Indicators and actions to address stunting across multiple sectors relevant at subnational level

PROTOCOL: Impact of the food environment on diet-related health outcomes in school-age children and adolescents in low- and middle-income countries: a systematic review.

Much of the existing literature on social protection for immigrants focuses on what people do as individuals and households or on national policy. However, there is a third set of actors which deserves attention: sub-national and local governments. Drawing comparisons both within and between the United States and Spain, this article analyzes the extent to which sub-national governments step in when national policies block immigrant access to healthcare. Using cross-national surveys, national and sub-national data, we find that sub-national governments often provide some level of social protection, even in the case of undocumented immigrants. However, their responses vary significantly and are not easily explained by left-right political divides, changes in levels of diversity, or the relative political power of immigrants. Future work is needed not only to explain variations in non-citizen health coverage policies at the sub-national level in receiving countries, but also to offer a more complete picture of immigrant resource environments through a parallel analysis of sending-state social protection policies.

Mitigating the financial effects of tuberculosis requires more than expansion of services.

This roundtable will follow up from the Workshop on Planetary Healthy Diets for All and explore practical solutions to tie increased sustainability of food systems to reductions in food insecurity in Europe. There is a disconnect between the level of scientific evidence supporting the need for action on food and agricultural systems and the willingness to uptake it at the national and local level. Countries' reluctance to implement evidence-based policy options often results from the perception that the data and solutions do not reflect their national realities. At the same time, there is a rising trend in food insecurity in Europe. Part of it is driven by the food system itself and part of it by social determinants that exacerbate the effects of elements such as food prices or the availability of affordable healthy foods. In terms of the current response to food insecurity in Europe, there is enough evidence that it is inadequate. The most notable example of inadequacy are food banks: they are unsustainable and perpetuate deficiencies of the foods system, such as waste. At the same time, food banks contribute to widening health inequities because they are stigmatizing, and the quality and reliability of the food they offer exacerbates health problems. They also mask failures of social protection and of food policy to protect those at the bottom. Yet, they are proliferating all around Europe. The WHO European Regional Office for Europe will share practical steps that it is taking to assist policy makers at national level to bridge evidence and action. WHO will present a novel on-line, readily accessible tool that public health officials from Member States can use to guide policy decisions. This tool uses a food systems model considering food consumption, food production, environmental impacts and health impacts to identify practical solutions for countries to create food systems that both have a lower impact on the climate and promote healthier diets. The roundtable will also highlight the transformative example of Copenhagen's public food procurement strategy, which, starting from a target on organic food in public canteens, has evolved into a comprehensive approach to achieve tasty, healthy, sustainable meals with social added value and without increasing procurement costs. In sum, against the backdrop of both nutritional and environmental challenges to food systems in Europe, participants at the roundtable will share barriers and opportunities to the uptake of evidence-based solutions to transform food systems and tackle food insecurity at the national and local levels, including in the context of the ongoing reform of the EU's Common Agricultural Policy (CAP) and the new 'Farm to Fork' Strategy for sustainable food. This discussion will allow participants to share their insights and enrich each other's understanding of the issues at stake and the tools and opportunities on offer to support, in an action-oriented way, a sustainable food systems transition that overcomes food insecurity. Key messages Global reference diets need application on a national and subnational level. Food insecurity, can be major barrier to the uptake of healthy diets and must be tackled as such. The new data platform and training materials will empower policymakers within countries to develop and introduce national level initiatives, such as sustainable and healthy public procurement.

Priority focus areas for a sub-national response to climate change and health: A South African provincial case study

Many countries, including South Africa, have implemented population-based household surveys to estimate HIV prevalence and the burden of HIV infection. Most household HIV surveys are designed to provide reliable estimates down to only the first subnational geopolitical level which, in South Africa, is composed of nine provinces. However HIV prevalence estimates are needed down to at least the second subnational level in order to better target the delivery of HIV care, treatment and prevention services. The second subnational level in South Africa is composed of 52 districts. Achieving adequate precision at the second subnational level therefore requires either a substantial increase in survey sample size or use of model-based estimation capable of incorporating other pre-existing data. Our purpose is demonstration of the efficacy of relatively simple small-area estimation of HIV prevalence in the 52 districts of South Africa using data from the South African National HIV Prevalence, Incidence and Behavior Survey, 2012, district-level HIV prevalence estimates obtained from testing of pregnant women who attended antenatal care (ANC) clinics in 2012, and 2012 demographic data. The best-fitting model included only ANC prevalence and dependency ratio as out-of-survey predictors. Our key finding is that ANC prevalence was the superior auxiliary covariate, and provided substantially improved precision in many district-level estimates of HIV prevalence in the general population. Inclusion of a district-level spatial simultaneously autoregressive covariance structure did not result in improved estimation.

