Implementing an Integrated Nutrition Programme - Health Systems ...

Implementing an Integrated Nutrition Programme:
A situation analysis of progress in the Lower Orange
Region of the Northern Cape
Northern Cape ISDS Technical Report # 4
April 2000
Compiled by: Elsabe Immelman and Lesley Bamford
In collaboration with health and nutrition workers in the Lower Orange
District and Provincial Office

WHY HAS THIS REPORT BEEN WRITTEN?
This report aims to outline the progress which has been made in implementing an Integrated
Nutrition Programme in the Lower Orange Region or District of the Northern Cape.
This situation analysis was undertaken with a number of different aims and a number of
different target audiences in mind. These were:
1. To act as a resource document for health and other service providers in the district.
Health services have historically been provided in a fragmented manner and the process
of drawing all information together can be an important step in developing a more
integrated approach to nutrition and nutrition services. No primary research was
undertaken – the analysis rather aimed to collate and review all information that is
currently available.
2. To outline the progress which has been made within the district and the province as a
whole in implementing a decentralised and integrated nutrition programme. Although
conditions in other provinces are often different to those in the Northern Cape, other
districts and provinces can learn from the Northern Cape experience.
3. It is hoped that the report will motivate other districts to undertake a similar situation
analysis of nutritional status and interventions in their districts as an important step in
developing and implementing a District Integrated Nutrition Programme. It is hoped that
the framework, which was used for this situation analysis, will prove useful to other
districts.
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Framework for District INP Situation Analysis
Chapter One: District profile
1. Nutritional status in the district
1.1. Severe protein-energy malnutrition
1.2. Anthropometric information
Facility-based information
Community-based surveys
1.3. Micronutrient deficiencies
1.4. Low birthweight rate
1.5. Exclusive breastfeeding at four months
1.6. Prevalence of diseases which result from poor nutrition
2. Underlying causes of malnutrition
2.1. Socio-economic conditions
2.2. Maternal and child care
2.3. Identification of at-risk communities
Chapter Two: Management of the INP
1. The role of the Provincial Office
2. District level
2.1. Role of the INP in the district
2.2. Personnel
2.3. Nutritional surveillance
2.4. District Nutrition Plan
2.5. Support from other district systems
Chapter Three: Nutrition-related activities in the district
1. Facility-based activities
1.1. Breastfeeding promotion
1.2. The Baby Friendly Hospital Initiative
1.3. Nutrition education
1.4. Growth monitoring
1.5. Management and referral of children with growth faltering
1.6. PEM scheme
1.7. Management of children with severe PEM
1.8. Micronutrient supplementation
1.9. Parasite control
2. Community-based nutrition projects
3. Primary School Nutrition Programme
3.1. Organisation and management
3.2. Financial resources and control
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3.3. Problems with implementation
3.4. Involvement of NGO’s and CBO’s
3.5. Nutrition education projects
3.6. Parasite eradication and micronutrient supplementation
Chapter Four: Contribution of other sectors
Chapter Five: Factors which facilitate and constrain the programme
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List of Tables
Table 1: Admissions to Gordonia Hospital of children with severe PEM.
Table 2: Percentage of children who were UWFA (October to December 1997).
Table 3: Percentages of children who were UWFA or stunted (SAVCG study)
Table 4: Percentage of children with severe malnutrition (SAVCG study)
Table 5: Percentage of school entrants with low anthropometric values (DoH study)
Table 6: Summary of anthropometric data
Table 7: Percentage of Coloured School Children (6-12 years) with low anthropometric
indices
Table 8: Micronutrient deficiencies
Table 9: Socio-economic indicators for Upington Municipal Area
Table 10: Maternal and perinatal statistics: Gordonia Hospital: April 1998 to March 1999
Table 11: Admissions to Children’s Ward at Gordonia Hospital
Table 12: PEM scheme budget for Lower Orange
Table 13: Budget for PSNP, Lower Orange
Appendices
Appendix A: Results of Department Of Health Survey of Preschool Children
Appendix B: Job Descriptions
Appendix C: District Nutrition Plan
Appendix D: Schools participating in the PSNP
Appendix E: Projects funded by the Alleviation of Poverty Fund
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Chapter One: District profile
Lower Orange is one of the six health regions or districts of the Northern Cape. Although it
is the largest health district in South Africa, covering an area of 91 450 km 2 , it has a
population of only 165 000 people. The area is arid, with extremely high temperatures in
summer and low rainfall. The banks of the Orange River are irrigated and the grapes grown
in the vineyards which line the river provide the basis for most economic activity in the area.
The district can be divided into four areas based on the patterns of settlement:
• Upington with a population of approximately 55 000 people is the largest town and the
centre of the district.
• A number of small towns such as Keimoes, Kakamas and Groblershoop are situated
along the banks of the Orange River.
• Farming areas along the irrigated banks of the river – the main activity is grape farming
which is relatively labour intensive. Farm workers live on the farms or in small
settlements, which were established during the 1970s. In addition, large numbers of
seasonal workers migrate to the area from the North West province during grapepicking
and pruning seasons.
• Isolated communities who live either on large (usually cattle) farms or as independent
communities. Provision of basic services to these communities is often very difficult and
many such communities still lack access to such services.
1 Nutritional status in the district
It is estimated that there are approximately 18 000 children under the age of five years in the
district. Reliable information regarding the nutritional status of these children is not available.
Although some information is available for the province as a whole, for the most part, this
information is not disaggregated by district. The information is nevertheless presented below
as it gives an indication of the situation in the district.
1.1 Severe protein-energy malnutrition
Children diagnosed as having severe protein energy malnutrition are admitted to one of the
three hospitals in the district. Until recently no formal system of surveillance of the number of
children admitted with severe PEM existed. The results of a retrospective review of
admission data for Gordonia Hospital, the district hospital situated in Upington, are shown in
Table 2. Children were classified by the Medical Officer in charge of the ward at the time of
admission using the Wellcome Classification.
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Table 1: Admissions to Gordonia Hospital of children with severe PEM.
Kwashiorkor Average (per
month)
Marasmus Average (per
month)
Deaths Case
fatality
March – Dec 1996 30 3 7 0.7 3 8.1%
Jan – Dec 1997 32 2.7 5 0.4 4 10.8%
Jan - July 1998 17 2.4 8 1.1 4 16%
TOTAL 79 2.7 20 0.7 11 11.1%
The figures suggest that the number of children admitted with severe PEM is decreasing
slowly over time. At the same time the case fatality rate is increasing. The contribution of
HIV/ AIDS to the increase in the number of deaths is not known.
Figures for other hospitals in the district are not available.
1.2 Anthropometric information
1.2.1 Facility-based information
A lot of effort has been expended on facility-based nutritional surveillance (see latter section
on nutritional surveillance).
Figures for the period October to December 1997 are shown in Table 3. During that period
a mean of 14 % of children who were weighed at clinics or community health centres were
found to be underweight-for-age (UWFA).
Table 2: Percentage of children who were UWFA (October to December 1997).
% of children who are
UWFA
Estimated % of children
weighed per month
Upington Sub-district 17 43
Keimoes Sub-district 4 37
Kakamas Sub-district 19 39
Pofadder Sub-district 21 25
Kenhardt Sub-district 17 43
Mier Sub-district 10 29
The variation between the sub-districts and over time points to some of the limitations of this
kind of nutritional information. Nevertheless it can be estimated that approximately 15 % of
under-fives who are weighed at PHC facilities are underweight-for-age.
1.2.2 Community-based surveys
Anthropometric information based on community surveys in the Northern Cape is extremely
limited. Although children from the district have been included in a number of national
studies, the information has not been disaggregated by district.
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Preschool children
Three studies have documented the anthropometry of preschool children in the province,
namely the 1994 Vitamin A (SAVCG) study 1 , the SALDRU/World Bank study 2 and a
national survey undertaken by the Department of Health 3 in 1994 which measured the
anthropometry of children on school entrance.
Vitamin A (SAVCG) study
Nationally 10.6% of children were found to be underweight-for-age. Only 2.5% of children
were underweight for their height (wasted). This suggests that acute malnutrition is not a
major problem. Levels of stunting were however found to be extremely high (27%)
suggesting that chronic malnutrition is a major problem.
Table 3: Percentages of children who were UWFA or stunted (SAVCG study)
Underweight-for-age Stunted
Northern Cape 15.6 22.8
Free State 13.6 28.7
North West 13.2 24.7
Northern Province 12.6 34.2
Eastern Cape 11.4 28.8
Mpumalanga 7.3 20.4
Western Cape 7.0 11.6
Gauteng 5.6 11.5
Kwazulu/Natal 4.2 15.6
National average 10.6 27.0
The Northern Cape had the highest rate of underweight-for-age of all provinces in the
country (15.6%). Four provinces, the Northern Province, Eastern Cape, Free State and
North West had figures which revealed higher levels of stunting than the Northern Cape
(22,8%) which had levels below the national average.
The province therefore had a similar pattern of high stunting and low wasting which is found
in most of South Africa, although the difference between the number of children who were
underweight-for-age and stunted was much smaller.
The figures for children who were severely malnourished i.e. -3 Z-scores or more are shown
in Table 4. There were fewer children who were severely malnourished in the Northern
Cape than the national average.
Table 4: Percentage of children with severe malnutrition (SAVCG study)
-2 Z score -3 Z score
Measurement N.Cape National N.Cape National
Weight for age 15.6 10.6 1.1 1.8
Weight for height 2.5 2.8 0.1 2.8
Height for age 22.8 27.0 5.9 8.4
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Department of Health survey
The National Department of Health undertook a survey of school entrants in 1994. A total
of 97 790 children, equal to 4.9% of school entrants, were included in the study. The
average age was 7.4 years.
Figures for the province are shown in Table 5 with the national figures in brackets.
Breakdown by population group is shown in Appendix A.
Table 5: Percentage of school entrants with low anthropometric values (DoH study)
Measurement -2 Z score -3 Z score Sample size
Weight-for-age 19.2 (13.2) 3.7 (2.6) 5 053 (97 790)
Weight-for-height 5.4 (2.6) 0.3 (0.2) Average age
Height-for-age 20.9 (9.0) 1.3 (0.5) 7.6 (7.4)
The data is in line with the Vitamin A study and again indicates that wasting (low weight-forheight)
is not a serious problem on a national basis. Once again the Northern Cape was
found to have a high rate of UWFA when compared with other provinces.
SALDRU study
A study undertaken by SALDRU reported that 35.6% of Northern Cape children had low
height-for-age i.e. were stunted. This was well above the national average of 25.4% found in
the study.
Interpreting the results
The results from the three studies are summarised in the table below.
Table 6: Summary of anthropometric data
Study Percentage stunting Percentage UWFA
N.Cape National N.Cape National
Preschool (SAVACG) 22.8 27.0 15.6 10.6
Preschool (SALDRU) 35.6 25.4 -
School entrants (DoH) 19.2 13.2 20.9 9.0
Overall the studies suggest that approximately 20 - 30 % of preschool children in the
Northern Cape are stunted and that approximately 15 - 20 % of children are underweightfor-age
(UWFA).
The average prevalence of underweight-for-age is therefore high in comparison to other
provinces. This can in part be explained by the demographics of the province. Analysis of
demographic data collected by several researchers from 1976 to 1996 from more than 60
000 preschool children revealed that amongst coloured, white and Indian children mean
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prevalence of children with low weight-for-age were higher than those with low height-forage.
This indicates that underweight was a more serious problem than stunting.
In the Northern Cape, the fact that coloured children make up a high proportion of the
population, results in a similar picture for the province as a whole.
Primary school children
Anthropometric information about school age children in the district is not available.
A study undertaken amongst coloured school children in the Richtersveld area of
Namaqualand Health District revealed extremely low anthropometric values 4 . Although
these figures are not representative of the whole area, conditions in the Richtersveld are
similar to those found in parts of the Lower Orange district, particularly in isolated rural
areas.
Table 7: Percentage of Coloured School Children (6-12 years) with low anthropometric indices
Children 7 - 10 years
Gender Sample size Measurement % below the 5 th percentile
Male 131 Weight for age 33
Height for age 36
Female 139 Weight for age 35
Height for age 47
Children 11 - 14 years
Gender Sample size Measurement % below the 5 th percentile
Male 98 Weight for age 52
Height for age 63
Female 114 Weight for age 53
Height for age 53
The figures reveal extremely high levels of stunting and underweight-for-age (weight-forheight
was not reported) with almost half of children between seven and ten years falling
below the 5 th percentile. These figures were even higher for children between 11 and 14
years. This difference is difficult to interpret, but suggests that pubertal growth was delayed.
1.3 Micronutrient deficiencies 1
Once again, information is only available for the province as a whole (Table 8). At a national
level, 33% of children were found to have marginal deficiency with children living in rural
areas and with poorly educated mothers being the most disadvantaged. Although the
percentage of children with marginal Vitamin A deficiency was lower in the Northern Cape,
almost 1 in 5 children fell into this group.
21.5% of children between 6 - 72 months of age were found to be anaemic (Hb

