4.7 (boys)
Not reported
2 However, because the South Africa Demographic and Health Sur-
vey sample size is limited, confidence intervals are broad when data
is disaggregated to lower levels, particularly in regions with small
populations, such as the Northern Cape.
3 The studies carried out as part of this latest initiative are being pub-
lished as part of a topical collection in Food Security (found here:
https:// link. sprin ger. com/ journ al/ 12571/ topic alCol lecti on/ AC_
92bea 28647 14a58 198b2 8b3ed 88640 49). These papers build on a
‘first wave’ of similar studies carried out between 2015 and 2017 that
were published in a Special Issue of Global Food Security in 2017
(Gillespie etal., 2017).

Stories of Challenge in nutrition: the case of South Africa
1 3
with a focus on the enabling environment domains of knowl-
edge and evidence, politics and governance, and capacity
and financial resources. Section5 discusses what these
findings mean for addressing nutrition challenges in South
Africa and how broader lessons learned from this study are
relevant for other contexts. The last section concludes.
2 An enabling environment fornutrition
Conceptualisation of the study, along with data collection
and analysis is informed by Gillespie etal.’s (2013) frame-
work of an “enabling environment” for nutrition, defined
as “the political and policy processes that build and sus-
tain momentum for the effective implementation of actions
that reduce undernutrition” (Gillespie etal., 2013, p. 553)
(Table2). While evidence on causes of malnutrition as well
as the appropriate nutrition-specific and nutrition-sensitive
interventions to address them is well-established, the politics
around nutrition issues and the way in which policies are
developed and translated into actual implementation on the
ground has been less straightforward and has become an
important area of research.
The framework draws on existing evidence to identify
three domains that are important for creating and sustaining
momentum on nutrition and for translating this momentum
into impact. These domains informed the design of inter-
view guides as well as the codebooks used for analysis of
interviews, in order to assess the enabling environment for
nutrition in South Africa.4
3 Methodology
3.1 Study setting
The study focused on examining changes in the enabling
environment for nutrition by focusing on national level pol-
icy dynamics, as well as examining these at provincial level
through a more in-depth focus on three provinces: Western
Cape, North West and KwaZulu-Natal (Fig.1).
These provinces were selected based on a diversity of
nutrition outcomes, risk factors, policy emphasis and gov-
ernance arrangements. North West and the Western Cape
were chosen because of high levels of young child malnu-
trition, child poverty and hunger rates along with differ-
ing governance arrangements, with KwaZulu-Natal being
added at the request of the National Department of Health
because of a perception that the provincial government had
handled nutrition in an innovative inter-sectoral manner
(Fig.2).
Child hunger rates are highest in the North West and
KwaZulu-Natal provinces, affecting 19 percent and 18
percent of children, respectively, according to an analysis
of child hunger rates within provinces (May etal., 2020).
Poverty rates across provinces differ significantly. The child
poverty rate in KwaZulu-Natal is 71 percent whilst the low-
est child poverty rates are in Gauteng and the Western Cape,
with 40% and 23%, respectively (May etal., 2020). Child
poverty is still most prevalent in the former homelands'
rural areas, such as KwaZulu-Natal and North West, where
81 percent of children live in poverty. According to 2016
figures, the Western Cape experienced relatively high rates
of hunger (12% of households), despite being a relatively
wealthy province in comparison to the others. This may be
Table 2 Enabling environment framework for nutrition
Source: Gillespie etal. (2013)
Issues and challenges for creating and sustaining momentum Issues and challenges for converting momentum into results
Framing, generation, and communication of knowledge and evidence
• Framing and narratives
• Evidence of outcomes and benefits
• What works and how well do nutrition interventions work relative to others?
• Advocacy to increase priority (civil society)
• Evidence of coverage, scale, quality
• Implementation research (what works, why, and how?)
• Programme evaluation (impact pathways)
• Generation of demand for evidence of effectiveness
Political economy of stakeholders, ideas, and interests
• Incentivising and delivering horizontal coherence (multisectoral
coordination)
• Development of accountability to citizens
• Enabling and incentivising positive contributions from the private sector
• Delivery of vertical coherence
• The role of civil society and the private sector in delivery
Capacity (individual, organisational, systemic) and financial resources
• Leadership and championing
• Systemic and strategic capacity
• Making the case for additional resource mobilisation
• Delivery and operational capacity
• New forms of resource mobilisation
• Prioritisation and sequencing of nutrition action
• Implementation and scale-up
4 Interview guides and codebooks used for analysis are available
upon request.

S.Drimie et al.
1 3
a result of the high rates of poverty in urban slum regions
and the low levels of agricultural activities among provincial
households. This was despite having some of the highest
consumption levels across all food groups with fruit con-
sumption being the highest in the Western Cape, where 46%
of households reported consumption, and spending on veg-
etables was 50% higher than the national average (Omotayo
etal., 2019).
3.2 Data collection andanalysis
Research for this study was carried out between May 2019
and February 2021. The study covered the time period
from 1994 to 2021; 1994 was chosen as the starting point
as this was the year of South Africa’s first democratic
election after the end of apartheid, initiating significant
changes in policy in the country. Data collection relied on
a mixed qualitative approach, as follows:
1. Tracking change in young child nutrition outcomes.
To track young child nutrition outcomes over time
at national and provincial level, we relied primarily
on the recent Child Gauge report (May etal., 2020),
which examines data from different national surveys
since 1998.
2. Review of existing literature: A literature review (a
review of reviews) was carried out to identify existing
research on how policies to address malnutrition and
related comorbidities have been ratified and/or enacted
in the post-apartheid period (see Hagen-Zanker &
Mallett, 2013). The review focused on peer-reviewed
published research on undernutrition (particularly
stunting) and overweight/obesity in South Africa from
1994 onwards, at national and at provincial level (see
Appendix A for the search strategy and study evaluation
criteria).5 Ultimately, information was reviewed from
117 reviews.
3. Policy mapping: A rapid policy mapping exercise was
carried out to develop a comprehensive overview of
nutrition-relevant policy in South Africa from 1994 to
2021, as well as ongoing policy in Western Cape, North
West, and KwaZulu-Natal provinces. This search was
Fig. 1 Map of South Africa’s
provinces. Source: Map of
South Africa - Bing images:
5fc81 53f06 66651 0cee7 b99e8
54074 87. jpg (583 × 625) (pin-
img. com)
5 The intention is to publish this literature review separately; we draw
on it here specifically to provide data for the analysis of the three
domains of the enabling environment.

Stories of Challenge in nutrition: the case of South Africa
1 3
intended to complement information on policy retrieved
through the literature review, which produced fewer
results for the subnational level. The mapping was car-
ried out by searching identified institutional websites,
such as, e.g., the government of South Africa. Strategic
goals identified through the targeted search for nutri-
tion-relevant policies in each of the three provinces were
mapped against strategic goals in key national policy
and against Sustainable Development Goals. Further
insights on policy at both national and subnational level
were sought through semi-structured interviews and
stakeholder consultations.
4. Semi-structured interviews and stakeholder consulta-
tions: Two rounds of interviews were held. As part of
the first round, fourteen key informants were selected
representing civil society, academia, research and the
private sector. Apart from the first two, all interviews
were conducted virtually as a direct result of Covid-19
restrictions. These interviews focused on the challenges
of translating nutrition-relevant policies into impact on
nutrition outcomes, in South Africa broadly but also in
specific provinces. Interviews allowed for a detailed evo-
lution of policy to emerge and brought out stakeholder
perceptions on key challenges to young child nutrition in
Fig. 2 Study selection diagram