Transforming global food systems to promote food and nutritional security can help alleviate both poverty and ill-health, and support sustainable development. Such transformations need to be tailored and sensitive to the vulnerabilities and needs of marginalized communities yet are hindered by knowledge gaps. In particular, the food and nutrition security needs of the most vulnerable are often poorly understood, as are the policy frameworks and resource requirements associated with meeting their needs. To aid the development of frameworks to address these gaps, we review the current state of indicators relating to food systems for the improvement of food and nutrition security at the national and sub-national levels in South Africa. We identify gaps in the decision-making data in South Africa, including absence of food and nutrition security indicators. Integration of the South African Multidimensional Poverty Index and Food System Dashboard indicators could help address this, especially if applied at a sub-national level. Participatory food system mapping could also link data collection with system-level interactions and feedback loops to inform sub-national stakeholders in achieving food and nutritional security.

<scp>IFST</scp> vision for a <scp>UK</scp>‐wide national food strategy

Various health departments worldwide needed to react to the coronavirus disease 2019 (COVID-19) pandemic: first, conveying information about the virus itself, and later, announcing and promoting vaccinations. Multilingual, multimodal communication is essential during a crisis. Studies from early in the pandemic show some positive efforts and shortfalls in language inclusivity. We build on these to study COVID-19 communications with a later issue, vaccination, in South Africa and the United States. Analysis of online resources available from national government websites and one sub-national government from each country (Western Cape and Pennsylvania) followed O’Brien et al.’s (2018) framework of availability, accessibility, acceptability, and adaptability. Both countries only partly implemented their language policies and the number of English resources available exceeded that of other languages. Also, both countries had multimodal resources. Although there were resources in non-majority languages, they offered only isolated materials in less populous minority, indigenous, and migrant languages. The use of automatic translation or professional translators affected acceptability. Websites varied in the accessibility or ease of finding materials in languages other than English.

Given the globalised nature of work in the twenty-first century, labour and social security law issues relating to worker-posting are sure to increase in the years to come. The purpose of this note is to assess critically the social protection of workers posted abroad from a South African perspective. The contribution addresses this topic by discussing various questions. It concludes by stressing the need for the adoption of a coherent approach as far as social protection for posted workers is concerned by, inter alia, promulgating an act of parliament to regulate the social security and labour law entitlements and obligations of these workers as well as their employers.In addition, it emphasises the need for and the importance of bilateral and multilateral social security and labour agreements between South Africa and other countries, particularly those where South African companies have established themselves. A sizeable number of South African companies (such as MTN, Vodacom, SABMiller, Sasol, Woolworths and Debonairs) have established, or are successfully establishing themselves, in African countries and beyond. At the same time, foreign companies (such as BMW, Levi Strauss, Barclays Bank and Vodafone) have registered, or are in the process of registering, in South Africa at an unprecedented rate. It is true that these companies do employ locals. However, situations do arise requiring a global company to send a worker for a limited period (usually not exceeding twelve months) to carry out work in the territory of a State other than the State in which he or she normally works. This scenario is commonly known as worker-posting and does yield some benefits (including international exposure) to the (posted) workers, their employers and the economy in general. Nevertheless, if not properly regulated, worker-posting may have an undesirable effect, particularly on workers. For example, posted workers may find themselves concurrently covered (ie, at home and abroad) by social insurance schemes or not covered at all. As will be explained later, this can yield undesirable results. For example, it unnecessarily raises the costs of doing business for transnational employers. Furthermore, the period of stay for posted workers is limited and, as a result often does not lead to any entitlement to benefits. In addition, in the labour law sphere, posted workers may fall victim to abuse as regards the basic conditions of employment (eg, relating to pay and working time). The purpose of this paper is to assess critically the social protection of workers posted abroad from a South African perspective. According to the Asian Development Bank (ADB), “social protection” consists of policies and programmes designed to reduce poverty and vulnerability by promoting efficient labour markets, diminishing people’s exposure to risks, enhancing their capacity to protect themselves against hazards and interruption/loss of income”. The aim of social protection for that reason, is to avert or minimise social risks – in that way preventing or minimising human damage – by increasing capabilities and opportunities. As noted by the UN Commission: “The ultimate purpose of social protection is to increase capabilities and opportunities and, thereby, human development. While by its very nature social protection aims at providing at least minimum standards of well-being to people in dire circumstances enabling them to live with dignity, one should not overlook that social protection should not simply be seen as a residual policy function of assuring the welfare of the poorest – but as a foundation at a societal level for promoting social justice and social cohesion, developing human capabilities and promoting economic dynamism and creativity”. This contribution addresses this topic by discussing the following questions: What is the social protection status, with reference to social security and labour law, of workers posted to and from South Africa? Is the present social security and labour law protection framework ideal for extending social security and labour law protection to posted workers? To the extent that it is not, where and what are the gaps and challenges that are likely to hinder efforts to extend or strengthen social security and labour law coverage to this category of workers? Finally, what are the alternatives for improving, in a worker-posting context, the current social protection framework?