serum ferritin levels below 12ug/l as opposed to a national figure of 9.8%. This indicates that
anaemia is a significant problem in the province.
Table 8: Micronutrient deficiencies
% of children below cut-off point
Measurement Cut-off point National N.Cape
Serum retinol < 20 µg/dL 33% 18.5%
Haemoglobin < 11g/dL 21% 21.5%
Serum ferritin < 12µg/dL 9.8% 10.9%
1.4 Low birthweight rate
20% of babies born in the district between October and December1997 weighed less than
2.5kg. Although accurate figures for the country as a whole are not available, a rate of 20%
is extremely high. Such high rates are associated with low socio-economic status and poor
maternal nutrition.
1.5 Exclusive breastfeeding at four months
No data concerning breastfeeding is available. The information is not collected routinely nor
have any surveys been undertaken. Health workers in Upington report that breastfeeding
rates have increased following efforts at Gordonia Hospital to become more Baby Friendly
(see below).
1.6 Prevalence of diseases which result from poor nutrition
Information about health status is poor. The district is known to have one of the highest
incidences of TB in the country with a reported incidence of 845 cases per 100 000 for
1996.
Information regarding deaths is also not available at present.
2 Underlying causes of malnutrition (based on UNICEF
conceptual framework)
2.1 Socio-economic conditions
2.1.1 Household food security
Information specifically about household food security in the district is not available.
Although the area’s economy is dependent on agriculture, this is almost exclusively
commercial farming with small-scale farming making only a small contribution in rural areas.
The majority of households rely exclusively on purchasing food and are therefore dependent
on wages and other sources of income.
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2.1.2 Household income
Information regarding household and per capita income is very limited. The October
household survey of 1994 reported on income for workers in the formal sector 5 . Within the
Northern Cape 41% of workers in this sector earned less than R500 per month -
interestingly only 31% of working women earned less than R500 per month as compared to
45 % of men. Per capita income appears to be higher in Upington than for the province as a
whole (see box below). This is to be expected – in general incomes in urban areas are
higher than rural areas and Upington is considered to be the most prosperous town in the
province.
There are also no accurate unemployment figures for the province. The October Household
Survey estimated that 32,5% of an estimated 278 743 economically active people were
unemployed. Rates were higher for Coloureds (37.9%) and Blacks (39,4%) than Whites
(7,2%). Fifty-seven percent of unemployed people had been unemployed for more than a
year at the time of the survey. Almost seventy-five percent of unemployed people were not
trained or skilled for specific work.
Agriculture is the major economic activity in the Lower Orange District. The main produce is
grapes and sun-dried fruits. Although the water supply limits development of agriculture,
exploitation of overseas markets provides opportunity for some economic growth. Apart
from some food processing (wine and sun-dried fruits), there is no manufacturing or
industrial activity.
Employment opportunities are therefore limited with strong seasonal variation in availability
of work. Pensions and other grants form an important source of income for many
households. Although there are no accurate figures, there is no doubt that a sizeable
proportion of the population live in poverty.
2.1.3 Provision of basic services
The figures for the Northern Cape are shown below. In the Lower Orange district, a higher
proportion of people live in rural areas. It can therefore be expected that a lower proportion
of people have access to basic services when compared to the provincial figures.
Main source of domestic water
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15%
1%
11%
1%
Tap in house
Tapwater on site
Communal tap
Borehole/Well
River/dam/spring
Other
27%
45%
Main energy source for cooking
28%
2%
16%
Electricity
Gas
Paraffin
Wood
Coal
10%
44%
Sanitation
19%
16% 10%
Flush/chemical toilet
in dwelling
Flush/chemical toilet
outside dwelling
Latrine with bucket
system
Pit latrine
41%
No facility
14%
Refuse disposal
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18%
14%
2%
Removed by Local
Authority
Communal refuse
dump
Own refuse dump
None
66%
The situation in the smaller towns is more varied, although refuse is removed from all
settlements. Although variable, living conditions on many farms are extremely poor.
UPINGTON
A socio-economic profile of the Upington municipal area was undertaken in 1998 6 . Some
of the results are shown below.
Table 9: Socio-economic indicators for Upington Municipal Area
Total population 55 334
Population