S.Drimie et al.
1 3
South Africa from the time of the democratic transition
to a more recent broader systemic approach focused on
food systems, food environments and social-ecological
systems (Table3). A (virtual) consultation workshop
was subsequently held on 14 October 2020, midway
through the study, to review findings and inform the
remainder of the study. The second round of nineteen
interviews went into further depth and hence this time
included government representatives. These interviews
focused on implementation of policy, drawing in senior
officials overseeing various policies at national level
and officials charged with overseeing the translation
and implementation of these policies at provincial level
(Table3). A second (virtual) consultation/validation was
held with key stakeholders on 17 March 2021 to review
findings and finalise recommendations (SoChall, 2021).
Interviews were audio recorded and transcribed ver-
batim. Transcripts were reviewed and an initial cod-
ing was undertaken using themes framing the enabling
environment, namely knowledge and evidence, politi-
cal commitment, role of change leaders or champions,
coherence, capacity to act, opportunities and barriers
to change and sustainability . These were expanded to
cover the “evolution of policy 1994-2021; critique of the
enabling environment” and “new agendas” in nutrition”.
The enabling environment framework was also used to
triangulate data from the different data collection activities.
Findings were distinguished by framework domain (knowl-
edge and evidence; political economy of stakeholders, ideas,
and interest; capacity and financial resources) and accord-
ing to “creating and sustaining momentum” and “converting
momentum into results”, and written up and synthesized in
narrative form.
The Health Research Ethics Committee of Stellenbosch
University approved the research (Ref nr: N19/10/130).
Participation in interviews and workshops were voluntary.
Informed consent forms (ICF) were completed before all
interviews. Workshop participation provided informed
consent via the online platforms. Permission to record all
interviews and workshop proceedings were requested from
all participants.
4 Results
Findings from the data collection activities are discussed
in accordance with the enabling environment framework
domains on knowledge and evidence, politics and govern-
ance, and capacity and financial resources. Throughout,
the voices of the respondents have been elevated to provide
unique perspectives of the challenges facing nutrition and
how best to address these.
4.1 The enabling environment fornutrition
inSouth Africa
4.1.1 Framing, generating, andcommunicating knowledge
andevidence
Framing the policy agenda In terms of the policy response
in post-apartheid South Africa, national strategies and pro-
grammes across sectors have declared food security a pri-
ority for all citizens (Hendriks, 2014). The South African
government and partners have thus taken various steps to
address the nutrition challenge with a clear trajectory for
nutrition- and health-sensitive policy since 1994, which
appears to be growing in momentum (WHO,2020). A key
finding from the literature and policy reviews, and later sub-
stantiated by key informant interviews, is the positive exam-
ple that South Africa provides for the African continent in
developing a policy response to malnutrition.
Despite impressive policy development, however, a review
of the literature revealed that these efforts have not trans-
lated into the intended improvements in nutrition, an issue
reiterated by many key informants. The breadth of these
policies is depicted in the World Health Organisation,
Global database on the Implementation of Nutrition Action
(GINA) (who. int).
The failure to reach the intended improvements in mal-
nutrition suggests that these policies and programmes have
been poorly implemented, or that inequality and poverty
have diminished the impact (Jonah etal., 2018). The lit-
erature review found that in some cases, the policy docu-
ments lacked detail, particularly in adequately contextualis-
ing and diagnosing the underlying issues and appropriate
Table 3 Summary of interviews
Type of interviewee No. of interviews
National-level Provincial-
level
Key informant interviews
(Nov 2019 – Oct 2020)
Academia 6
Civil society 5
Private sector 2
United Nations 1
Semi-structured interviews
(Nov 2020 – March 2021)
Government departments 7 9
Academia 2
Civil society 1
Total 22 11

Stories of Challenge in nutrition: the case of South Africa
1 3
responses. To place these policies in context, the literature
review highlighted poverty as a key underlying driver of
malnutrition, which is in turn driven by the high unemploy-
ment and low levels of income for many who are employed,
particularly women.
The need for more and better nutrition data on which
to base policy and programmes became a core tenet of
nutrition programming in South Africa since 1994. In the
early 2000s, a dearth of data on food and nutrition security
existed (see Hendriks, 2005). Subsequently a number of
national surveys and case studies were undertaken that
shed light on the nutritional status of South Africans (Rose
& Charlton, 2002; Bourne etal., 2007; Labadarios etal.,
2011; Iversen etal., 2011). However, as Labadarios etal.
(2011) highlight, the findings from these datasets differ and
so a food security‐specific national survey was initiated.
In 2012, the SANHANES‐1 (first South African National
Health and Nutrition Examination Survey) aimed to rectify
this gap and provided a comprehensive snapshot of food
and nutrition security in South Africa (Pereira, 2014).
Following these national surveys, various recommendations
from survey reports were implemented, notably the Vitamin
A supplementation programme and the Food Fortification
programme (Ac3). These reports provided important
evidence to inform policy formulation by a broader range
of stakeholders.
Framing new agendas: food environments and food‑
scapes Research respondents from across sectors indicated
that the nutrition challenge needed to be framed in the future
beyond the emphasis on undernutrition, to an overt recogni-
tion of obesogenic food environments. Evidence from key
respondents highlighted the concept of food environments as
determinants of overweight, obesity and non-communicable
diseases (NCDs) due to the prevalence of highly processed,
high energy, low nutrient foods (NGO2), and as a key issue
that was not well articulated within policy (Ac1). The lit-
erature review held that these problems were related to the
intersection of poverty and foodsystemtransitions leading
to changes in the types of food available and accessible to
people in the local food environment.
Raising this as an issue facing both the urban and rural
context, respondents agreed that addressing these chal-
lenges is not a matter of individual food choices, as these
aredriven by broader obesogenic food environments, includ-
ing availability and physical access, affordability, promo-
tion,advertisingand information as well as food quality and
safety issues. These perspectives raised by research respond-
ents have important policy implications. Regulating food
environments in such a way that consumers find it easier
to make more healthy food choices draws attention to the
policy domain governed by cities and municipalities (Ac1).
Local government regulation does not consider the health
and nutritional impacts of food traded, and often restricts
street trade offering healthy foods, while spazas (conveni-
ence store) selling unhealthier options are under-regulated
(NGO2).
Consistent with these observations, the literature review
highlighted that household income and food expenditure did
not correlate with a healthy diet, with malnutrition issues
being observed across income groups and being shaped by
underlying and structural dimensions of foodscapes and
nutrition insecurity (An, 2013; Arthur etal., 2015; Bonti-
Ankomah, 2001; Labadarios etal., 2011; Temple & Steyn,
2011). Foodscapes reflect the spatiality of food systems and
include the physical structures, such as availability of super-
markets and grocery shops, as well as social and economic
factors that influence how residents in an area access differ-
ent foods and make dietary choices or decisions (Miewald
& McCann, 2014). Dietary practices and food choices are
directly dependent on the external environment (An, 2013;
Hawkes etal., 2013; Reddy & Moletsane, 2009). The rapid
spread of formal supermarkets and fast-food chains influ-
ences consumer behaviour and food consumption patterns.
This expansion, while offering consumers a wider range of
products, also entails major organisational changes in the
whole food supply chain and wider food system. It is a major
driver of the rise of obesity, particularly in young children,
underlining the role of structural factors in shaping a food
environment that promotes a high energy, low-quality diet
(An, 2013; Igumbor etal., 2012; Mabhaudhi etal., 2018b;
Mpandeli etal., 2018; Reddy & Moletsane, 2009; Schram
etal., 2013; Temple & Steyn, 2011).
Framing nutrition as a “multi‑sectoral” issue: in discourse,
not practice The framing of nutrition has had an impact on
the institutional arrangements constructed to drive policy
priorities. Seen largely as a health issue, nutrition has been
positioned within the Department of Health (DoH) since
1994, which was tasked to oversee largely nutrition-specific
interventions. The Department was mandated to lead the
government's response to nutrition with priority interventions
(during the late 1990s and early 2000s) mostly being nutrition
specific (including Vitamin A supplementation; Food fortifi-
cation, infant and young child feeding (IYCF) guidelines). The
Nutrition Roadmap of2013to2017, attempted to broaden
the scope of interventions and supported the notion of multi-
sectoral work(May etal., 2020). The Comprehensive Package
of Key Nutritional Interventions highlighted in the Roadmap,
however, remained mostly nutrition-specific.
Respondents recognised that the Department of Agricul-
ture has led the broader food security agenda since 1994 at
national level (Gov9). This is most evident in the Integrated
Food Security Strategy (IFSS) (Department of Agriculture,
2002). The IFSS was expected to provide the overarching
framework and guidance for multisectoral collaboration