Food systems have a profound impact on diets, nutrition, health, economic development, and environmental sustainability. Yet their complexity poses a persistent challenge in identifying the policy actions that are needed to improve human and planetary health outcomes. Typologies are a useful classification tool to identify similarities and differences among food systems, while reducing this analytical complexity. This study presents a new food system typology, implemented at the country level using parsimonious data that characterize food supply chains, food environments, consumer-related factors, and key outcomes, including dietary intake, nutritional status, health, and environmental impacts. Five food system types are identified: rural and traditional; informal and expanding; emerging and diversifying; modernizing and formalizing; and industrial and consolidated. Patterns across the five system types in key outcome variables align with narratives provided by the food systems and nutrition transition literature, demonstrating the usefulness of this classification method. Substantial heterogeneity nonetheless still exists within individual food system types. Therefore, the recommended use of the typology is in early stages of hypothesis generation, to identify potential risk factors or constraints in the food system that can be explored further at national and sub-national levels.

BackgroundNational community health worker (CHW) programmes are returning to favour as an integral part of primary health care systems, often on the back of pre-existing community based initiatives. There are significant challenges to the integration and support of such programmes, and they require coordination and stewardship at all levels of the health system. This paper explores the leadership and governance tasks of large-scale CHW programmes at sub-national level, through the case of national reforms to South Africa’s community based sector, referred to as the Ward Based Outreach Team (WBOT) strategy.MethodsA cross case analysis of leadership and governance roles, drawing on three case studies of adoption and implementation of the WBOTs strategy at provincial level (Western Cape, North West and Gauteng) was conducted. The primary case studies mapped system components and assessed implementation processes and contexts. They involved teams of researchers and over 200 interviews with stakeholders from senior to frontline, document reviews and analyses of routine data. The secondary, cross case analysis specifically focused on the issues and challenges facing, and strategies adopted by provincial and district policy makers and managers, as they engaged with the new national mandate. From this key sub-national leadership and governance roles were formulated.ResultsFour key roles are identified and discussed:Negotiating a fit between national mandates and provincial and district histories and strategies of community based servicesDefining new organisational and accountability relationships between CHWs, local health services, communities and NGOsRevising and developing new aligned and integrated planning, human resource, financing and information systemsLeading change by building new collective visions, mobilising political, including budgetary, support and designing implementation strategies.ConclusionsThis analysis, from real-life systems, adds to understanding of the processes involved in developing CHW programmes at scale, and specifically the negotiated and multilevel nature of leadership and governance in such programmes, spanning analytic, managerial, technical and political roles.

Energizing Comparative Environmental Politics and Comparative Political Economy

Governance and leadership are recognized as central to health system development in low- and middle-income countries, yet few existing studies consider the influence of multilevel governance systems. South Africa is one of the many (quasi-)federal states. Provincial governments have responsibility for managing health care delivery within national policy frameworks and norms. The early post-apartheid period saw country-wide efforts to address the apartheid legacy of health system inequity and inefficiency, but health system transformation subsequently stalled in many provinces. In contrast, the Western Cape provincial health department sustained service delivery reform and strengthened management processes over the period 1994–2016. This department can be considered a ‘pocket of relative bureaucratic effectiveness’: an organizational entity that, compared to others, is relatively effective in carrying out its functions in pursuit of the public good. This paper considers what factors enabled the development of the Western Cape health system in the period 1994–2016. Two phases of data collection entailed document review, participatory workshops, 43 in-depth interviews with purposively selected key informants from inside and outside the Western Cape and a structured survey testing initial insights (response rate 42%). Analysis included triangulation across data sets, comparison between the Western Cape and other provincial experience and deeper reflection on these experiences drawing on POE theory and public administration literature. The analysis highlights the Western Cape experience of stable and astute sub-national governance and leadership and the deepening of administrative and technical capacity over time—within a specific provincial historical and political economy context that sustained the separation of political and administrative powers. Multilevel governance systems can create the space for sub-national POEs to emerge in their mediation of wider political economy forces, generating spaces for skilled reform leaders to act in the public interest, support the emergence of distributed leadership and develop robust management processes.

Understanding food environments and how they shape dietary and nutrition outcomes is key to ensuring that food systems can support healthy and sustainable diets for the most vulnerable. Using subnational data from 20 low and lower-middle income countries, we explored how assortment, relative and absolute food prices relate to the dietary intake of children aged 6–23 months. We found that greater assortment of nutrient-dense foods in the market showed a positive association with dietary intake (foods rich in iron or vitamin A) of children 6–23 months of age at the subnational level. Higher relative price of nutrient-dense foods compared to starchy staples was negatively associated with intake of foods rich in iron or vitamin A and minimum dietary diversity. We also found negative association between minimum price of nutrient-dense foods and the same dietary intake indicators. This provides evidence on the degree to which assortment and the relative price of foods influence household food choices. The variability in assortment and price within countries highlights the importance of collecting information on food environments at the subnational level, as they determine which foods households can access, and by extension, how diverse and nutritious the diets of children aged 6–23 months in the household, can be.