On average socio-economic conditions and provision of basic services are good when
compared to conditions elsewhere in the country. There are however significant numbers of
households with incomes below the poverty level.
There is no information regarding household income in the rural areas, but incomes would be
expected to be lower than in Upington. Although basic services are provided in the
municipal areas in most of the small towns in the area, this is not so in the more rural areas.
2.2 Maternal and child care
2.2.1 Status of women and female literacy rates
No information is available.
2.2.2 Maternal and Child Health services
Maternal and child health services are provided at all PHC facilities in the district. All
facilities provide preventative and curative services.
Child Health Services include growth monitoring and immunisation services as well as
curative care. Little is known about the quality of these services. Traditionally many clinics
provided certain services on certain days. Many clinics still have an “Immunisation Day”
when children who attend for immunisations receive preferential treatment.
Antenatal and postnatal care and family planning services are provided by all clinics. High
risk pregnancies are referred to Gordonia Hospital for ANC and hospitals and Community
Health Centres supervise deliveries. Termination of pregnancy is available only at Gordonia
hospital - women can be referred and transport is provided free of charge.
In the past, reliable figures regarding maternal and child health status were not available. This
situation is improving although the majority of figures are still based on facility records and
do not necessarily reflect what is happening in the district as a whole.
The perinatal mortality rate is high with stillbirths accounting for more than half of the deaths.
Figures for Gordonia Hospital for the period April 1998 to March 1999 are shown below.
Table 10: Maternal and perinatal statistics: Gordonia Hospital: April 1998 to March 1999
Total deliveries 1 596
Average per month 133
Maternal deaths 0
Teenage pregnancy rate 21 %
Caesarian section rate – public patients 9 %
Caesarian section rate – private patients 53 %
Stillbirth rate 38 per 1 000
Perinatal mortality rate 60 per 1 000
Low Birth Weight rate 22 %
The following figures are available for the period September 1998 to March 1999.
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Table 11: Admissions to Children’s Ward at Gordonia Hospital
Condition No of children % of total
Diarrhoeal disease 469 38%
Acute respiratory infections 186 15 %
Severe malnutrition* 36* -
Total 1236 100 %
* this covers the period April 1998 to March 1999
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Breastfeeding and weaning practices
Little is known about breastfeeding and weaning practices in the district or in the province as
a whole.
A recent evaluation of the PEM scheme included a section on these practices 7 . It should be
noted that the research was done in the Diamond Fields area - practices in the Lower
Orange district may be different
Key findings were:
• All but one of the mothers had delivered in a health facility.
• 86% of mothers initiated breastfeeding.
• Infants were exclusively breastfed for an average of 2.3 months.
• At least 20% of babies were given a feed other than breastmilk as their first feed.
• Most mothers breastfeed on demand.
• Nurses were the most common source of breastfeeding support.
• Nurses were reported to have advised introduction of formula feeds.
• No significant differences in breastfeeding practices were detected between mothers of
well-nourished as compared with mothers of malnourished children.
• The average age of weaning was three months.
2.2.3 Prevalence of diseases which contribute to poor nutrition e.g. parasite
infestation, HIV infection
The Eighth Annual HIV seroprevalence survey of women attending antenatal clinics in the
district documented an HIV prevalence rate of 7% 8 . Although this is lower than in many
areas of the country, increasing number of patients are being seen.
No studies have documented the levels of parasite infestation in the district.
2.3 Identification of at-risk communities/groups
Information to identify at-risk communities is not available. People living in towns,
particularly Upington have better access to jobs and basic services when compared to
people living on farms and in small settlements.
CONCLUSION
• Overall the figures suggest that approximately 15% of preschool children in the district
are underweight-for-age. Although case fatality rates for severe PEM are relatively low,
it is apparent that children are still dying as a direct result of malnutrition.
• Undernutrition is therefore an important problem facing the district. The fact that such a
high proportion of children are underweight for age, rather than stunted, suggests that
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lack of food (as opposed to poor access to health and other basic services combined
with poor feeding practices) remains a problem.
• Although the levels of Vitamin A deficiency is lower than in most parts of the country,
levels are still unacceptably high. Levels of anaemia are also high.
• Low birth weight rates are extremely high. This contributes to the high perinatal mortality
in the district.
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Chapter Two: Management of the INP
1 The role of the Provincial Office
The provincial Nutrition Sub-directorate falls under the Provincial Programme and Support
Directorate. Management of nutrition services in the province was traditionally extremely
centralised with all planning and budgeting being done in the provincial office. Following
implementation of the District Health System, management of the INP has been
decentralised to the districts. Attempts were made to ensure that the decentralisation
process occurred in a planned and logical way.
As a first step in this process, the respective roles of the provincial and district offices were
defined as follows:
PROVINCIAL FUNCTIONS
Determine policy; standards, norms
and identify indicators
Monitor, evaluate and manage information on
programmes (e.g. PSNP, PEM-scheme and
CBNP) to make decisions regarding the
budget, staff allocation etc.
Conduct research and development.
Initiative, develop and co-ordinate training
programmes according to needs of personnel.
Provide a comprehensive advisory service e.g.
budgets.
DISTRICT FUNCTIONS
Implement policies according to the needs of
the district.
Develop operational objectives and plans to
achieve set indicators.
Process and summarise data to make an input
to provincial office regarding nutrition
surveillance PEM-scheme (monitoring tool).
Monitor and evaluate CBNP according to
suggested work programme.
Submit quarterly progress reports on CBNP to
Provincial office.
Monitor and improve reliability of nutritional
data collected.
Initiate surveys by indicating which areas need
to be investigated.
Participate in surveys.
Identify training needs of personnel and PHC
workers in district.
Train personnel and PHC workers in order to
implement policies; gather information and
monitor programmes and do nutrition
education.
Plan district budget according to planned
activities.
Countercheck monthly expenditure of
programmes.
Manage decentralised budgets of Nutrition
Programmes.
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Develop criteria for performance audit e.g. job
descriptions
Liaise with associated Professional Boards
and National office.
Develop and maintain intersectoral links.
Co-ordinate and handle tender contracts
>R25 000.
Develop Nutrition Education Promotion
Strategy
• Nutrition packages for nutrition and
breastfeeding week;
• Key messages;
• School Nutrition Education Programmes;
• Lobby for donor funding;
• BFHI
Write monthly/quarterly reports to district
manager and/or Provincial office.
Set opportunities for staff capacity building.
Liaise with local NGO’s and other
Departments to co-ordinate and disseminate
nutrition information.
Comment on draft policies.
Represent nutritional component at
management and intersectoral meetings.
Manage and approve tender contracts < R25
000.
Prepare proposals and business plans of
CBNP’s for funding.
Organise and conduct nutrition promotion
activities and campaigns.
Incorporate and strengthen nutrition education
at clinics, schools and community groups.
Therapeutic Nutrition and Food-service
administration.
Once the respective roles of the provincial and district offices were defined, a process for
decentralisation of budgetary control from provincial to district level was outlined.
Step 1: Assessment of capacity in the districts.
This included ensuring that adequate personnel was available to manage the programme and
that there was adequate administrative support for financial management. In the Lower
Orange, an administrator was seconded from the Education Department to manage the
PSNP.
Step 2: Training in financial management
Skills on financial management were transferred to the district staff through a series of
workshops given by the provincial department.
Training included the payment process as well as advance payment, re-imbursement and
control and monitoring procedures.
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Step 3: Orientation on programme planning and budgeting.
This included:
• Operational plans for 1999/2000/2001
• Budgeting process
• Allocation of funds
• Monitoring and information management
Districts are now responsible for management of all aspects of the district INP including
budgetary planning and control. The nutritionists from each district hold monthly meetings in
Kimberley. The district staff feel that the support provided through this meeting and through
other contacts is appropriate.
2 District Level
2.1 Role of the INP within the district
Significant progress has been made in implementing the District Health System in the
Northern Cape. Although PHC services are still provided by a number of separate local
authorities, the district office plays an important co-ordinating role and is responsible for
day-to-day supervision and management of all facilities.
The district office was established in Upington in 1996 following the appointment of a district
manager and management and interim governance structures have been established.
The District Management Team is small and it is not anticipated that it will increase in size.
The district nutritionist is a member of the team which meets on a weekly basis.
2.2 Personnel
District nutritionist
The district nutritionist is responsible for managing and implementing the Integrated Nutrition
Programme. She is a qualified dietician and was appointed in 1997 having previously
worked for the House of Representatives. She has an office at the district office in Upington
and also at one at the CHC in Groblershoop.
She has a clear job description (see Appendix B). Her main tasks are to:
• Co-ordinate all nutrition services in the district.
• Implement all Provincial nutrition policies.
• Monitor and evaluate all nutrition programmes in the district.
• Monitor the district nutrition budget.
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She is assisted by three auxiliary service officers (see below) who are primary responsible
for provision of nutrition education. The nutrition advisors visit each facility on a monthly
basis. For the most part implementation of nutrition activities in the clinics is the responsibility
of the professional nurses in the facilities.
Nutrition advisors
The nutrition advisors were trained in the district (in-service training over a two year period).
They have responsibility for certain sub-districts and have also recently been trained as
DOTS supervisors.
Nutrition Advisors
Mrs W.M. Reed
Mrs C.A. Jansen
Mrs E.M.J. Prins
Sub-districts
Kakamas, Pofadder, Part of Mier
Rural areas of Upington, Kenhardt, Keimoes, Part of Mier
Upington - urban area.
Hospital dietician
There is a part-time dietitician at Gordonia Hospital. Her tasks include supervision and
support of the catering services at the hospital and provision of nutritional support and
advice to patients and staff at the hospital. She has also played a key role in the hospital’s
efforts to become more baby-friendly.
She provides a link between the hospital and the community nutrition services and works
very closely with the district nutritionist.
PSNP - administrator and clerk
As from August 1998, an administrator has been seconded from the Department of
Education to the Nutrition Programme for a period of three years. Her role is to oversee the
decentralisation of the PSNP to district level. Initially her role focussed on administration but
following the appointment of a clerk in July 1999, she will be able to focus more on
monitoring of the programme, as well as paying attention to the developmental aims of the
PSNP.
All staff have clear job descriptions which they feel are realistic and which accurately
describe the work which they do.
2.3 District Nutrition Plan
As part of the planning and budgeting process for the district as a whole, a District Nutrition
Plan was drawn up by the nutrition staff in consultation with the District Management Team.
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Five key performance areas were identified and objectives, activities and outcomes
identified together with the responsible person. The District Nutrition Plan is shown in full in
Appendix C.
The key performance areas were:
• Food assistance including the PSNP, food assistance for creches and the PEM scheme.
• Nutrition education focusing on curriculum development component of the PSNP, the
BFHI, the Lunch Box campaign and health promotion.
• Monitoring and evaluation of PSNP, PEM scheme and CBNPs. Improvements in data
collection and analysis.
• Capacity building
• Community development and intersectoral collaboration.
2.4 Nutritional Surveillance
A lot of confusion exists regarding nutrition surveillance. Over the last five years a number of
different systems have been in place. All systems have relied on information collected in
PHC facilities. The information is collected to be forwarded to the provincial office who
presumably forward it to the national Department of Health. The information is not used in
planning or evaluation of services.
1993 – 1996
In 1993, a system of facility-based nutrition surveillance was introduced in all clinics in the
Northern Cape. All children under-five were to be weighed once a month and their weights
plotted on a Master card. At the end of the month, a summary form was completed which
summarised the findings for the month. There were five age categories and five weight
categories, therefore each clinic had to complete thirty indicators. Nurses found this an
extremely time-consuming exercise.
> 97 th %tile
0 - 12 mnths 13 – 24
mnths
25 – 36
mnths
37 – 42
mnths
43 – 60
mnths
> 50 th : < 97 th % tile
> 3 rd : < 50 th % tile
60 % EWA: < 3 rd % tile
< 60 % EWA
Total
In addition, clinic nurses were also required to record the birthweights of children born in
their areas. Because clinics do not supervise deliveries, they had to obtain this information
from the local hospital. Infants, who were born at home but attended the clinic for
immunisation or other reasons, were also included.
23