S.Drimie et al.
1 3
towards addressing food security issues (Gov9). One of
the key criticisms of the IFSS, however, was that it had an
emphasis on the production side of food security to the det-
riment of other aspects, in particular nutrition (Drimie &
Ruysenaar, 2010). In developing the subsequent National
Policy on Food and Nutrition Security, the departments con-
vening the process acknowledged this weakness in the IFSS,
given by its leaning towards agricultural issues other than
the broader issues for food and nutrition security (Gov9).
Positioning nutrition as a multi-sectoral issue has faced
challenges in the government’s fixed planning structure.
Respondents reported that there have been attempts to
engage nutrition-sensitive work within the primary health
care approach, to shift the framing of nutrition to a more
inclusive space. The challenge has been, however, that
planning in government happens in silos and performance
therefore happens in silos. The architecture of government
structures was thus identified as a major constraint despite
the multi-sectoral framing of food and nutrition security. In
particular, existing mechanisms for reporting periodic per-
formance (e.g. Annual Performance Plans (APPs) and lines
of accountability (UN1), and the lack of streamlined targets
and indicators to ensure coherence between design, budg-
eting, implementation, monitoring and evaluation (Gov1),
were cited as factors hindering effectiveness.
Arguments about the need for a coordination mechanism
to align nutrition-related programmes were raised in cri-
tiques of the IFSS (see Drimie & Ruysenaar, 2010), and
the subsequent National Food Security and Nutrition Plan
(NFSNP) was critiqued for its lack of a legislative frame-
work and implementation strategy necessary to achieve its
goals (Hendriks & Olivier, 2015).
In terms of framing nutrition to influence governance
arrangements, there has been progress with inter-sectoral
technical committees working within government, but a
major gap exists at the political level. The NFSNP envisages
the establishment of the National Food and Nutrition Secu-
rity Council, intended as a “game changer” designed to “pro-
vide leadership and oversight for all efforts of government
and society to enhance food security and good nutrition”
(DSD & DAFF, 2017: 6). To date, this Council has not been
established. The failure to establish the Council as a multi-
stakeholder forum has made it difficult for government to
respond effectively to the impacts of the Covid-19 pandemic
resulting in litigation and community-based organisations
intervening in order to provide food relief to those affected
by the pandemic (May etal., 2020).
What works? Monitoring and evaluation Nutrition-sensitive
programming within the NFSNP relates directly to monitor-
ing and evaluation (M&E). A senior academic argued that
“if you look at the M&E part [in the NFSNP], the person
who is heading up that M&E…is the custodian of the whole
food security M&E system…[they] fall under the chief
director for smallholder agriculture, which food security
falls under. We cannot get them to understand what indica-
tors are needed” (Ac2). A related issue was a lack of align-
ment between departmental monitoring systems: “Everyone
has their own information management system and all these
are sitting independent to each other” (Gov3).
Echoing insights from interviews, findings from the liter-
ature highlight that disaggregated data is particularly impor-
tant given how nutrition outcomes continue to differ mark-
edly between age groups, between boys and girls, between
ethnic groups and between geographical areas (Dalal etal.,
2011; Rossouw etal., 2012; Seonandan & McKerrow, 2016;
Vorster etal., 1999). There are strong age-dependent trends
from early childhood to late adolescence that are especially
evident (Rossouw etal., 2012).
Based on national and subnational evidence (Gilbert
& Gilbert, 2004; Labadarios et al., 2005; Hendriks,
2014; Hendriks & Olivier, 2015; Pereira & Drimie, 2016;
Boatemaa etal., 2018; Boatemaa etal., 2019; Mabhaudhi
etal., 2018a; Godsmark etal., 2019), many reviews point
to a need to implement interventions for addressing
malnutrition that are equity driven and specific to the
targeted populations, as well as differentiated so that they
are relevant to settings in rural, urban and peri-urban
environments. This is due to some key differential drivers
and entry points. Major limitations in the comparability
of data from both national and subnational surveys limit
the benefits that can be derived from better coordinated
M&E methodologies and systems. Stratified information
concerning population groups at national and provincial
levels is needed to capture how determinants of nutrition
and health outcomes affect population groups across and
within settings, in consideration of the contextual elements
which constitute foodscapes in particular settings.
Until the 2020 National Income Dynamics Study-
Coronavirus Rapid MobileSurvey(NIDS-CRAM), there has
been a data disconnect in that surveys rarely include health
and food and nutrition security and agricultural indicators.
This makes it difficult to link underlying causes from non-
health factors to nutrition outcomes.
4.1.2 Politics andgovernance
Political commitment Post-apartheid nutrition policies have
changed markedly in emphasis, indicating how success-
fully the agenda has aligned to a Constitutional democracy
influenced by human rights (Constitution of the Republic
of South Africa, 1996). A senior academic who had worked
in the food and nutrition space since the 1990s explained
the stark difference in emphasis across time, with nutrition
policy during apartheid being “about feeding the masses and
feeding them as cheaply and efficiently as you could while

Stories of Challenge in nutrition: the case of South Africa
1 3
advancing white farming capacity. And then you see the shift
after that to a far more human approach” (Ac2). The post-
apartheid government achieved a great deal in developing a
suite of policies focused on nutrition ranging from “nutrition
and school feeding”, “dietary guidelines”, “nutrition educa-
tion…if you look at what a state could do, South Africa hits
almost all the boxes. NCD policy, this policy, that. It really
is extraordinary” (Ac2).
At the level of broad policy frameworks, commitment to
addressing food and nutrition insecurity seems clear in
writing. However, the stated commitment in policy docu-
ments has not translated into action. Referring to high-
level political commitment, a senior government official
explained that “one of our biggest problems is that there’s
no political will…when there’s the will and commitment,
you’ll see actions” (Gov2). Arguably, securing political sup-
port for nutrition would provide impetus for real change. In
other words, it was not policy and programmes that were
perceived to be the problem, but rather the political will to
prioritise their implementation.
Using the right to food enforced by the legal system was
identified as a key strategy by an interviewee working within
public litigation. The respondent argued that a functional
process would see: “…the courts to then compel the state
to legislate”. This would entail a “declaratory order coming
from the courts and going back through parliament” which
would prompt the drafting of legislation to govern the food
space (NGO4). Legal processes were needed to mitigate
“rampant capital interests that are running loose in our food
value chain, with no legislation, with no accountability”,
and call for stakeholders to spell out their involvement with
relation to the right to food in the country and clarify their
lines of accountability (NGO4).
Commitment to delivering horizontal coherence The issue
of legal processes raises the importance of pressure for
commitment emanating from outside of the state, particu-
larly from civil society organisations. The HIV agenda was
raised as an example: “it wasn’t government officials or
medical experts or HIV experts or so on, it was NGOs. For
example TAC [Treatment Action Campaign], which made a
noise and did advocacy, whatever, and created that demand
and made politicians to hear them through unconventional
ways, like toyi-toyiing [dance used in political protests] and
so on” (Gov2).
Every survey since 1994 has proposed a national coordi-
nating body for nutrition. Notably, the last national survey in
2012, SANHANES-1, recommended that a special task force
was needed to look at short-, medium- and long-term food
and nutrition security interventions for populations in differ-
ent localities (Shisana etal., 2013). In 2014, the NFNSP for-
mulated this recommendation as its key strategic objective
number 1: ‘A Food and Nutrition Security Council would
be established [and] chaired by the president with premiers
of provinces chairing provincial food and nutrition secu-
rity councils and mayors chairing district food and nutrition
security councils’ (DSD & DAFF, 2017; Masilela, 2020).
The immediate task of the Council would be to advocate for
the integration of policies, legislation, and programmes, to
achieve coherence. Further detail about this Council, and
its underpinning institutional arrangements, are absent in
official documentation.
The National Food and Nutrition Security Coordinat-
ing Committee has been established and is chaired by the
Department of Performance Monitoring and Evaluation
(DPME) to steer the implementation of the six strategic
objectives of the NFSNP (Gov3). In terms of function, the
Committee meets to discuss sectoral progress against the
strategic objectives and shares information about imple-
mentation. A senior official in a participating department
reflected on the DPME’s success in galvanising and shaping
coordination, noting that: “Maybe at a lower level we have
to strengthen some aspects to make sure that we have these
sector departments truly planning and working together to
deliver the same objectives and outcomes. But at national
[level] that [coordination] is a problem of the past” (Gov3).
There may, however, be a misplaced confidence in these
structures to generate change. A major challenge is the
alignment of sectors, in particular agriculture and health,
to converge on a nutrition outcome when such policies lack
nutrition indicators and budgets. As reflected by a partici-
pating official: “even at national level we are not engaging
as much as we should, because as agriculture we still have a
number of interventions and programmes that we are plan-
ning without necessarily having a consultation per se with
the Department of Health” (Gov9).
Beyond consultation, the official raised the issue of the
authority of the structure to ensure that departments worked
together, highlighting the sectoral mandates and structures:
“There is nothing that forces the department to ensure that
whatever programme that it implements is in line with the
nutrition sensitivity guidelines or something like that”
(Gov9). The Food and Nutrition Security Council was often
raised by respondents as a way of providing stronger politi-
cal commitment to nutrition through high-level political
leadership, and representatives from across society to pro-
vide strategic guidance and oversight, including for conver-
gence and advocating for funding. Without some legislation
forcing departments to adhere to a common framework for
nutrition sensitivity, emerging programmes may continue to
emerge without any proper consideration of nutrition.
Subnational governance and vertical coherence A high
level of local specificity in the causes, experiences and
consequences of food insecurity is evident from the reviewed
research at provincial level. From an operational perspective,

