A Critical Review of the multisector response to the National Strategy for the Prevention and Management of Non-Communicable Diseases (NCDs) 2013-2017 in South Africa

Thesis (MNutr)--Stellenbosch University, 2019.ENGLISH ABSTRACT: The prevalence of non-communicable diseases (NCDs) continues to increase in South Africa, with these diseases now accounting for 51% of all deaths. The food environment, and therefore consumption trends, are in a state of flux. Burgeoning urbanisation, persistently high unemployment, poverty and inequality in an environment in which food security is reliant on wage income inform widespread malnutrition. Evolving food systems and lifestyles have created a context in which households negotiate food prices and incomes to inform food acquisition strategies that aim to meet complex functional and aspirational needs in unevenly served urban and rural areas. It is in this environment that this review critically assessed the multi-sector response to the National Strategy for the Prevention and Management of Non-Communicable Diseases (2013 to 2017). The research project employed a desktop review through the application of a systematic search strategy. It aimed to identify actions by government, civil society, the food industry and the private sector, that addressed NCDs in South Africans over the age of 5 years between September 2011 and September 2018. Results indicate that the Department of Health has led in the implementation of structural and individual interventions, a number of which have been on a legislative basis. Most interventions have been in food reformulation, food labelling and school interventions. Nutrition education, fiscal measures and mass-media interventions were modest in number. Very few interventions in workplaces or physician counselling were identified. Whilst a number of collaborative and capacity building efforts were found, most appeared to be disjointed in practice. Almost no studies investigating funding for NCD interventions were identified. Three main themes emerged. Firstly, there is poor evidence of implementation, monitoring and evaluation of NCD interventions across sectors. Food control is fragmented, horizontally and vertically, with poor co-ordination of activities. Other than salt reformulation and some school activities, almost none of the interventions have been evaluated. This will make it difficult to draw any conclusions about their efficiency and effectiveness in the future. In addition, effective monitoring tools, inclusive of harmonised indicators, comprehensive local food composition tables as well as co-ordinated monitoring, evaluation and enforcement arrangements need urgent review. Secondly, significant gaps exist in research that is needed for policy recommendations, particularly around nationally representative dietary intake data, funding, less technocratic solutions drawn from communities living with NCDs as well as longitudinal data on food acquisition strategies. Very limited research studies were identified that investigated emerging at-risk communities including adolescent girls and women with higher incomes. Informal residence, whether urban or rural, seems like a risk factor for poor quality diets when dietary diversity scores and food expenditure are used as proxies. This is likely to be rooted in poverty or inequality. Thirdly, governance arrangements and coherence of actions need urgent review. Despite the call for multisectoral, multi-level working arrangements in the strategy and in theoretical policies, little evidence echoes recommended health-in-all policies in practice.AFRIKAANSE OPSOMMING: Die voorkoms van nie-oordraagbare siektes in Suid-Afrika styg voortdurend, en tans veroorsaak hierdie siektes 51% van alle sterftes. Die voedselomgewing, en dus verbruikerstendense, is in ‘n staat van verandering. Groeiende verstedeliking, volgehoue hoë werkloosheids- en armoedevlakke, asook hoë ongelykheidsvlakke in ‘n omgewing waar voedselsekerheid afhanklik is van inkomste, spreek van wydverspreide ondervoeding. Ontwikkelende voedselstelsels en leefstyle het ‘n konteks geskep waarbinne huishoudings beding oor voedselpryse en inkomstes om strategieë wat probeer voldoen aan komplekse funksionele en verlangde voedselverkrygingsbehoeftes in ongelyk bediende stedelike en landelike gebiede. Dit is binne dié omgewing wat hierdie oorsig die multisektorale reaksie op die Nasionale Strategie vir die Voorkoming en Beheer van Nie-oordraagbare Siektes geassesseer het. (2013 tot 2017). Die navorsingsprojek het gebruik gemaak van ‘n rekenaarbeskouing (desktop review) deur die toepassing van ‘n sistematiese soekstrategie. Die doel was om voorkomings- en hanteringsaksies te identifiseer deur velerlei sektore, insluitend die regering, burgerlike gemeenskap, voedselbedryf en die privaat sektor, wat ten doel het om nie-oordraagbare siektes in Suid-Afrikaners oor die ouderdom van 5 jaar tussen September 2011 en September 2018 – soos uiteengesit in die NCD-strategie – aan te spreek. Resultate van die literatuurnavorsing wys op ‘n aantal aktiwiteite. Hoofsaaklik gelei deur die Departement van Gesondheid, was die meerderheid van die intervensies in voedselherformulering, fiskale maatreëls, die etiketteer en adverteer van voedsel, asook van skole. Intervensies in voedingsonderrig en massamedia-aksie was gering. Daar is min intervensies geïdentifiseer in werkplekke en die raadpleeg van dokters, wat die minste koste-effektief is. Hoewel ‘n aantal samewerkende en kapasiteitsbou-pogings aangetref is, het die meeste onsamehangend voorgekom. Data oor befondsing vir NOS-intervensies is nie geïdentifiseer nie. Drie belangrike temas kom na vore. Eerstens is daar swak monitering, evaluering en toepassing van die NOS-intervensies. Voedselkontrole word horisontaal en vertikaal gefragmenteer, met swak koördinasie van aktiwiteite. Behalwe vir soutvermindering en enkele skoolintervensies, is byna geen van die intervensies wat geïmplementeer is, behoorlik geëvalueer nie. Dit sal enige gevolgtrekkings oor die bevoegdheid en doeltreffendheid daarvan bemoeilik. Daarbenewens moet gekyk word na effektiewe moniteringswerktuie, insluitend gekoördineerde aanduiders, omvattende plaaslike voedselsamestellingstabelle, asook gekoördineerde monitering, evaluering en toepassing. Tweedens bestaan daar aansienlike gapings in navorsing wat benodig sal word vir beleidsaanbevelings. Dit is veral rondom nasionaal verteenwoordigende voedselinname-data, die minder tegnokratiese stem van gemeenskappe wat leef met Nie-Oordraagbare Siektes, asook langprofiel-data. By hoër-inkomstegroepe en huishoudings met beter opvoeding, waar vetsugvlakke die hoogste is, ontbreek navorsing en intervensies. Omdat hierdie families openbaresektor-dienste (en -intervensies) kan bekostig en neig om nie daarvan gebruik te maak nie, val hulle uit. Derdens moet daar ernstig gekyk word na die regering se maatreëls en aksie-samehang. Ten spyte van die oproep na multisektorale werksreëlings in die strategie en in teoretiese beleide, is daar min bewys van ‘n beleid van aanbevole gesondheid-vir-almal in die praktyk.Master