Clinics were also required to report on the number of cases of severe PEM and pellagra
which were seen at the clinic. Hospitals were not required to supply this information although
during this period most severely ill children would have bypassed the clinics and gone
straight to hospital.
The information was forwarded on a monthly basis to the district office in Kimberley. The
clinics did not receive any feedback.
1996 - 1998
From 1996, the forms were sent to the district office rather than to Kimberley. Nurses were
required to separate children into those enrolled on the PEM scheme for each weight and
age category and also identify how many children were showing signs of growth faltering.
This meant that each child who was weighed had to be classified into one of ninety-six
categories. The form also required each clinic to supply information regarding birth weights,
catchment population and clinic attendance (so that an estimate of the number of children
targeted for growth monitoring could be made) and information regarding the number of TB
patients and pregnant or lactating women seen at the clinic and whether or not they were
gaining weight.
Problems with this system of surveillance included:
‣ Only children who attended the clinic were included.
‣ Nursing staff complained that the system was extremely time-consuming – in particular
completion of the form at the end of the month.
‣ Although the district nutritionist collated the information on a monthly basis and each
clinic received feedback in the form of hand-drawn graphs each month, the information
was not used for planning and evaluation.
‣ It was not clear how the system fitted into to nutritional surveillance at a national level.
1998 onwards
At the beginning of 1998, a simplified version of the form was introduced with a total of 12
data items. A computer programme for analysis of the information has also been developed
and information has been entered into it for the past two years.
This process has occurred in parallel to other efforts to streamline and improve the District’s
Health Information System.
2.5 Support from other district level systems
Progress has been made in implementing the District Health System in the district and the
nutrition programme receives good support from the management systems in the district.
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Transport
The district has a pool of vehicles which are managed by the district transport officer.
Nutrition personnel make use of these cars. In addition some staff, including the district
nutritionist, make use of the subsidised car scheme.
The activities of the nutrition programme are not limited by lack of vehicles. Since 1998 the
nutrition programme has been required to cover the costs of travel from its own budget.
During that financial year, the amount allocated to the Nutrition Programme was inadequate
to cover these costs which may result in a reduction of travel within the district. This affected
all nutrition staff, in particular the nutrition advisors as the main bulk of their work is done in
the outlying areas. Subsequently however the programmes budget has increased so as to
allow it to operate adequately.
Drugs and other supplies
Supplements for the PEM Scheme as well as for micronutrient supplementation are always
available at clinics, except in the case of a local authority’s budget for the PEM Scheme
being depleted or when a local authority does not order supplements in advance and then
runs out of stock.
Health Information System
The nutrition surveillance system has developed outside of the District’s Health Information
System. Now that district HIS is being developed, it will be important to ensure that the two
systems are integrated into one to avoid duplication.
PHC services and other programmes
There is good co-operation between the Nutrition programme and other PHC services.
Most facility-based nutrition activities are implemented by the PHC nurses who run the
clinics and Community Health Centres.
25

Chapter Three: Nutrition-related activities within the district
1 Facility-based activities
Most primary health services are provided by Local Authorities. Integrated Primary Health
Care is provided by a number of types of facilities.
These include:
• Community health centres which provide primary health care services including
supervision of deliveries. They provide a 24 hour service.
• Fixed clinics – these are for the most part situated in the small towns and fall under the
local municipalities. They provide services during working hours only.
• Satellite clinics. These are fixed clinics which are visited by the mobile services. They are
usually open one or two days a week.
• Mobile services provide services to farm workers. The frequency of the visits to farms
varies – some remote areas are visited only on a quarterly basis.
Until recently the mobile and satellite clinics fell under the District Council. They have now
been taken over by the district.
In addition there are three hospitals in the district. These are:
• Gordonia Hospital acts as a community hospital for the Upington sub-district and as the
referral hospital for other hospitals in Lower Orange. The hospital provides a limited
range of secondary level services and serves as the referral hospital for two neighbouring
districts (Hantam and Namaqualand).
• Kakamas and Keimoes have small community hospitals.
1.1 Breastfeeding promotion
Promotion of breastfeeding is regarded as a key activity. The following activities take place
on a ongoing basis:
• Promotion of breastfeeding as a key part of nutrition education.
• Implementation of the Baby Friendly Hospital Initiative
• The nutrition team is actively involved in Breastfeeding promotion activities during
National Breastfeeding Week in August each year.
1.2 Baby Friendly Hospital Initiative
Hospital management at Keimoes and Kakamas Hospital have been made aware of the
Baby Friendly Hospital Initiative and the importance thereof.
Gordonia hospital has been implementing the Baby Friendly Hospital Initiative. In 1997, four
Department of Health officials (the nutritionist, the hospital dietician and two professional
26

nurses) attended an eighty hour course where they were trained as trainers in lactation
management. The course was presented by UNICEF in Kimberley. After the training, a
meeting was held with the management of Gordonia Hospital during which they agreed to
implement the Baby Friendly Hospital Initiative. A Breastfeeding Committee was established
consisting of the following people from the hospital:
• The obstetrician
• The paediatrician
• The professional nurse from maternity
• The dietician
• The professional nurse responsible for training
• A health advisor
Interventions
• A breastfeeding policy for the hospital was developed and communicated to all staff
members
• In September 1997 formal in-service training of hospital started. All categories of staff,
including nurses, housekeepers and general assistants, were trained by the district
nutritionist and the hospital dietician using courses based on the 18 hour UNICEF
standard. By mid-1999 80% of staff had received training.
• All the categories of nursing staff form Upington Municipality and Lower Orange District
Council were trained so as to ensure that the ante-natal and post-natal management of
breastfeeding at primary health care clinics is done according to the Ten Steps.
• Personnel of other departments in Gordonia Hospital (administration, kitchen and
laundry staff) attended a one hour information sessions about the BFHI.
• Ten short breastfeeding related messages were developed. These messages will form
the basis of breastfeeding education at Gordonia Hospital’s ante-natal clinics and at all
PHC facilities in the district (which provide the bulk of ante-natal care).
• Procedures were introduced to ensure that mothers initiate breastfeeding within an hour
of delivery.
• A standard procedure/ routine on how to show all mothers in the maternity ward how to
breastfeed was implemented.
• “Acceptable medical conditions” where breastfeeding is not recommended were
developed for the maternity ward,
• Rooming-in was introduced. The nursery is now used as a special care unit where the
premature babies lie with their mothers. Breastfeeding on demand is encouraged and is
possible because babies stay with their mothers for 24 hours. Premature babies who
cannot breast or cup-fed, receive expressed breastmilk through tubes administered by
the mothers themselves.
• Breastfeeding on demand is encouraged. There are no feeding schedules.
• Mothers at discharge are referred to PHC clinics in their areas. A standard procedure of
referral, which ensures that mothers are seen regularly at the clinics, must still be
developed.
27