S.Drimie et al.
1 3
the ‘how’ of interventions – their process – matters at least as
much as their ‘what’ – their content (Misselhorn & Hendriks,
2017). This concerns the process of finding alignment between
resources from provincial line departments. Some findings
from the literature review suggest that provincial governments
were overambitious in terms of the quantity of initiatives
undertaken for short-term political gains, while losing track
of the quality of provision which impacts on outcomes in the
longer term (Monyeki etal., 2015).
Nutrition policies with high potential for addressing multi-
ple forms of malnutrition simultaneously faced implementation
challenges on the ground (Monyeki etal., 2015; Seonandan
& McKerrow, 2016). A key issue was a minimal structure for
coordination, co-creation, and cooperation in most provinces
(Boatemaa etal., 2018). This was reflected in insights gained
through interviews. A key informant who participated in the
national coordinating structure questioned whether this struc-
ture informed “integrated action at lower spheres of govern-
ment” (Gov9). This meant that ultimately “the frontline workers
are functioning in accordance to their sectoral functions and the
coordination is not happening at that level. And there’s nothing
that binds departments to ensure that it happens” (Gov9). This
was a striking reflection emerging from North West province
(Gov5). Consequently, the compounding impact of Covid-19
revealed that little changed in the North West in response to the
pandemic and its effects on malnutrition.
In contrast, there was evidence of effective structures
emerging at lower administrative levels in KwaZulu-Natal
and Western Cape. Pre-Covid-19, the Operation Sukuma
Sakhe Implementation Plan in KwaZulu-Natal was noted
as an example of an effective intergovernmental approach.
In KwaZulu-Natal, the importance given to nutrition was
‘evident in the existence of effective coordination mecha-
nisms for food/nutrition interventions from the level of the
premier down to the ward level’ (Khulisa Management
Services, 2013). This had, however, dissipated over time
(Gov3). In the Western Cape, a strong network of officials,
activists, academics, researchers and other stakeholders has
emerged since 2010, unfolding at different levels includ-
ing at province, city and within local government (Haysom,
2020). These groupings built an understanding of nutrition
and mobilised political support culminating in a “web of
actors” being mobilised during Covid-19 that were able
to move rapidly to mitigate the impact of the pandemic on
local communities (Adelle etal., 2021). This partly involved
building alliances, as actors had learnt to know (and trust)
each other over the preceding decade (Gov6).
4.1.3 Capacity andfinancial resources
Nutrition capacity The previous sections have shown that
leadership at national level, including government, civil
society, and nutrition professionals, has raised awareness of
multi-sectorality of nutrition and improved coordination. The
effective translation of policy into implementation requires
the appointment of committed and well-qualified officials
to lead sector programmes. Addressing the complexity of
malnutrition cannot be achieved without the “bureaucratic
space” for innovation and learning such that programmes
can be adapted.
There are arguably an inadequate number of posts available
within government considering the extent of the nutrition
challenge (Goeiman etal., 2019). This was confirmed by a
senior provincial nutrition manager’s observation that atten-
tion should be paid to capacity of the workforce in terms of
their numbers and of their ability to act on a technical and
practical level (Gov 6).
Although several postgraduate degrees exist in South Africa
focused on nutrition and dietetics, this has largely fed into the
private sector as opposed to the need within the state. A senior
academic involved in establishing postgraduate courses com-
mented that “…most of them are going into private practice
and so they’re not filtering into the system” (Ac2).
Gillespie etal. (2013) makes it clear, however, that
human and organisational capacity goes beyond nutrition
know-how. It should include a set of soft-power skills to
operate effectively across boundaries and disciplines. This
was articulated by a retired senior government programme
manager, now consultant, in noting that: “within the nutri-
tion community certainly there is a will to do it [shift mal-
nutrition] and to make it better. I don’t think that we have got
enough people to do it and I don’t think we have got enough
of the skill sets at the right level” (Con1). Such a skill set
has been described to include, apart from “leadership for
alliance building and networking”, also “communication of
the case for collaboration, leveraging of resources, and being
able to convey evidence clearly to those in power” (Gillespie
etal., 2013).
Leadership in nutrition is key for driving the changes at
different levels in government and more broadly in soci-
ety. In particular, leadership within lead organisations for
national level programmes with the ability to influence polit-
ical decision-makers is essential. Although some influential
leaders have emerged, this has not been widespread. In the
view of a senior academic, “the right level of leadership has
not been in place to drive nutrition into a core priority of
government” (Ac2).
Building political acumen amongst nutrition profession‑
als Some respondents, including those at a senior level in
government, argued that nutrition professionals needed a
greater sense of the “politics of nutrition” and the impor-
tance of working with political levers “to make people have
some political acumen, to see things, have an insight of

Stories of Challenge in nutrition: the case of South Africa
1 3
politics…It really makes a huge difference if we bring poli-
tics into, not politics for Parties and whatever, but to see how
politics drives the health agenda or the nutrition agenda”
(Gov2). Apart from exposing early career professionals to
local level dynamics, training at universities should include
understanding the importance of agency, influence and how
to enable change.
Delivery and operational capacity for implementation Look-
ing ahead, there is a need for increasing the number of
trained nutrition professionals. A lack of personnel, espe-
cially at implementation levels, was identified in all three
provinces as a key issue, exacerbating technical capacity
gaps and high frontline workloads. The issue of inadequate
capacity pertains to both nutrition-specific and nutrition-
sensitive programming at lower administrative levels. An
academic respondent who had worked in the food and nutri-
tion space for over two decades reflected on this in terms
of the Department of Agriculture, where: “22% of posts in
agricultural development are not filled. If a fifth of your
workforce is not in place in your organogram, certain things
are going to slip” (Ac2).
As a result, existing personnel struggle to make an
impact. In a study conducted at implementation level in the
Breede Valley, Western Cape Province, Du Plessis etal.
(2018) investigated the domain of capacity and resources
and found accounts of government officials being over-
whelmed with high workloads and a lack of resources.
Different stakeholders were reluctant to take ownership of
issues not aligned with their budgets, targets and objectives.
Technical and funding challenges meant policies were only
implemented in a few areas or nodes, reflecting a lack of
budget to facilitate further coherence across sectors and
between administrative levels.
There is, however, an opportunity to increase nutrition’s
reach and impact by ensuring that the scope of the dietetics
and nutrition profession is well understood and respected,
but also to share the responsibility of realising optimum
nutrition for all in South Africa, with a broader base of
professionals and civil society (Goeiman etal., 2019). A
senior provincial nutrition manager from the Western Cape
expressed a “whole of society” approach as follows: “The
opportunity is there to make it clear what the roles and func-
tions of your nutrition professional is and how it relates to
the rest of the workforce that is also part of the nutrition
workforce… the fact that we have the vision that we need
to work as whole of government, whole of society brings
forth great opportunity for nutrition to point out the role that
nutrition can play in the other sectors” (Gov6).
It is noteworthy that the current undergraduate training
programme for dietitians in the country was reviewed and
will be revised in future to better serve the needs of the
country. The purpose of the new programme is to train a
dietitian nutritionist who is in possession of graduate-level
scientific knowledge, skills and attitudes necessary to prac-
tice independently, cost-effectively and responsibly in any
of the areas of therapeutic nutrition, community and public
health nutrition and food service management, in line with
national and international trends and requirements (Spies &
Wentzel-Viljoen, 2023).
Nutritionists employed in the public sector could, as a pri-
ority, be enrolled in existing programmes such as the Afri-
can Nutrition Leadership Programme (ANLP) (Ac3). The
ANLP has a growing track record of impact across the con-
tinent anecdotally reflected through testimonies of alumni.6
Although strong leaders exist across national, provincial and
local levels, the concentration of these is not adequate to
address the malnutrition challenge at present.
An integrated approach for nutrition actions is desirable
and the role of community health workers can be invaluable.
This sentiment was echoed by a nutrition consultant with
experience in senior programme management in govern-
ment. They implied, however, that community health work-
ers are expected to be champions for many causes: “If you
look at, for example, the role that community health workers
are and could and should be playing in terms of preventive
nutrition, it’s huge. That’s a resource. There is your health
promotion practitioners, then you have your clinic staff
and everybody there at their different levels with different
responsibilities” (Con1).
New forms of resource mobilisation There is evidence
that the National Treasury has recognised the importance
of nutrition and allocated increasing budgets to specific
programmes over time, partly reflected in the Treasury
study (Carter etal., 2015). The NFSNP, however, remains
unfunded. A senior official involved in developing the pol-
icy recalls: “we…wrote to the Presidency…after we had
costed the plan and it had come to about R86 billion7 over a
five-year period, which is on average just under R20 billion
[annually]…The big question was, what’s going to be the
source of funding for the R86 billion?” (Gov1). This large
amount raised concerns amongst “the political leadership
about going out there publicly and making this public com-
mitment to this plan” (Gov1) when there was uncertainty
about the source of funding.
To date, the plan has not received its own dedicated
budget, with the Treasury arguing that existing funds
allocated to participating departments should be used
to achieve the targets. These include programmes cur-
rently funded within the budget and coordinated through
6 see https:// afric anutr ition leade rship. org/ the- leader
7 This is approximately 5.8 billion United States Dollars (USD). In
2021 the average exchange rate was 1 USD equivalent to 14.79 South
African Rand.

