Research for impact: SU scholars co-design anti-stunting intervention

Innovative project could reshape South Africa’s fight against stunting

An innovative pilot may offer new momentum in the country’s efforts to reduce childhood stunting. Announced on World Health Day – marked this year with the theme ‘Healthy Beginnings, Hopeful Futures’ – the initiative reflects growing urgency to invest in maternal and infant health.

The first 1 000 days of a child’s life – from conception to their second birthday – are when the foundations for healthy growth are laid.

This includes the proper development of the brain and the emotional and cognitive capacities it supports, along with the organs and immune system. If that window is missed, the child may suffer long-term developmental setbacks that are difficult to reverse. When a mother’s health or nutritional status is compromised during pregnancy, and when, after birth, the baby’s feeding is inadequate, infections are frequent, or care is inconsistent, the child can fall behind. This can result in stunting – a condition in which a child does not reach the expected height for their age.

The consequences can echo throughout life. Stunting is linked to reduced neurodevelopment, cognitive deficits, lower educational attainment, increased risk of obesity and non-communicable diseases, and intergenerational poverty.

In South Africa, over a quarter of children under five are stunted. In the Western Cape, the stunting rate is 17,5% according to a 2023 baseline survey, but that is still worryingly high. It is, however, 5,4 percentage points lower than the 2016 figure of 22,9%, suggesting that previous interventions may be having an effect. Still, the decline is too slow to meet the WHO/UNICEF target of halving stunting by 2030.

“The context, causes and consequences of stunting are all well documented. Yet it remains complex and challenging to prevent and treat due to its systemic roots across multiple sectors,” says Prof Lisanne du Plessis of the Division of Human Nutrition at Stellenbosch University (SU).

A new path

Now, an “extraordinary innovation” – in the words of Southern Africa Food Lab co-director Prof Scott Drimie – is set to be piloted in the Western Cape.

Announcing the initiative in her 2025 budget speech on 7 April, Western Cape Health and Wellness Minister Mireille Wenger described it as “a bold new pilot” to tackle the root causes of stunting.

“Every day we delay addressing malnutrition, we rob our province, and our country, of its greatest resource: its people,” she warned.

The pilot is expected to start later this year and to run until October 2026. It will be rolled out in three high-risk communities – Worcester, Khayelitsha and Mitchells Plain.

The initiative will focus on pregnant women – those who are underweight and at risk of having a low-birthweight baby (under 2,5 kg) – and new mothers of babies born with a low birthweight.

An estimated 1 700 women will be included across the three pilot sites.

Two-pronged approach

Speaking during a recent panel discussion at SU’s Faculty of Medicine and Health Sciences, Drimie said the pilot was an example of a ‘cash + care’ programme – an intervention combining financial assistance with tailored health and social support.

The panel discussion was linked to SU’s Public Squares initiative – a university-wide effort to promote transdisciplinary and socially engaged research, led by SU’s Division of Research Development.

While South Africa has trialled ‘cash + care’ approaches before – like the CoCare Maternal Support Study, which provided digital food vouchers to pregnant women during Covid-19 – the new pilot is believed to be the first to combine financial support over and above existing social grants, an enhanced package of health and psychosocial care, and a specific focus on preventing low birthweight from pregnancy.

Each participant in the pilot will receive a monthly voucher to spend at selected outlets. “We are currently in discussion with potential retail partners to support the delivery mechanisms for this pilot,” Wenger said.

Participants will be able to choose from a curated basket of protein-rich, nutritious foods identified by the NGO Grow Great. Most items are already staples in low-income communities and have a long shelf-life.

Good maternal nutrition increases the likelihood of a healthy birthweight, supports postnatal recovery, and helps establish the conditions for breastfeeding and care in the crucial early months.

However, vouchers alone are not enough. Participants will also have regular contact with trained community health workers, who will provide information about maintaining healthy pregnancies, health services for mothers and babies, breastfeeding advice, growth monitoring and mental health support.

Collaboration key

The initiative draws on a ‘quadruple helix’ model, involving government, civil society, academia and communities. This is exemplified by the involvement of members of SU’s ‘Break Free, Grow Tall, Reach Far‘ Public Square in co-designing the pilot.

“Building strong, collaborative relationships among stakeholders has been vital from the outset,” says Cameron Cyster, public policy analyst in the Western Cape Government’s Department of the Premier.

Testing the model

The DG Murray Trust (DGMT), a public innovator, is one of the funders, of the pilot, which will be implemented with contributions from Health and Wellness and other Western Cape Government departments.

“We’ll start small, assess how we can build this out, and explore integration with other systems. We’re piloting a minimum viable product to see what we can learn,” says Liezel Engelbrecht, nutrition lead for the Hold My Hand accelerator, incubated by DGMT.

Framed as a proof of concept, the pilot includes monitoring and evaluation from the outset, overseen by the Department of the Premier. This is a deliberate step to overcome what the 2023 evaluation of South Africa’s National Food and Nutrition Security Plan identified as a key weakness.

Political will

In his February State of the Province Address, Premier Alan Winde said, “stunted growth and development is a serious problem with a devastating knock-on effect.” He also pointed to the recent formation of a cabinet-level committee on food security and nutrition to coordinate efforts across government departments in the Western Cape.

The pilot builds on the foundations of the First 1 000 Days campaign and the Nourish to Flourish strategy, both launched by the Western Cape Government in 2016. It also reflects a significant shift that has taken place in the meantime.

“Historically, we worked in rigid, siloed programmes. Now, we’ve transitioned to a life-course approach, considering the whole child and family, including their interconnected issues,” says Nicolette Henney, a deputy director at the Western Cape Department of Health and Wellness.

Intervening before birth

South Africa’s social welfare system includes the Child Support Grant (R560 per child per month) and the Social Relief of Distress Grant (R370 per month), but both only begin after birth.

The pilot seeks to fix this by starting early during pregnancy – echoing calls from civil society and researchers for a Maternal Support Grant, which is championed by the national Department of Social Development but has not yet been approved. Fiscal constraints are often cited, yet research shows it could save the public health system billions by reducing low birthweight and related complications.

The new ‘cash + care’ pilot is one of the ways in which provincial and national governments can support pregnant women, showing how targeted, early intervention could help disrupt cycles of poverty and malnutrition.

If it succeeds, it could offer South Africa a scalable model for tackling childhood stunting – one of the country’s most persistent and costly public health crises.

* Desmond Thompson is a freelance journalist