The above interventions have also been introduced at Kakamas Hospital.
In September 1998, an Interim Hospital Assessment was undertaken by a nutritionist from
the Child Health Policy Institute and a professional nurse from St Monica’s Hospital, the first
hospital in South Africa to officially be declared Baby Friendly. Their assessment showed
that the hospital had made significant progress in implementing all ten steps. Until now the
hospital has not been able to officially be accredited as being Baby-Friendly due to the lack
of recognised assessors in South Africa.
It is hoped that during the second half of 1999, two assessors from each province will be
trained as accreditors. The district nutritionist and the dietician from the hospital have been
chosen as the two representatives for the Northern Cape. After the training, a pool of
recognised accreditors will be readily available and it is hoped that Gordonia will rapidly be
able to achieve official recognition for their efforts at becoming baby-friendly.
1.3 Nutrition education.
Nutrition education is done by the nutrition advisors and by nursing personnel. Key
messages include:
• Growth monitoring
• The Growth chart
• Interpretation of the growth chart
• Nutritional deficiencies
• Management of diarrhoea
• The use of Oral Rehydration Solution
• How to make Sugar/Salt solution
• Weaning practices
• Breastfeeding recommendations
• Micronutrients
• PEM scheme
• PEM intervention strategy
• PEM protocols
• Referral organogram
• Nutrition during pregnancy and lactation
• General problems
• Management of overweight patients
• Management of diabetic patients
• Management of TB and HIV-positive patients
1.4 Growth monitoring
Growth monitoring is done by all PHC facilities in the district. All facilities are equipped with
baby scales although the quality of the monitoring has not been assessed.
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In theory every preschool child who attends the clinic is weighed once a month. The child’s
weight is plotted on the Road to Health Card.
1.5 Management and referral of children with growth faltering
Nurses have been trained in identification of children with severe malnutrition and growth
faltering.
• Children who have clinical signs of severe PEM are referred to hospital.
• Children with growth faltering are managed according to the referral protocol which is
available in all clinics.
• Food supplements are provided when the entry criteria for the PEM Scheme are met.
• Children on the PEM scheme who are not gaining weight adequately are screened for
conditions such as TB, anaemia and parasites.
1.6 PEM scheme
Most PHC facilities in the district participate in the PEM scheme.
During 1997, an evaluation of the scheme in the Northern Cape was undertaken by the
Child Health Unit of the University of Cape Town in collaboration with the Provincial
Nutrition Sub-directorate. The main findings of the evaluation 7 are shown below:
Operational activities
• During the 1996 - 1997 financial year, 67% of the allocated provincial budget for the
PEM scheme was utilised.
• During the same period the PEM scheme was estimated to have reached 30 - 40% of
malnourished preschool children in the province and 35% - 60% of pregnant and
lactating women.
• Eighty-five percent of the health facilities in the province participated in the scheme.
• Nursing staff who implemented the Scheme had not received training.
• No management information system existed at district or provincial level.
Implementation at local level
• Clinic nurses regarded infants 0 - 6 months, children 6 - 24 months and the chronically ill
as the main target groups.
• Some clinics enrolled children over six years, siblings and unemployed people on the
scheme despite the fact that they did not meet the inclusion criteria.
• Inclusion and exclusion criteria were poorly applied to pregnant and lactating women.
• Many participants received incorrect quantities of milk powder and PVM.
• Conditions such as foetal alcohol syndrome, anaemia and chronic disease were not
routinely excluded.
29

• Nutrition education was given regularly at most, but not all clinics. The main focus of
nutrition education was on the preparation of supplements, promotion of breastfeeding
and dietary advice.
• 63% of clinic nurses who implemented the Scheme felt that children participating in the
scheme achieve good catch-up growth. Perceived problems with the scheme included:
products not reaching the target groups, dependency on the supplements, irregular clinic
attendance by participants and unacceptability of the supplements.
• Suggestions for improving the scheme included: increasing supplies and resources,
supervised feeding of the target groups at a central point, increasing the regularity of
supplies and increasing personnel to assist in running the scheme.
Impact of the Scheme
This was assessed in two ways:
Retrospective analysis:
Records of 386 participants obtained from 34 clinics were analysed.
• Birthweights were recorded for 222 children. Ninety-two (41%) had low birth weights.
• Only 9.6% of children moved into the normal Z score range after a mean follow-up of
7.5 months.
• Fifty-eight children in the sample were diagnosed as having tuberculosis and one had
HIV.
Prospective study:
A monitoring tool was devised and tested in the Diamond Fields District for three months.
• The target groups who were enrolled were children 0 - 6 years (88%), lactating women
(3%), pregnant women (1%) and the chronically ill (8%).
• The main reasons for enrolment were underweight for age and growth faltering.
• The correct amounts of milk given to children were as follows:
0 - 6 months 26%
6 - 12 months 18%
12 - 72 months 43%
• The correct amounts of PVM were given in the following cases:
6 - 12 months 25%
12 - 72 months 35%
• Thirty-one percent of infants 0 - 6 months were inappropriately given PVM.
• An analysis of the weight-for-age Z scores at the first and third visits showed that 11%
of children had moved from below to above - 2 Z scores.
• 66% of children had dropped out of the Scheme by the third visit.
Acceptability of the products
30

• The mothers of children on the scheme reported that their children liked consuming the
available products.
• Only one third of mothers said that they would like to have other products on the
scheme.
Management of the PEM scheme has been decentralised to district level. The district is
responsible for allocating the funds to the various facilities within the district.
Efforts have been made to increase the enrolment of eligible children to the Scheme. As a
result the number of children participating in the Scheme has increased, whilst the budget has
decreased. As a result, a number of facilities have insufficient supplies. This situation will
need to be addressed – either more funds will need to be allocated or the target groups will
need to be redefined.
Table 12: PEM scheme budget for Lower Orange
Budget
97/98 Financial Year R125,000
98/99 Financial Year R111,024
99/2000 Financial Year R110,000
1.7 Management of children with severe PEM
Management of children with severe malnutrition at Gordonia Hospital
All children who are diagnosed as having kwashiorkor are admitted to the paediatric ward.
Most children remain in the hospital for three to four weeks.
Investigations
The following investigations are done routinely on all children admitted with severe
malnutrition:
• Full blood count, ESR, Total Protein and Albumen
• Blood culture, urine microscopy and culture.
• Tuberculin skin test (monotest) is done on admission and repeated after six weeks.
• Chest X-ray
Electrolytes and renal functions are measured if indicated.
Management
Feeding is initiated as soon as possible. Where possible, breastfeeding is encouraged,
otherwise standard infant formula is used unless diarrhoea is a major problem in which case
a soya-based formula is used. Children are fed three-hourly and nurses are instructed to
insert a nasogastric tube if the child is not feeding well.
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Supplementation
Children with kwashiorkor are routinely given pottasium and magnesium supplementation, as
well as a multivitamin mixture and iron and folate. High dose Vitamin A is not routinely
administered.
Treatment of complications
Children are not routinely given antibiotics unless indicated. Amoxycillin or Penicillin are
used as first line drugs.
Stimulation
Once a child’s condition improves, stimulation is regarded as being very important. The
occupational therapist has been involved in trying to make the environment more stimulating.
Nutrition education
Accommodation is provided only for mothers who are breastfeeding. Nursing staff provide
nutrition education to mothers on a informal basis – the mothers are encouraged to visit the
children as often as possible, particularly during the day, when nursing staff are available.
Follow-up
On discharge, the child is referred to the local clinic for follow-up and ongoing
supplementation when required. The relevant nutrition advisor is informed.
PEM Committee
Recently, a PEM committee has been formed at Gordonia Hospital. This is made up of the
paediatric doctor, the nutritionist, and the nutrition advisors as well as representatives of the
Welfare Department and the Child Protection Unit.
1.8 Micronutrient supplementation
Micronutrient supplementation is not routinely given. Discussions concerning the introduction
of routine supplementation with Vitamin A have taken place between the MCH directorate,
Nutrition sub-directorate and pharmaceutical services at provincial level. However no
definite policy has been decided on.
Recent evaluation of EPI services in the Kalahari district of the Northern Cape revealed a
good quality service with good coverage. A Vitamin A supplementation linked to EPI could
therefore be expected to achieve a high coverage.
32

1.9 Parasite control
There are no programmes for parasite control in the district. Treatment for worms is
available at all PHC clinics, but is not administered on a routine basis.
2 Community-based nutrition programmes or projects
Few non-governmental or Community-based organisations are active in the district. As a
result government departments have been encouraged to play a direct role in communitybased
projects. This situation is not ideal as nutrition workers do not necessarily have the
time nor skills to act as development officers. In addition, projects have been poorly coordinated
between the various departments. For instance there has been no contact between
the Department of Agriculture, which is involved in supporting small-scale farming in
Riemvasmaak (part of the Kakamas sub-district) and the Department of Health, which has
been supporting the establishment of a community garden in the town itself.
It is hoped that consolidation of all community-based projects under the Alleviation of
Poverty Fund will lead to better co-ordination. The Fund falls under the Department of
Welfare (which is now a separate department). In the future, the Nutrition Programme views
its role as providing nutritional input to projects rather than being responsible for initiating
community-based projects. The projects which will be funded during the 1999/2000
financial year in the district are shown in Appendix E.
The Nutrition Programme has however been directly involved in two community-based
nutrition programmes over the past few years. It is encouraging to note that both projects
have now been taken up by community members and that the nutrition staff are able to
downscale their involvement in the projects.
2.1 Kakamas community vegetable garden
History
The project began late in 1996 when the SANTA branch in Kakamas approached the
provincial Department of Welfare with a request for assistance in establishing a community
garden for TB patients in Kakamas. As a food production project it was referred to
Nutrition sub-directorate of the Department of Health which agreed to fund the project.
In1997, R39 000 was allocated to the project which was seen as part of an overall strategy
to reduce the TB incidence in Kakamas.
Organisational Structure
The Project committee is responsible for running the project including control of finances.
The committee consists of a project leader, a treasurer and a secretary. The sister-in-charge
of the local clinic, the nutrition advisor and the local social worker are also members.
33