S.Drimie et al.
1 3
the DoH, including multiple macronutrient supplementa-
tion programmes, child healthcare problem identification,
deworming amongst others, and two programmes currently
funded in the budget of the Department for Basic Educa-
tion (DBE) and related to school nutrition. These are the
National School Nutrition Programme and the School Food
– Gardens Programme. The NSNP budget is protected by the
Treasury: “Yes, they are protected because, first of all, it is
a nutritional grant…And therefore it has been ring-fenced
for all these years” (Gov7).
5 Discussion
The Stories of Challenge South Africa study used a mixed
(qualitative) methods approach to examine the “enabling
environment” for nutrition in South Africa since 1994 to
understand what underpins the lack of positive changes
in critical nutrition outcomes. This revealed a paradox, in
that significant strides have been made since the advent of
democracy in terms of establishing a comprehensive frame-
work of policy and programming, yet this has been insuf-
ficient to address young child malnutrition. Improvements
in the overall policy frameworks and expressions of com-
mitment have not translated sufficiently into changes in key
young child malnutrition indicators, particularly stunting
and overweight. We discuss these findings in accordance
with the enabling environment dimensions: knowledge and
evidence, politics and governance, and capacity and finan-
cial resources.
5.1 Framing, generation, andcommunication
ofknowledge andevidence
The framing of nutrition in government has changed over time
to promote a broader, multi-sectoral approach to nutrition
(beyond health), although the reality of sectoral mandates and
structures overrides the language of “multi-sectoralism”. Our
findings stress the need to frame the issue as multisectoral,
not only in discourse but also in institutional arrangements,
so that coordinated responses can be translated into practice.
Other limitations persist such as a failure to characterise the
issue within obesogenic food environments. The broad pol-
icy domain reflects this framing. Another major challenge
remains: the framing of malnutrition’s relationship with per-
sistent poverty and increasing inequality.
Regularly collected quality data is critical for informing
policy decisions and communication to policy makers. Since
1994, various national surveys have been implemented to
better understand continuing disparities. However, a data
disconnect persists in that surveys rarely include health
and food and nutrition security and agricultural indicators,
making it difficult to link underlying causes from non-health
factors to nutrition outcomes. While the collection of accu-
rate nutrition data is critical, so is the management, analysis,
and dissemination of these data among relevant sectors and
stakeholders. Information systems are needed that strengthen
accountability and drive and inform action at all levels.
Thus, improved systems are required to inform understand-
ing about the relationship between poverty, inequality and
food and nutrition security, including agriculture-nutrition
linkages and potential “double duty” actions. These systems
are also required to enable accountability. This has a bear-
ing for other countries trying to build an effective enabling
environment.
5.2 Politics andgovernance
As Gillespie etal. (2013) have argued, nutrition-specific
and nutrition-sensitive actions need to be underpinned by
policy and institutional environments that are enabling in
nature.As revealed in the literature review, a range of poli-
cies exist that have a direct bearing on the food system.
While each has a specific focus, it is not clear how they fit
into an overall policy framework. The promotion of nutrition
will only succeed with greater alignment in this multi-policy,
multi-institutional and system-wide frame.
Findings revealed that political commitment at the high-
est level is considered a major issue. This is exacerbated by
insufficient pressure from civil society groups. The broader
implication of this is that the development of a coherent
policy architecture that reflects the most pressing nutrition
issues is insufficient to enable change. The lack of impact of
policy and therefore commitment on changes in malnutrition
was particularly revealed by the Covid-19 pandemic, which
foregrounded the failures of the food system to provide suf-
ficient, healthy, nutritious food.
With regards to governance and policy coherence, forms
of multi-stakeholder arrangements, particularly the NFSNP
interdepartmental coordinating committee, have been estab-
lished to coordinate nutrition-relevant programmes, at least
at national level. Lessons learnt from the enabling environ-
ment at subnational level underline that effective governance
structures require concerted efforts to build relationships and
trust within and beyond the organisational structures that
exist in theory.
There is thus evidence from our results that different lev-
els of governance have been effective. Nonetheless, chal-
lenges remain with these examples; despite the intersectoral
coordinating committee, nutrition interventions at national
and provincial level have remained overwhelmingly nutri-
tion-specific, largely because the issue is positioned as the
mandate of the Department of Health, with the food security
agenda led by the Department of Agriculture.

Stories of Challenge in nutrition: the case of South Africa
1 3
5.3 Capacity andfinancial resources
Within the new generation of nutrition professionals,
stronger strategic and operational capacities are needed to
complement technical skill sets. In particular, there is a need
to strengthen the capacity of individuals in non-health sec-
tors, to empower and motivate them to apply a nutrition lens
in their work, and to contribute to nutrition-relevant change
through their programming and investments. As argued by
Du Plessis etal. (2018), investment in the “people” element
warrants stronger emphasis within the three linked dimen-
sions of an enabling environment, suggesting that a defini-
tion of the enabling environment at implementation level
could expand on the international definition, as follows:
“political, policy and people-centred processes that build
and sustain momentum for the effective implementation of
actions that reduce malnutrition” (2018).
Linked to this, value-based collaborations such as trust
and relationships between government departments and
other stakeholders consistently lead to successful partner-
ships (Garrett etal., 2014). This argument, derived from a
range of country examples, is echoed in South Africa with
a positive example emerging in the Western Cape. Without
building and sharpening the skills to understand, facilitate
and guide multisectoral processes, a crucial element in
capacity for addressing malnutrition will be amiss. With
a broader bearing beyond South Africa, these competen-
cies must go way beyond just knowing the biological and
social dimensions of malnutrition, and include, for example,
service-learning and demonstrating leadership (Shrimpton
etal., 2016).
Existing government policies acknowledge the need to
draw in the wide range of actors needed to recalibrate the
food system as a whole. Nutrition champions at all levels
are required to catalyse social and political change and make
development policy in general more nutrition-sensitive. The
next generation of nutrition leaders need to be developed and
existing initiatives strengthened, including academies and
curricula that aim to build leadership capacity (Shrimpton
etal., 2016).
Many respondents perceived funding as a major chal-
lenge. Some sectors such as education reported increases
in nutrition-relevant funding, but others such as the NFSNP
argued that limited progress has been made in generating
adequate finance. Some examples at subnational level reflect
efforts to better align existing resources to have greater
impact at community level and include non-state actors
through partnerships (Gorgens, 2021; WCG, 2017). Overall,
however, fiscal austerity challenges undermined adequate
state responses. Clearly, political commitment to support the
adequate allocation of resources remains a priority in many
different contexts.
5.4 Limitations
A limitation of this study was the low number of respond-
ents in the third province (North West) partly due to a weak
interest in the research on behalf of officials. However, this
was offset by drawing on three key informants outside of
government who have knowledge of governance arrange-
ments and impact in the province. Another limitation was
not fully assessing local government regulation and inter-
viewing local government officials, as food and nutrition
security and other dietary issues at local level are dominant
determinants of why young children in South Africa are mal-
nourished. By extension, policy and interventions are also
required at local level.
6 Conclusion
This study described the changes in the enabling environ-
ment for young child malnutrition in South Africa since
1994 at national level and in three provinces: North West,
Western Cape, and KwaZulu-Natal. We aimed to better
understand the drivers and pathways of nutrition-relevant
change in South Africa, the challenges that influence politi-
cal commitment, policy and programme coherence, and the
implementation of nutrition-relevant actions in the country.
As part of the broader Stories of Change in Nutrition
studies, the findings have relevance for a growing body
of country studies. Indeed, whilst some of the observed
challenges are specific to the country context, others offer
important insights on the complexities of food systems more
generally and point to potential entry points related to double
duty interventions, which can address undernutrition and
overweight and obesity simultaneously in countries that are
similarly experiencing multiple burdens of malnutrition.
The South Africa study reflects the inherent challenges
of implementation due to a weak enabling environment
despite the existence of a relatively coherent and compre-
hensive policy framework. Given the inherent multi-sectoral
nature of nutrition, the study shows the challenge of ensur-
ing coherence across sectors with some promising experi-
ments emerging in KwaZulu-Natal and the Western Cape.
However, challenges remain with regards to political leader-
ship on nutrition and elevating nutrition sufficiently on the
political agenda, setting up a national coordination struc-
ture to lead on nutrition (the National Food and Nutrition
Security Council), contextualising interventions according
to disaggregated data that provide information on how nutri-
tion outcomes differ by population group, age, and gender
in particular, as well as with regards to capacity building
and training of nutrition professionals, and support to com-
munity health workers.

