1. Micronutrient Programmes in South Africa: Where have we come from? Where are we now? and Where are we going? Ms Chantell Witten Prof David Sanders Dr Mickey Chopra

2. South Africa in Context

3. Demographics Total population (millions)40.1 Urban population (%)55.4 % population < 15 years34 % population > 60 years7 Estimated % HIV prevalence* % maternal HIV prevalence* 10 22.9 1996 Census * Department of Health 1999

4. Demographics % Fully immunized Maternal education level - high Maternal education level - low 63 54 72.5 Gini Coefficient0.68 Under-5 mortality rate per 1000 Maternal education level - high Maternal education level - low 59 29.3 83.8 Infant mortality rate per 100045 South African Demographic and Health Survey 1998

5. Where have we come from? Pre-1994 – Fragmented Health System racially, geographically, structurally, functionally 1994 – ANC Health Plan Reconstruction and Development Programme (RDP) Single Health System in 9 Provinces 1997 – White Paper for the transformation of the South African Health System Comprehensive Primary Health Care District Health System 1994 – First Democratic Elections

6. Major Nutrition Activities National Nutrition and Social Development Programme (pre 1994) Community based programmes Protein Energy Malnutrition Scheme (pre 1994) Facility based programmes Primary School Nutrition Programme (1994) Provide snack 20% - 25% RDA Energy To improve active learning capacity To improve school attendance

7. Focus Areas of Integrated Nutrition Programme (INP) Disease-specific nutrition support, treatment and counselling Growth monitoring and promotion Nutrition education, promotion and advocacy Micronutrient malnutrition control Food service management Promotion, protection and support of breastfeeding Contribution to household food security

8. Malnutrition in South Africa South African Vitamin A Consultative Group (SAVACG,1994) children 6 – 71 months Stunted1 in 4 (24.9%) Underweight1 in 10 (9.8%) Wasting- National Food Consumption Survey (NFCS,1999) children 1 - 9 years Stunted1 in 5 (21,6%) Underweight1 in 10 (10,3%) Wasting1 in 25 (3.7%)

9. Malnutrition in South Africa Prevalence of Stunting in children 1 – 9 years (NFCS, 1999)

10. Malnutrition in South Africa Prevalence of Underweight in children 1 – 9 years (NFCS, 1999)

11. Malnutrition in South Africa Prevalence of Wasting in children 1 – 9 years (NFCS, 1999)

12. Iodine Deficiency Disorder (IDD) Visible goitre 1% SAVACG, 1994 children 6 – 71 months Northern Cape4% Gauteng0.2% No difference when comparing Rural vs Urban areas

13. Malnutrition in South Africa Iron status of children 6 – 72 months (SAVACG, 1994)

14. Iron Deficiency Anemia (IDA) Anemia (Hb<11g/dl) 21% SAVACG, 1994 children 6 – 71 months Rural areas8% Urban Areas12% Children with VAD higher risk of being anemic and having iron deficiency anemia (IDA)

15. Vitamin A Deficiency (VAD) Night blindness12% Bitot’s spots 0.4% – 0.8% Corneal Xerosis0.2% – 0.7% Keratomalacia0.1% SAVACG, 1994 children 6 – 71 months Subclinical VAD (<20µg/dl) 33% Rural areas38% Urban Areas25%

16. Policies and Programmes to address Micronutrient Malnutrition (MM) Vitamin A High dose Supplementation (2000) Food Fortification Diet Diversification Iron Routine Iron supplementation in children 6 – 24 months Routine Iron supplementation during pregnancy Iodine Mandatory salt iodisation (1995)

17. Policy and Programmes to address IDD Impact of compulsory Iodisation of food grade salt Iodine increase from 14 ppm to 33 ppm within one year Coverage of iodised salt from 30% to 62% of households in the country Issues with IDD Vulnerable groups: rural and low socio-economic groups Inadequate iodised salt (19,2%) at retail level Monitoring and evaluation by salt producers

18. Policy to address IDA Policy High dose supplementation of children 6 – 24 months Routine supplementation of pregnant women Issues with IDA Availability of high dose supplements Compliance with routine supplementation of pregnant women Monitoring and evaluation

19. Policy to address VAD Vitamin A supplementation (2000) Lactating women - single dose of 200 000 IU Vitamin A within 8 weeks post partum Children 6-60 months: 6 - 11 months:1 x 100 000 IU every 3 months (preferably at 9 months) 12 - 60 months:1 x 100 000 IU every 3 months or1 x 200 000 IU every 6 months

20. Availability, accessibility and affordability of high dose supplements Mode of distribution: campaigns vs Extended Programme of Immunisation (EPI) Monitoring and evaluation Issues with Vitamin A supplementation

21. Issues with Vitamin A fortification Technical Investigation of suitable food vehicles (NFCS, 1999 – 2001) Monitoring and evaluation processes No legislation in place

22. Issues with Vitamin A fortification Commercial Proposed vehicles (NFCS, 2001):  maize  white and brown wheat flour  white retail sugar Concerns of prospective industries  SA Sugar Industry  SA Maize Milling Industry Cost Monitoring and evaluation processes

23. Where are we now? Gap between policy and implementation Policies in place with no programmes Lack of monitoring and evaluation Challenges to implementation Ineffective Leadership Complex bureaucracy Inadequate human resource capacity Industry autonomy IDD versus VAD and IDA

24. Where are we going? Advocacy Research institutions International agencies Conferences Engagement with industry National Food Fortification Task Team Capacity Development SoPH Winter School Wageningen Agricultural University (The Netherlands) Development of models of implementation MOST (USAID) - Eastern Cape HKI – Mpumalanga, Northern Province

25. Thank You School Of Public Health, UWC South Africa