Resources
The vegetable garden is situated in the grounds of the Kakamas hospital. The ground is
provided free of charge, but the project pays for water. Two of the project committee
members are from Kakamas Secondary School and the school is used for the project
committee’s monthly meetings.
Activities
The project aims to achieve the following goals:
• Production of vegetables (for use by TB patients).
• Provision of nutrition education for TB patients and their families.
• Monitoring and evaluation of TB patient’s nutritional status.
The garden is now producing vegetables, although it is not yet able to supply all TB patients
with a regular supply of fresh vegetables. Other activities include holding weekly soup
kitchen where the nutritional status of patients is monitored and nutrition education given.
More funding has been received for training of community members in food processing
techniques – it is hoped that the garden will be able to generate income in the future.
Intersectoral links
As outlined above, this project can be regarded as a joint project between SANTA and the
health services. The Welfare Department is also involved, but communication between the
two departments is not always very good.
The Kakamas Local Authority has been supportive of the project. Co-operation between
the various government departments has been sub-optiamal. For example, the project
approached the Department of Agriculture to assist with analysis of the soil. The samples
were taken, but were subsequently lost and the project received no feedback. They would
have had to pay for repeat samples to be taken.
Involvement in the district
Kakamas has an extremely high incidence of TB. The district has identified TB as a priority
health issue and has developed plans to tackle the problem. There is close co-operation
between SANTA and the health services (both the local clinic and at district level). It is
hoped that this project will help to strengthen this co-operation.
Interaction with health facilities
TB patients on treatment at the clinic will be referred to the project. Patients’ nutritional
status will be monitored at the clinic on a regular basis.
2.2 Grootdrink Community Nutrition Surveillance Project
History
From nutrition surveillance data it was found that a high percentage of preschool children
were underweight for age in the Grootdrink community. A meeting was held with the Local
34

Development Forum (LDF) and the UNICEF conceptual framework was used to determine
causes of the high incidence of malnutrition. The health committee of the LDF became
involved and a community based nutrition surveillance programme was started.
Organisational Structure
The health committee identified a number of volunteer workers who took responsibility for
nutrition surveillance and education in the community.
Resources
A local church hall is used for the monthly weighing sessions that are organised by the
volunteer workers.
Activities
• Training in basic nutrition topics for volunteer workers (done by health educator).
• Monthly weighing and record keeping of preschool children.
• Referral of children to the clinic when necessary.
• Educating mothers who bring their children for monthly weighing.
Target Groups
Preschool children and their parents.
Interaction with health facilities
Children are referred from the community-based nutrition surveillance project to the clinic
when food supplementation is necessary.
Future plans
Funds have been allocated to the community for establishment of a community bakery.
3 Primary School Nutrition Programme
3.1 Organisation and management
As in other provinces, the PSNP accounts for the largest portion of expenditure on nutrition
at district level.
In the Northern Cape, the PSNP is jointly managed by the Departments of Health (Nutrition
sub-directorate) and Education (Educational Support Systems). Particular attention has
been given to reaching farm and rural schools. With decentralisation of the programme, the
health department has taken on most of the responsibility for management and administration
of the scheme.
The relationship between the health and education departments at district level is variable.
Initially within Lower Orange, the health department left the running of the PSNP to the
education department. More recently a teacher has been seconded from the Education
Department to the Nutrition Programme for a period of three years.
35

Each participating school has a PSNP committee, which is responsible for running the
programme. Parents have been encouraged to become involved – and schools are
encouraged to buy supplies from local suppliers in order to support the local economy.
3.2 Financial resources and control
The number of schools and pupils as well as the budget for the PSNP is shown in Table 13.
Funding is calculated based on the number of pupils per school. The school receives 50c
per child per day for feeding and between 5c and 15c per child for administrative costs.
Administrative costs are used to pay incentives to parents who are involved in the scheme
and to cover transport and other administrative costs.
Each committee has a bank account and cheque book. At the beginning of each financial
year, 30% of the school’s budget is paid into the account – subsequent payments are made
when receipts and bank statements are submitted for re-imbursement.
Table 13: Budget for PSNP, Lower Orange
No. of schools No. of pupils Budget
97/98 Financial Year - R1,682,042
98/99 Financial Year 50 16,331 R1,573,122
99/2000 Financial Year 56 16,625 R1,520,559
3.3 Problems with implementation
Provincial level
The programme is thought to be working well with the majority of pupils being reached. No
formal evaluation has been done, but there are numerous anecdotal reports of improved
school attendance and improved concentration. Lack of human resources is a problem, with
only one community development officer being responsible for a whole district (some of the
districts, although sparsely populated are larger than Kwazulu/Natal). Monitoring of the
programme has therefore been difficult.
Concerns have been raised regarding the sustainability of the programme, bearing in mind
that the RDP funds allocated to the programme will be withdrawn over the next few years.
At the beginning of 1998, the governing bodies of eight urban schools were approached and
requested to contribute towards the PSNP. The schools approached were those where it
was felt that the majority of children do not require to be part of the programme and that
parents and communities’ have the resources to contribute towards the scheme. Three of the
eight schools agreed - the other five felt that although they were situated in wealthier areas,
most of their pupils came from informal settlements and needed the scheme.
36

Other concerns raised included that little empowerment has been achieved. It is hoped that
the nutrition education projects which are described below will enhance community
involvement.
District level
From an administrative point of view, the scheme is running smoothly – an achievement
which should not be underestimated. Monitoring and evaluation of the scheme is relatively
weak however. It is hoped that the appointment of an administrative clerk in July will free
the administrator to be more involved in developing the programme as a whole.
3.4 Involvement of NGO’s and CBO’s
No non-governmental organisations are involved in the PSNP in the province. This reflects
the paucity of such organisations in the province. It is hoped that CBOs will become more
involved in the scheme in the futrue.
3.5 Nutrition education projects
The provincial Educational Support Services are involved in a number of projects which aim
to improve nutrition through education:
• At present, nutrition education does not form part of the formal curriculum. However
Valley Trust has been commissioned to develop a formal nutrition curriculum for all pupils
in Grades 1 to 7. The curriculum has been piloted in the Diamond Fields district as well
as six schools in Upington. It will be evaluated during the course of the year with a view
to expanding the programme.
• The Educational Support Services are developing a programme which encourages
community and parents to take control of the running of the PSNP. This is linked to a
number of key nutrition messages e.g. that children still need three meals a day.
• They are working with the department of Arts and Culture on a programme which
encourages schools on the PSNP to start food gardens. It is hoped that these gardens
will not only provide food, but will be used for learning activities.
3.6 Parasite eradication and micronutrient supplementation
These strategies are as yet not linked to the PSNP.
37

Chapter Four: Contribution of other sectors
Intersectoral collaboration has been a problem in the Lower Orange district. This is partly
due to the fact that a number of departments are not as decentralised as the health
department and, although all departments (with the exception of education) use the same
sub-divisions, some departments remain very centralised and are run directly from
Kimberley.
In addition, in the past each department funded one or two development projects, but there
was little co-ordination between the departments. This resulted in a situation where, for
instance in the Kakamas sub-district, both the Health Department and the Agriculture
Department were involved in projects which encouraged vegetable gardening, but there was
no communication between the two projects. Co-ordination between Health and Welfare
which until recently was one department has also been poor.
The provincial government has attempted to address this issue. All funding from the
provincial department has been combined into one fund known as the Alleviation of Poverty
Fund. All projects funded through this fund in the Lower Orange district are shown in
Appendix E.
An intersectoral committee has been established in the Lower Orange. The committee is
responsible for overseeing projects funded by the Alleviation of Poverty Fund and
encouraging collaboration both between government departments and between government
and other organisations.
38

Chapter Five: Factors which facilitate/constrain the INP in
Lower Orange
Strengths
Provincial Level
• Nutrition is recognised as a priority area.
• The respective roles of the Provincial and District Nutrition programmes are clearly
defined.
• Clear policy guidelines exist.
• The Provincial Nutrition sub-directorate provides consistent and appropriate support to
the district INP and nutrition staff.
District Level
• The basic components of a District are in place.
• The District Nutritionist is recognised as a key member of the DMT.
• District Management systems such as transport, drug management provide good
support to the Nutrition programme.
• Nutrition and other programmes are integrated into PHC.
• Capacity exists for adequate financial control of programmes such as the PEM scheme
and the PSNP.
Facility Level
• Most facility-based components of the INP are provided as part of comprehensive
primary health care at all PHC facilities.
• All facilities have scales for growth monitoring as well as clear guidelines for treatment
and referral of children with growth faltering and failure.
• Gordonia and Kakamas Hospitals have made good progress in achieving Baby Friendly
Status.
Weaknesses
Provincial level
• The large distances make it difficult to provide on-site support to district nutritionists.
• Nutrition and MCH sub-directorates are separate at provincial level.
39