S.Drimie et al.
1 3
Looking ahead, the relative immaturity of the policy sec-
tor in dealing with issues such as obesity and overweight,
and associated influences in the wider food environment,
adds a further challenge to South Africa. Identifying and
securing the necessary resources and capacity to drive these
changes consolidates this call for a social compact to address
young child malnutrition in all its forms.
Appendix: Literature review parameters
andsearch strategy
Parameters considered important for the review were speci-
fied using the PICO framework that considers the problem,
process, context, outcome and, study type, which has been
adapted for qualitative studies (Hagen-Zanker & Mallett,
2013; Tricco etal., 2018). The PICO acronym stands for
“P – Patient, problem or population”, “I – Intervention”, “C
– Comparison, control or comparator” and “O – Outcomes”.
The search strategy used search strings consisting of key
terms relevant to food, diet and nutrition, multiple forms of
malnutrition, including macro- and micro-nutrient imbal-
ances, underweight, stunting, wasting, overweight, obesity,
nutrition-related infectious and non-communicable diseases
(NCDs), outcome measures, policy and legislation, political
commitment, political economy and enabling environment,
and setting. The search was carried out in four databases:
Scopus, PubMed, Web of Science, and Google Scholar. Due
to the timeframe (twenty-six-year period between 1994 and
2020) and time constraints of the study, the literature search
was limited to peer-reviewed reviews, published in English
only. Reviews were classified based on cross-checking of
author and journal review classifications against the SALSA
analytical framework – Search, Appraisal, Synthesis &
Analysis (Grant & Booth, 2009). Based on the classifica-
tion, the following review types were included: systematic
review, systematic review and meta-analysis, systematic
overview, overview, scoping review, literature review, nar-
rative review, critical review, mixed methods review, and
review of the evidence. Additional reviews relevant to the
objective of the review, i.e., review of policies and legisla-
tion, policy development, policy implementation, as well
as review of progress (e.g. MDGs/SDGs), review of syn-
demic relationships, review of methodologies/monitor-
ing mechanisms, were also included. A final 117 reviews
were included. (Fig.1). Relevant data from these reviews
was extrapolated into a standard extraction matrix accord-
ing to the PICO criteria, and an inductive/grounded theory
approach was used to organize information into themes and
sub-themes, after which these were developed into narrative
summaries. Drawing on the Cochrane Collaboration Qualita-
tive Methods Group (CCQMG) (2011) rationale for critical
appraisal and the DfID (2014) approach to assess quality
of evidence, the team built an integrated critical appraisal
tool consistent with the Cochrane rationale for qualitative
evidence (CCQMG 2011), which was adapted to our review
of mixed methods reviews. All of the retrieved reviews were
included in the final synthesis.
Acknowledgements We would like to thank the South Africa Depart-
ment of Health for endorsing this research and co-hosting two virtual
consultations. We also thank the Division of Human Nutrition, Depart-
ment of Global Health,Faculty of Medicine and Health Sciences at
Stellenbosch University for co-hosting the two virtual consultations.
We are also grateful for the support from Namukolo Covic (ILRI) for
providing reflection and support throughout and chairing the two vir-
tual consultations and for providing strategic guidance on the overall
study. We thank Angela Coetzee and Tasneem Jhetam (Stellenbosch
University) for supporting us with conducting interviews.
Authors’ contribution Scott Drimie, Mara van den Bold, and Namukolo
Covic led conceptualisation and design of this study, with Scott Drimie
as study lead. Laura Casu led the literature review and policy analysis.
Scott Drimie and Lisanne du Plessis led data collection and analysis of
interviews. The first draft of the manuscript was written by Scott Drimie,
and all authors commented on and contributed to this and subsequent
versions of the manuscript. All authors read and approved the final manu-
script. Tasneem Jhetam and Angela Coetzee helped with field work and
data collection.
Funding Open access funding provided by Stellenbosch University.
This work was funded by the Consultative Group on International Agri-
cultural Research (CGIAR) Research Program Agriculture for Nutrition
and Health.
Declarations
Conflict of interest The authors report no conflicts of interest.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
References
Adelle, C., Kroll, F., Battersby, J., Haysom, G., & Drimie, S. (2021).
Civil Society Organisations should have a central role in food
governance. Policy Brief 3/2021. Cape Town: DSI/NRF Centre of
Excellence in Food Security. https:// foods ecuri ty. ac. za/ wp- conte
nt/ uploa ds/ 2021/ 07/ Civil_ Socie ty_ colour_ 20210 713. pdf
An, R. P. (2013). Effectiveness of subsidies in promoting healthy food
purchases and consumption: A review of field experiments. Pub-
lic Health Nutrition, 16(7), 1215–1228. https:// doi. org/ 10. 1017/
S1368 98001 20047 15
Arthur, S. S., Nyide, B., Soura, A. B., Kahn, K., Weston, M., & Sankoh,
O. (2015). Tackling malnutrition: A systematic review of 15-year

Stories of Challenge in nutrition: the case of South Africa
1 3
research evidence from INDEPTH health and demographic sur-
veillance systems. Global Health Action, 8, 1–13. https:// doi. org/
10. 3402/ gha. v8. 28298
Boatemaa, S., Drimie, S., & Pereira, L. (2018). Addressing food and
nutrition security in South Africa: A review of policy responses
since 2002. African Journal of Agricultural and Resource Econom-
ics (AFJARE), 13(3), 264–279.
Boatemaa, S., Barney, M., Drimie, S., Harper, J., Korsten, L., &
Pereira, L. (2019). Awakening from the listeriosis crisis: Food
safety challenges, practices and governance in the food retail sec-
tor in South Africa. Food Control, 104, 333–342. https:// doi. org/
10. 1016/j. foodc ont. 2019. 05. 009
Bonti-Ankomah, S. (2001). Addressing food insecurity in South
Africa. SARPN Conference on land reform and poverty allevia-
tion in Southern Africa, 4th–5th June 2001. http:// www. sarpn.
org/ docum ents/ e0000 008/ 20010 605Bo nti. pdf
Bourne, L. T., Hendricks, M. K., Marais, D., & Eley, B. (2007).
Addressing malnutrition in young children in South Africa. Set-
ting the national context for paediatric food-based dietary guide-
lines. Maternal and Child Nutrition. https:// doi. org/ 10. 1111/j.
1740- 8709. 2007. 00108.x
Carter, J., Barberton, C., Abdoll, C., Berhane, E., & Drimie, S. (2015).
Performance and Expenditure Review: Nutrition and food security
for children under five years old. Unpublished research report by
Cornerstone Economic Research for National Treasury. Retrieved
February 27, 2023, fromhttps:// www. corne rston esa. net/ images/
18.2_ Techn ical_ report. pdf
Cochrane Collaboration Qualitative Methods Group (CCQMG), &
Hannes K. (2011). Chapter4: Critical appraisal of qualitative
research. In J. Noyes, A. Booth, K. Hannes, A. Harden, J. Harris, S.
Lewin, & C. Lockwood (Eds.), Supplementary guidance for inclu-
sion of qualitative research in Cochrane systematic reviews of inter-
ventions (Version 1). Cochrane Collaboration Qualitative Methods
Group. Retrieved February 27, 2023, from http:// cqrmg. cochr ane.
org/ suppl ement al- handb ook- guida nce
Constitution of the Republic of South Africa, Act 108 of 1996, sections
26(2), 27(2), and 29(1)(b). Retrieved February 27, 2023, from
https:// www. gov. za/ sites/ defau lt/ files/ images/ a108- 96. pdf
Dalal, S., Beunza, J. J., Volmink, J., Adebamowo, C., Bajunirwe, F.,
Njelekela, M., Mozaffarian, D., Fawzi, W., Willett, W., Adami,
H. O., & Holmes, M. D. (2011). Non-communicable diseases in
sub-Saharan Africa: What we know now. International Journal
of Epidemiology, 40, 885–901. https:// doi. org/ 10. 1093/ ije/ dyr050
Department for International Development (DfID). (2014). How to note:
Assessing the strength of the evidence. Department for International
Development, UK Government. Retrieved February 27, 2023, from
https:// www. gov. uk/ gover nment/ publi catio ns/ how- to- no te- asses si ng-
the- stren gth- of- evide nce
Department of Agriculture. (2002). The integrated food security strategy
for South Africa. Republic of South Africa. Retrieved February 27,
2023, from https:// www. gov. za/ docum ents/ integ rated- food- secur ity-
strat egy- south- africa
Department of Social Development, Department of Agriculture Forestry
and Fisheries. (2017). National food and nutrition security plan for
South Africa: Version 7. DSD. Retrieved August 14, 2023, from
https:// faolex. fao. org/ docs/ pdf/ saf21 1944. pdf
Development Initiatives. (2020). Global Nutrition Report: Action
on equity to end malnutrition. Development Initiatives. https://
globa lnutr ition report. org/ docum ents/ 566/ 2020_ Global_
Nutri tion_ Report_ 2hrss Ko. pdf
Development Initiatives. (2022). Global Nutrition Report: Stronger
commitments for greater action. Development Initiatives.
https:// globa lnutr ition report. org/ docum ents/ 922/ 2022_ Global_
Nutri tion_ Report. pdf
Drimie, S., & Ruysenaar, S. (2010). The Integrated Food Security
Strategy of South Africa: An institutional analysis. Agrekon,
49(3), 316–337.
Du Plessis, L. M., McLachlan, M. H., & Drimie, S. E. (2018). What
does an enabling environment for infant and young child nutri-
tion look like at implementation level? Perspectives from a multi-
stakeholder process in the Breede Valley Sub-District, Western
Cape, South Africa. BMC Public Health, 18, 240. https:// doi. org/
10. 1186/ s12889- 018- 5165-7. http:// rdcu. be/ GPZl
FAO, European Union, CIRAD and DSI-NRF Centre of Excellence in
Food Security (CoE-FS). (2022). Food Systems Profile – South
Africa. Catalysing the sustainable and inclusive transformation of
food systems. Rome, Brussels, Montpellier, France and Bellville,
South Africa. https:// doi. org/ 10. 4060/ cc007 1en
Garrett, J., Kadiyala, S., & Kohli, N. (2014). Working multisectorally
to improve nutrition: Global lessons and current status in India.
POSHAN policy note 1. International Food Policy Research Insti-
tute. Retrieved August 14, 2022, from https:// poshan. ifpri. info/
2014/ 01/ 01/ lesso ns- learn ed- worki ng- multi secto rally- to- impro ve-
nutri tion- globa lly- and- india-2/
Gilbert, T., & Gilbert, L. (2004). Globalisation and local power: Influ-
ences on health matters in South Africa. Health Policy, 67, 245–
255. https:// doi. org/ 10. 1016/ S0168- 8510(03) 00120-9
Gillespie, S., Haddad, L., Mannar, V., Menon, P., & Nisbett, N. (2013).
The politics of reducing malnutrition: Building commitment and
accelerating progress. The Lancet, 382(9891), 552–569. https://
doi. org/ 10. 1016/ S0140- 6736(13) 60842-9
Gillespie, S., van den Bold, M., Menon, P., & Nisbett, N. (2017). Special
Issue: Stories of Change in Nutrition. Global Food Security, 13.
Retrieved August 14, 2022, from https:// www. scien cedir ect. com/
journ al/ global- food- secur ity/ vol/ 13/ suppl/C
Gillespie, S., Harris, J., & Nisbett, N,; & van den Bold, M. (2021). Sto-
ries of change in nutrition from Africa and Asia: An introduction
to a special series in food security. Food Security, 13(4), 799–802.
https:// doi. org/ 10. 1007/ s12571- 021- 01166-8
Goeiman, H. D., Swart, R., & Hughes, R. (2019). Developing a comprehen-
sive nutrition workforce planning framework for the public health sec-
tor to respond to the nutrition-related burden in South Africa. Retrieved
August 14, 2022, from https:// etd. uwc. ac. za/ handle/ 11394/ 6900
Godsmark, C. N., Irlam, J., van der Merwe, F., New, M., & Rother, H. A.
(2019). Priority focus areas for a sub-national response to climate
change and health: A South African provincial case study. Environment
International, 2, 31–51. https:// doi. org/ 10. 1016/j. envint. 2018. 11. 035
Gorgens, T. (2021). Nourish to Flourish Mobilisation Strategy: The
N2F priorities for collaborative action in 2021/22, unpublished
powerpoint presentation, 21 March 2021.
Grant, M. J., & Booth, A. (2009). A typology of reviews: An analysis
of 14 review types and associated methodologies. Health Informa-
tion & Libraries Journal, 26(2), 91–108. https:// doi. org/ 10. 1111/j.
1471- 1842. 2009. 00848.x
Hagen-Zanker, J., & Mallett, R. (2013). How to do a rigorous, evi-
dence-focused literature review in international development.
Haysom, G. (2020). We all need to be concerned about food insecurity
and we all have a role to play: New forums for urban food systems
governance are long over due. In Z. Barends & S. Drimie (Eds.),
Challenging false narratives in a global crisis: Reflections on
human rights, inequality and securing food systems (pp. 20–21).
Retrieved August 15, 2022, from https:// www. south ernaf ricaf ood-
lab. org/ wp- conte nt/ uploa ds/ 2020/ 05/ WORLD- HUNGER- 2020_
25052 020_ FINAL_ COMPR ESSED. pdf
Hawkes, C., Jewell, J., & Allen, K. (2013). A food policy package for
healthy diets and the prevention of obesity and diet-related non-
communicable diseases: The NOURISHING framework. Obesity
Reviews, 14(Suppl. 2), 159–168. https:// doi. org/ 10. 1111/ obr. 12098