District level
• Limited human resources – it is difficult for the nutritionist and nutrition advisors to cover
such a large area.
• Limited financial resources – the budget is decreasing.
• The systems for monitoring quality of service provided (e.g. quality of growth
monitoring, implementation of the PSNP) are poorly developed.
• The links between health and other sectors are poor.
Facility level
• Staff at facility level do not all regard nutrition as a priority.
• Little is known regarding the quality of the service provided.
Community level
• Few community-based organisations or initiatives exist.
• Nutrition workers do not always have the time and skills necessary to initiate and sustain
community-based projects.
Conclusion and recommendations
Overall the Integrated Nutrition Programme in Lower Orange can be regarded as a well-run
and managed programme. Most of the components of a District Integrated Nutrition
Programme are in place. Efforts can therefore focus on consolidating and improving the
quality of existing services.
Emphasis on improving the quality of care
More emphasis should be placed on monitoring and improving the quality of services,
provided particularly at facility level. Because most service are provided by PHC nurses this
needs to be done in collaboration with the PHC co-ordinator. The district staff are wellaware
of the need for more intensive evaluation and monitoring of their services, but may
need support in developing systems and methods for supervision and evaluation.
Strengthening Intersectoral Collaboration
The Nutrition Programme is well-established and is in a good position to play an important
role in improving collaboration between various sectors in the district. Opportunities for
intersectoral collaboration and partnerships with other government departments and
community organisations should be explored.
40

Integrating Nutritional Surveillance with the District Health Information System
Although nutritional surveillance is an important component of a district INP, it is important
that it does not distract nutrition and PHC workers from service delivery and development.
A district health information system is currently being developed in order to ensure that
information is available for planning and decision-making. Nutritional surveillance should
form part of this system. It is therefore important that there is good communication and coordination
between the two systems.
41

REFERENCES
1 SAVCG, 1995. Children aged 6 to 71 months in South Africa, 1994. Their
anthropometric, vitamin A, iron and immunisation coverage status. Isando. SAVCG.
2 SALDRU/World Bank . South Africa rich and poor. Baseline household statistics.
Unpublished report.
3 Department of Health. 1994. Anthropometric survey in primary schools in the RSA.
1994.
4 Steyn NP, Pettifor JM, Van der Westhuyzen J, Van Niekerk L. 1990. Nutritional
status of schoolchildren in the Richtersveld. South African Journal of Food Science and
Nutrition, 2 (3): 52 – 6
5 A National Household Survey of Health Inequalities in South Africa. The Community
Agency for Social Enquiry (CASE). October 1995. Kaiser Family Foundation.
6 Sosio-ekonomiese basis ban die munisipale gebied van Upington. November 1997.
Macroplan in collaboration with Paballelo Research Project.
7 Child Health Unit “An Evaluation of the South Africa’s Primary School Nutrition
Programme”. Health Systems Trust.
8 Department of Health. 1997.Eighth Annual National HIV sero-prevalence survey of
women attending antenatal clinics in South Africa
42

APPENDIX A: RESULTS OF DEPARTMENT OF HEALTH SURVEY OF
PRESCHOOL CHILDREN
Total
Percentage of children in the Northern Cape
(National figures in brackets)
Measurement -2 Z score -3 Z score Sample size
Weight for age 19.2 (13.2) 3.7 (2.6) 5 053 (97 790)
Weight for height 5.4 (2.6) 0.3 (0.2) Average age
Height for age 20.9 (9.0) 1.3 (0.5) 7.6 (7.4)
Black children
Measurement -2 Z score -3 Z score Sample size
Weight for age 12.7 (14.6) 3.1 (3) 1510 (65 511)
Weight for height 4.1 (2.4) 0.2 (0.3) Average age
Height for age 17.6 (8.7) 1 (0.4) 7.6 (7.4)
Coloured children
Measurement -2 Z score -3 Z score Sample size
Weight for age 20.1 (18.2) 4.6 (3.2) 3 068 (16 455)
Weight for height 6.7 (4.1) 0.3 (0.2) Average age
Height for age 25.4 (16.9) 1.7 (1.2) 7.6 (7.4)
White children
Measurement -2 Z score -3 Z score Sample size
Weight for age 2.1 (1.8) 0.2 (0) 475 (13 263)
Weight for height 1.3 (0.9) 0.4 (0) Average age
Height for age 2.3 (1.1) 0 (0) 7.6 (7.4)
43

APPENDIX B: JOB DESCRIPTIONS
DISTRICT NUTRITIONIST
A. Administrative
1. Set goals for the district activities for the year
2. Coordinate tasks with the intersectoral team
3. Regularly convene formal personnel meetings
4. Compile quarterly district reports and send copy to Provincial Office
5. Represent Nutritional Component at District Management Meetings
6. Draw up district budget according to needs
7. Countercheck monthly expenditure
8. Identify and coordinate training needs for personnel
9. Monitor and evaluate personnel activities.
B. Information Gathering and Nutritional Surveillance
1. Establish and maintain a district nutritional surveillance system
2. Regular monitoring of the nutritional surveillance system in the district
3. Facilitate community - based nutritional surveillance
4. Training of personnel, including nutrition advisors, community health workers,
fieldworkers, NGO’s, etc.
5. Participate in surveys as needed.
C. Health Facility-Based Nutrition Programme
C1. Protein Energy Malnutrition Scheme
1. Identify clinics and community centres to partake in the scheme using data collected
through surveillance.
2. Draw up a screening schedule for participants, in conjunction with clinic personnel and
NGO’s.
3. Incorporate and strengthen nutrition education - develop relevant nutrition education
activities, according to the needs of the district.
4. Train all personnel working in the scheme
5. Monitor and evaluate the scheme
6. Liase with PHC nurses regarding the implementation of the scheme.
C2. Therapeutic Nutrition and Foodservice Systems
Give support to hospitals on therapeutic nutrition and foodservice systems.
D. Community-Based Nutrition Programme
44

1. Implementation of the policy
2. Monitoring and evaluation of projects
3. Support Nutrition Education in preschools and primary schools
4. Monitoring of the Primary School Nutrition Programme (Nutrition Component)
5. Give nutritional support to creches.
E. Nutrition Promotion and Communication
1. Plan and coordinate all Nutrition Promotion Campaigns in the district and participation in
Health Days.
2. Develop relevant nutrition education programmes and material for the district
3. Assist in developing the Nutrition Strategy for the district.
NUTRITION ADVISORS
A. Administrative
1. Write personal term report
2. Participate in planning own activities for the year
3. Represent division in community meetings on request
4. Keep records and statistics of activities
5. Maintain communication with development workers and other health workers
B. Nutrition Surveillance
1. Participate in community-based surveillance
2. Assist nursing personnel in growth monitoring and promotion
3. Assist nursing personnel with completion of nutritional surveillance forms
C. PEM Scheme
1. Acquaint yourself with the functioning of the scheme
2. Assist nursing personnel with screening for the participation in the scheme
3. Link up participants in the scheme with CBNP and other income-generating projects
4. Give nutrition education to all participants according to needs
5. Refer cases that need individual counselling to nutritionists
6. Advise nutritionists on clinic visits, where there is need
7. Assist in monitoring of the scheme
8. Initiate home visits where necessary.
D. Nutrition Education
1. Identify communities in need of nutrition education and prioritise needs
2. Give nutrition education to community groups as needed
3. Initiate nutrition promotion activities.
45

E. CBNP
1. Ascertain participation by identified cases from the PEM
2. Assist communities establish and sustain CBNP projects
3. Give nutrition education as needed
4. Organise health days with communities
46

APPENDIX C: DISTRICT NUTRTION PLAN
KEY PERFORMANCE OBJECTIVES ACTIVITY RESPONSIBILITY OUTCOME
AREAS
1. Food Assistance PSNP
Food supplements give to Department of Education Approx. 60 schools will get food
children in target schools
supplements. School attendance
will improve. Hygiene and
correct food will be served.
Creches food
assistance
Food assistance at
health care facilities
(PEM)
Monitoring the preparation +
handling out of food
supplements.
Train teachers in nutrition
(food gardens, etc.)
Buying of food supplements +
handing out to patients.
Department of Health
Department of Health and
Welfare
Local Authorities
Teachers trained to make food
gardens + balanced menus etc.
Approx. 24 clinics + CHC’s will
take part in PEM Scheme % of
pre-school children < 3% ile of
wa/a be reduced to 10%
2. Nutrition Education Primary School
Nutrition Curriculum
Development
Workshop for personnel of
Local Authorities +
Community Health Centres
Department of Health
Approx. 80 persons will receive
training on PEM Scheme.