S.Drimie et al.
1 3
Hendriks, S. L. (2005). The challenges facing empirical estimation of
household food (in)security in South Africa. Development South-
ern Africa, 22(1), 103–123.
Hendriks, S. L. (2014). Food security in South Africa: Status quo and
policy imperatives. Agrekon, 53(2), 1–24.
Hendriks, S. L., & Olivier, N. J. J. (2015). Review of the South African
agricultural legislative framework: Food security implications.
Development Southern Africa, 32(5), 555–576. https:// doi. org/ 10.
1080/ 03768 35X. 2015. 10440 75
Igumbor, E. U., Sanders, D., Puoane, T. R., Tsolekile, L., Schwarz, C.,
Purdy, C., Swart, R., Durão, S., & Hawkes, C. (2012). ‘Big food’,
the consumer food environment, health, and the policy response
in South Africa. PLoS Medicine, 9(7), e1001253.
Iversen, P. O., du Plessis, L., Marais, D., Morseth, M., Høisæther, E.
A., & Herselman, M. (2011). Nutritional health of young children
in South Africa over the first 16 years of democracy. South Afri-
can Journal of Child Health (SAJCH), 5(3), 72–77.
Jonah, C., Sambu, W., & May, J. (2018). When progressive fiscal poli-
cies do not reduce health inequalities: an examination of child
malnutrition in South Africa. Paper presented at United Nations
Department of Economic and Social Affairs (UNDESA) expert
group meeting. New York: 25 to 27 June 2018. Retrieved August
15, 2022, from https:// www. un. org/ devel opment/ desa/ dspd/ wp-
conte nt/ uploa ds/ sites/ 22/ 2018/ 06/ 6–1. pdf
Khulisa Management Services. (2013). KwaZulu-Natal Case Study:
Diagnostic/Implementation Evaluation of Nutrition Interventions
for Children from Conception to Age 5. The Presidency, Depart-
ment of Performance Monitoring and Evaluation, Republic of
South Africa, 17 March 2014. Retrieved October 27, 2022, from
https:// evalu ations. dpme. gov. za/ evalu ations/ 441
Labadarios, D., Swart, R., Maunder, E. M. W., Kruger, H. S., Gericke,
G. J., Kuzwayo, P. M. N., etal. (2008). Executive summary of
the National Food Consumption Survey Fortification Baseline
(NFCS-FB-I): South Africa, 2005. South African Journal of Clini-
cal Nutrition, 21(3), 245–300.
Labadarios, D., Mchiza, Z. J. R., Steyn, N. P., Gericke, G., Maunder, E.
M. W., Davids, Y. D., & Parker, W. A. (2011). Food security in South
Africa: A review of national surveys. Bulletin World Health Organi-
zation, 89, 891–899. https:// doi. org/ 10. 2471/ BLT. 11. 089243
Mabhaudhi, T., Chibarabada, T. P., Chimonyo, V. G. P., Murugani, V. G.,
Pereira, L. M., Sobratee, N., Govender, L., Slotow, R., & Modi, A.
T. (2018a). Mainstreaming underutilized indigenous and traditional
crops into food systems: A South African perspective. Sustainabil-
ity (switzerland), 11, 172. https:// doi. org/ 10. 3390/ su110 10172
Mabhaudhi, T., Mpandeli, S., Nhamo, L., Chimonyo, V. G. P.,
Nhemachena, C., Senzanje, A., Naidoo, D., & Modi, A. T. (2018b).
Prospects for Improving Irrigated Agriculture in Southern Africa:
Linking Water. Energy and Food. Water, 10(12), 1881. https:// doi.
org/ 10. 3390/ w1012 1881
Masilela, T. C. (2020). Overview of Progress Towards the National
Food and Nutrition Security Plan for South Africa. Food Security
Dialogues with the Department of Social Development, Human
Sciences Research Council and the National Development Agency,
unpublished powerpoint presentation, 13 October 2020.
May, J., Witten, C., & Lake, L. (eds). (2020). South African child gauge.
Cape Town: Children’s Institute, University of Cape Town. Retrieved
October 27, 2022, from http:// www. ci. uct. ac. za/ sites/ defau lt/ files/
image_ tool/ images/ 367/ Child_ Gauge/ South_ Afric an_ Child_ Gauge_
2020/ Child Gauge_ 2020_ lowres_ 18_ 02. pdf
McGuire, S. (2015). World Health Organization. Comprehensive imple-
mentation plan on maternal, infant, and young child nutrition.
Geneva, Switzerland, 2014. Advances in Nutrition, 6(1), 134–135.
Micha, R., Mannar, V., Afshin, A., Allemandi, L., Baker, P., Battersby,
J., etal. (2020). Global Nutrition Report: Action on equity to end
malnutrition. Report No.: 1916445276. Bristol, UK: Development
Initiatives.
Miewald, C., & McCann, E. (2014). Foodscapes and the geographies of
poverty: Sustenance, strategy, and politics in an urban neighbor-
hood. Antipode, 46(2), 537–556.
Misselhorn, A., & Hendriks, S. L. (2017). A systematic review of sub-
national food insecurity research in South Africa: Missed oppor-
tunities for policy insights. PLoS ONE, 12(8), e0182399. https://
doi. org/ 10. 1371/ journ al. pone. 01823 99
Monyeki, M. A., Awotidebe, A., Strydom, G. L., de Ridder, J. H., Mamabolo,
R. L., & Kemper, H. C. (2015). The challenges of underweight and
overweight in South African children: Are we winning or losing the
battle? A systematic review. International Journal of Environmental
Research and Public Health, 12, 1156–1173. https:// doi. org/ 10. 3390/
ijerp h1202 01156
Mpandeli, S., Naidoo, D., Mabhaudhi, T., Nhemachena, C., Nhamo, L.,
Liphadzi, S., Hlahla, S., & Modi, A. T. (2018). Climate Change
Adaptation through the Water-Energy-Food Nexus in Southern
Africa. International Journal of Environmental Research and Pub-
lic Health, 15(10), 2306. https:// doi. org/ 10. 3390/ ijerp h1510 2306
National Department of Health, Statistics South Africa, South African Medi-
cal Research Council. (2017). South African Demographic and Health
Survey 2016: Key indicators. National Department of Health.
Omotayo, A. O., Ogunniyi, A. I., & Aremu, A. O. (2019). Data
on food insufficiency status in South Africa: Insight from the
South Africa General Household Survey. Data in Brief, 23, 1–6.
Pereira, L. M. (2014). The future of South Africa’s food system: What is
research telling us? SA Food Lab. https:// www . south ernaf ricaf oodlab.
org/ wp- conte nt/ uploa ds/ 2016/ 05/ safl_ the_ future_ of_ south_ afric as_
food_ system- libre. pdf
Pereira, L., & Drimie, S. (2016). Governance arrangements for the
future food system: Addressing complexity in South Africa. Envi-
ronment: Science and Policy for Sustainable Development, 58(4).
https:// doi. org/ 10. 1080/ 00139 157. 2016. 11864 38
Reddy, V., & Moletsane, R. (2009). The gendered dimensions of food
security in South Africa: A review of the literature. Centre for
poverty, employment and growth/HSRC,pp. 1–27.
Rose, D., & Charlton, K. E. (2002). Quantitative Indicators from a Food
Expenditure Survey Can Be Used to Target the Food Insecure in
South Africa. Journal of Nutrition, 132, 3235–3242.
Rossouw, H. A., Grant, C. C., & Viljoen, M. (2012). Overweight and
obesity in children and adolescents: The South African problem.
South African Journal of Science, 108(5/6), 907. https:// doi. org/
10. 4102/ sajs. v108i5/ 6. 907
Ruel, M. T., Alderman, H., & Maternal Child Nutrition Study Group.
(2013). Nutrition sensitive interventions and programmes: How can
they help to accelerate progress in improving maternal and child
nutrition? The Lancet, 382(9891), 536–551.
Schram, A., Labonte, R., & Sanders, D. (2013). Urbanization and Interna-
tional Trade and Investment Policies as Determinants of Noncommuni-
cable Diseases in Sub-Saharan Africa. Progress in Cardiovascular Dis-
eases, 56(3), 281–301. https:// doi. org/ 10. 1186/ 1742- 4755- 10- S1- S1
Seonandan, P., & McKerrow, N. H. A. (2016). Review of infant and
young child feeding practice in hospital and the home in KwaZulu-
Natal Midlands. South African Journal of Clinical Nutrition, 29(3),
18–22. https:// doi. org/ 10. 1080/ 16070 658. 2016. 11985 67
Shrimpton, R., Du Plessis, L., Delisle, H., Blaney, S., Atwood, S.,
Sanders, D., Hughes, & R. (2016). Public health nutrition capac-
ity: Assuring the quality of workforce preparation for scaling up
nutrition programmes. Public Health Nutrition, 19(11), 2090–
2100. https:// doi. org/ 10. 1017/ S1368 98001 50037 8X
Shisana, O., Labadarios, D., Rehle, T., Simbayi, L., Zuma, K., Dhansay, A.
M., etal. (2013). South African national health and nutrition examina-
tion survey (SANHANES-1). Human Sciences Research Council Press.
Spies, L., & Wentzel-Viljoen, E. (2023). The new Dietitian Nutritionist.
Unpublished paper presented at the Biennial Nutrition Congress,
Somerset West, South Africa, 8-20 April 2023.

Stories of Challenge in nutrition: the case of South Africa
1 3
Steyn, N. P., Labadarios, D., Maunder, E., Nel, J., & Lombard, C. (2005).
Secondary anthropometric data analysis of the national food consump-
tion survey in South Africa: The double burden. Nutrition, 21(1), 4–13.
Stories of Challenge in Nutrition South Africa (SoChall). (2021). Sto-
ries of challenge validation workshop report. Virtual Meeting.
Temple, N. J., & Steyn, N. P. (2011). The cost of a healthy diet: A
South African perspective. Nutrition, 27, 505–508. https:// doi.
org/ 10. 1016/j. nut. 2010. 09. 005
Tricco, A. C., Lillie, E., Zarin, W., etal. (2018, September 4). Research
and Reporting Methods: PRISMA Extension for Scoping Reviews
(PRISMA-ScR): checklist and Explanation. Annals of Internal Medicine.
Vorster, H. H., Bourne, L. T., Venter, C. S., & Oosthuizen, W. (1999). Contribu-
tion of nutrition to the health transition in developing countries: A frame-
work for research and intervention. Nutrition Reviews, 57(11), 341–349.
Western Cape Government. (2017). Nourish to flourish: An overview
of the Western Cape Government Strategic Framework for House-
hold Food and Nutrition Security. Retrieved August 2, 2019, from
https:// www. weste rncape. gov. za/ assets/ food_ secur ity_ web. pdf
World Health Organization. (2020). Policies in South Africa. Global
database on the Implementation of Nutrition Action (GINA).
Retrieved August 15, 2020, from https:// www. who. int/
Scott Drimie has overtwo decades
of research and teaching expertise
related to food systems, liveli-
hoods and vulnerability in Africa,
with in-depth knowledge of food
and nutrition security. Taking a
largely political economy lens, he
has focused primarily on food
policy and the facilitation of new
institutional arrangements for
food system governance.
Scotthas wide-ranging skills in
cross-disciplinary research and, at
Stellenbosch University,is a Pro-
fessor at the Nutrition Division,
Department of Global Health,
Faculty of Health and Medicine
Sciences, South Africa.Hehas
directed the Southern Africa Food Lab (www. south ernaf ricaf oodlab. org)
since 2013. This is a multi-stakeholder initiative that brings together
stakeholders in the regional food system to identify and pilot innovative
means to achieve long-term, sustainable food security.
Mara van den Bold is PhD Can-
didate in the Graduate School of
Geography at Clark University,
Worcester, Massachusetts, United
States of America. From 2012 to
2021, she was a (Senior) Research
Analyst at the International Food
Policy Research Institute (IFPRI),
where her work focused on exam-
ining the impacts of nutrition-
sensitive agriculture programs on
nutrition andgender-related out-
comes, as well as carrying out mixed methodsresearch on the drivers of
nutrition change in a varietyof settings. Her work primarily fell under
several largeresearch consortia, including Transform Nutrition, Leverag-
ingAgriculture for Nutrition in South Asia LANSA), andTransform
Nutrition West Africa. Mara holds an MSc inAnthropology and Develop-
ment from the London School of Economics and Political Science(LSE)
and a BA in Anthropology and Latin American & Caribbean Studies from
UnionCollege.
Lisanne Du Plessis is a lecturer/
researcher in Public Health and
Community Nutrition in the
Division of Human Nutrition,
Department of Global Health,
Faculty of Medicine and Health
Sciences, Stellenbosch Univer-
sity, South Africa. She is dually
registered as dietitian and nutri-
tionist with the Health Profes-
sions Council of South Africa.
Her field of experience spans 27
years of engagement in Public
Health Nutrition. She has a spe-
cial interest in and research focus
on the environment that affects
Maternal, Infant and Young
Child Nutrition and Early Child-
hood Development. She currently lectures postgraduate modules to
nutrition students and undergraduate modules to dietetic, nursing, physi-
otherapy, and medical students, providing study leadership for under-
graduate and postgraduate research. She is active in various committees/
working groups with a link to social impact, among other, the Western
Cape Government, Department of Health: Nutrition Sub-Directorate -
Infant and Young Child Feeding Technical Working group.
Laura Casu is a research officer
and research consultant at the
Institute of Development Studies
(IDS) and International Food
Policy Research Institute (IFPRI),
and a doctoral researcher at Uni-
versity College London, United
Kingdom.After gaining a Mas-
ter’s in Development Studies at
IDS, she has worked in mixed
methods research, policy coher-
ence analysis, implementation
monitoring and impact evaluation
in low- and middle-income coun-
tries. Recent work includes
research on multiple forms of
malnutrition, health and syndem-
ics, food systems, governance and
accountability, under research projects led by the Institute of Develop-
ment Studies, International Food Policy Research Institute, CGIAR
Research Programme on Agriculture for Nutrition and Health (A4NH),
Supporting Policies, Programs and Enabling Action through Research
(SPEAR), Transform Nutrition West Africa (TNWA) and World Food
Programme (WFP), among others.