Baby Friendly Hospitals
Meetings to sensitize Hospital
Management for BFHI.
Establishing BF Committees.
Department of Health
Hospital management committed
to BFHI.
Attend training of trainercourse
in Lactation
Management.
Department of Health
4 Trainers will be trained for the
district.
Lunch Box Campaign
Health Promotion
Nutrition Education
(mothers)
Presenting 18 hour courses
for hospital + clinic+ CHC
personnel (catering,
stationery, etc,)
Organising BF -promotion
activities (e.g. BF week)
Organising Diseases of
Lifestyle Awareness Activities
(e.g. Diabetes / Heart week)
Do nutrition education at
PHC Clinics + CHC’s . Do
nutrition education in
communities + telephone
costs
Department of Health
Department of Health
Department of Health,
NGO’s Diabetes
Association + Heart
Foundation
Department of Health
By the end of 2000 all health
care staff will be trained in
Lactation Management.
BF - Rates will increase
Public made aware of BF
advantages.
Public made aware management
+ prevention of diseases of
lifestyle
Public will get education on BF
infant feeding etc.
48

3. Monitoring and
Evaluation
Implement monitoring
tool for PEM Scheme.
Train health care staff in use
of monitoring tool. Visit clinics
+ CHC;s regularly to see
whether monitoring is being
done.
Department of Health
Health care staff will monitor the
PEM Scheme at 24 points in
district.
PSNP Monitoring
Process to evaluate
effectiveness of PEM Scheme
+ give feedback to clinics +
CHC’s.
Visit participating schools to
monitor nutritional aspect of
programme
Department of Health
Department of Health
Feedback to clinics + CHC’s will
be given on a quarterly basis.
Hygienic + nutritional food will be
served. All participating school
will be visited at least twice a
year.
Improve reliability of
collected data via
Nutritional Surveillance
System.
Do in-service training of
Health Care staff.
Buy electronic scales for all
clinics + CHC’s + hospitals
Local Authorities
Department of Health
24 Clinics + CHC’s staff will be
trained.
24 Clinics + 5 hospitals will be
provided with electronic scales
Maintain electronic scale
(repairs, service, etc). Buy
computer programs
(maintenance).
Department of Health
Clinics + CHC’s will receive
computerised feedback on a
quarterly basis.
Do computerized processing
of districts data + give
feedback to clinics.
Visit CBNP - Projects +
Department of Health.
Local Authority data
collection (PEM).
Department of Health +
CBNP - Projects will be
monitored on a quarterly basis.
49

4. Capacity Building Capacity building of
Personnel
Attend continuing Nutrition
Education Courses, Nutrition
Congress, ADSA training,
courses for nutrition advisors.
Department of Health
Personnel will haveup to
date knowledge.
Get medical journals
Re nutrition.
Department of Health
Reorientation program
for nutrition personnel.
Organize workshops for
nutrition personnel (speakers
from outside).
Department of Health
Personnel will be reoriented
towards nutrition.
Improve infrastructure.
Buy electronic scales for 3
people - 2 nutrition advisors
+ 1 nutritionist. Buy camera
+ films.
Department of Health
Photos will be used for visual
presentation + communication
50

5. Community
Development +
Intersectoral
Collaboration
Establish 2 community
based projects.
Help identified communities
with Triple A process,
Conceptual Framework
during meetings.
Department of Health,
Community other
departments.
Establish School Food
Gardens.
Assist ready communities in
writing project proposals.
Allocate + transfer funds to
approved projects. Train
volunteer workers in
communities.
Subscribe to Food Garden
Foundation
Give food garden-making
demonstrations at schools
(buy necessary equipment)
Department of Health +
other role players.
Department of Health
Department of Health +
other role players
Department of Health
Department of Health,
Education and Agriculture
Information on Food Gardening
will received on a regular basis.
Pupils + Teachers will have
ability to make food gardens.
Income generating
projects.
Cooperation + joint
responsibility.
51

6. Clinical Nutrition
+ Food Service
Systems
Capacity Building of
Presonnel
Nutrition Clinic
Training of food service for
personnel
Organize nutrition clinics in
the district for individual diet
therapy referrals
Department of Health or
private companies
Department of Health
Food Service evaluation
Visits hospitals + inspect food
service systems.
Evaluate menus.
Department of Health
52

APPENDIX D: SCHOOLS PARTICIPATING IN THE PSNP
Category School No. of pupils Food Admin Total
Rural Alheit 100 R6,950 R2,085 R9,035
Rural Asumpta, Augrabies 327 R 22,727 R 4,545 R 27,272
Farm Bokpoort 21 R 1,460 R 438 R 1,898
Rural Blaauwskop 304 R21,128 R 4,225 R25,353
Rural Bloemsmond 49 R 3,406 R 1,022 R 4,428
Rural Brandboom 437 R30,371 R 6,074 R36,445
Farm Cillie 276 R19,182 R 3,836 R23,018
Farm Currieskamp 121 R 8,409 R 2,522 R10,931
Farm Duikersdal 30 R 2,085 R 626 R 2,711
Urban Franciscus, Upington 738 R51,291 R5,129 R56,420
Farm Frank Biggs, Louisvale 594 R41,283 R8,257 R49,540
Farm Friersdale 338 R23,491 R4,698 R28,189
Rural Gariepwater 124 R 8,618 R2,585 R11,203
Farm Geelkop 30 R 2,085 R 626 R 2,711
Rural Grootdrink 667 R46,356 R9,271 R55,627
Rural Grootmier, Mier 75 R 5,212 R1,563 R 6,775
Farm J.J.Adams, Askham 278 R19,331 R3,864 R23,195
Farm Kalkwerf 30 R 2,085 R 626 R 2,711
Rural Kalksloot 355 R24,673 R4,935 R29,608
Urban Keidebees, Upington 1 171 R81,385 R8,138 R89,523
Rural Keimoes Primary 520 R36,140 R7,228 R43,368
Farm Khoms 38 R 2,641 R 792 R 3,433
Farm Klein Mier 91 R 6,325 R1,897 R 8,222
Rural Klipeiland 56 R 3,892 R1,168 R 5,060
Rural Leerkrans 507 R35,236 R7,047 R42,283
Rural Loubos 127 R 8,827 R2,648 R11,475
Farm Loxtonvale 70 R 4,865 R1,460 R 6,325
Urban Lukhanyiso, Upington 434 R30,163 R6,033 R36,196
Farm Lutzburg 255 R17,723 R3,545 R21,268
Rural McTaggert's Kamp 355 R24,672 R4,934 R29,606
Rural Morelig 780 R54,210 R5,421 R59,631
Farm Neus 19 R 1,321 R 396 R 1,717
Farm Neilersdrift 458 R31,831 R6,366 R38,197
Farm Noeniesput 12 R 834 R 250 R 1,084
Farm Olyvenhoutsdrift 879 R61,091 R6,109 R67,200
Farm Omdraai 15 R 1,043 R 313 R 1,356
Urban Oranje-oewer, Upington 825 R57,338 R5,734 R63,072
Rural Orange-suid, Kakamas 1231 R85,555 R8,565 R94,120
Farm Perde-eiland 280 R19,460 R3,892 R23,352
Rural Philandersbron 218 R15,151 R3,030 R18,181
Farm Riemvasmaak 161 R11,190 R3,357 R14,547
Rural Rietfontein 458 R31,831 R6,366 R38,197
Rural Sandkopeiland 31 R 2,155 R 646 R 2,801
53

Farm Soverby 118 R 8,201 R2,460 R10,661
Rural St. Maria Goretti,
198 R13,761 R4,128 R17,889
Augrabies
Farm Sternham 730 R50,735 R5,073 R55,808
Farm Swarthmore 151 R10,495 R3,148 R13,643
Rural Topline 210 R14,595 R2,919 R17,514
Farm Uitsig 107 R 7,437 R2,231 R 9,668
Farm Vaalkoppies 78 R 5,421 R1,626 R 8,673
Urban Vala-langa, Upington 908 R63,106 R6,311 R69,417
Urban Vooruitsig, Upington 800 R52,195 R5,219 R57,414
Farm Vorstereiland 71 R 4,935 R1,480 R 6,415
Rural Vyeboseiland 76 R 5,282 R1,585 R 6,867
Rural Wegdraai 322 R22,379 R4,475 R26,854
Rural Welkom Primary, Askham 142 R 9,869 R2,961 R12,830
16625 R1,233,433 R205,878 R1,440,937
54

APPENDIX E: PROJECTS FUNDED BY ALLEVIATION OF POVERTY FUND
Upington sub-district Name of project Amount
Karos Hand printed Egg Project Yes R75 000
Karos Karos Clothing Project Yes R22 160
Rosedale Omni Funeral Support Services Yes R150 000
Swartkop Clothing Project Yes R78 365
Swartkop Woodwork Carpentry Project Yes R100 000
Grootdrink Grootdrink Bakery Yes R90 247
Groblershoop Oes enVis Projek Yes R70 000
Pabellelo Siyavuka Laundry Yes R100 000
Paballelo Paballelo Children’s Clothing Yes R20 000
Paballelo Arts and Craft Centre Yes R50 000
Boegoeberg Bakery and Take Away No R25 000
Leerkrans Leerkrans brickmaking Yes R20 000
Upington Nicro NC Cleaning Service No R158 000
Upington Captain Dorego’s Fast Food Franchise Yes R300 000
R1 258 772
Kakamas sub-district
Kakamas Community vegetable project No R39 730
Alheit Children’s clothing No R20 000
Marchand Vegetable garden Yes R100 000
Cille Vegetable garden Yes R55 000
Augrabies Noudonsies Curio Centre Yes R100 000
Riemvasmaak Vredesvallei Needlwork Group Yes R30 000
R344 730
Keimoes sub-district
Keimoes
Keimoes Op en Wakker Sewing
Project
No R18 000
R18 000

R34 385
Kalahari sub-district
Klein Mier Klein Mier One Stop Shop Yes R86 700
Askham Kameelduin Brickmaking Project Yes R100 000
R186 700
GRAND TOTAL R1 842 587