Weeks after pledging to end child stunting by 2030, President Cyril Ramaphosa has kick-started a task team to drive this urgent national mission. But what concrete steps could government actually take to end stunting? Spotlight sat down for an in-depth interview with one of the country's leading experts on the issue.
One of the most shocking of all the many health statistics in South Africa is the estimate that 27% of children under five are stunted. These malnourished children are short for their age, in part because of chronic malnutrition and inadequate healthcare before and after birth. Stunting is a largely preventable condition that can also impair brain development.
The issue first really hit home for David Harrison, a medical doctor, in 2015 while on sabbatical from his job at the DG Murray Trust (DGMT). He worried that the issue was going under the radar. "We had been fixating on [education and] learning outcomes and missing the basics - that you can't learn without food, without nutrition," he says.
For Harrison, this oversight echoes what happened with HIV in the early 1990s.
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In an interview with Spotlight, he recalls helping to start the Health Systems Trust in 1992. The goal was to reshape post-apartheid health services, with a focus on equitable reforms and building capacity. However, HIV was largely overlooked, buried in chapter 15 of the inaugural SA Health Review in 1995. "Here was this incredible epidemic that was bubbling ... yet not many - not me - recognised it at the time," he says.
Eventually, awareness of HIV in South Africa increased, although years of government AIDS denialism delayed the introduction of life-saving treatment until the tide turned definitively when Kgalema Motlanthe replaced Thabo Mbeki as South Africa's President in 2008.
Harrison hopes that President Cyril Ramaphosa's 2026 State of the Nation (SONA) commitment to tackle the "massive crisis" of child nutrition and stunting - with prenatal emphasis - marks a similar turning point after a decade of proposals, policy briefs and interventions.
"The challenge now is not 'what' needs to be done, but 'how' to operationalise this urgent mission," says Harrison. He offers three key elements for success: a bottom-up approach from pregnancy, a focus on protein and micronutrient-rich nutrition, and presidential leadership to ensure inter-governmental cohesion and external partnerships.
"One of the main reasons we have not dealt with malnutrition is that it is the responsibility of many government departments and delegated to junior officials. They do their best, but nobody's really in charge," reckons Harrison. "It is vital that there is dedicated leadership in the Presidency with the mandate and authority not only to mobilise government departments, but the business sector and civil society as well."
The way child nutrition is integrated into the government's work makes for a fragmented and messy organisational structure. For instance, the Children's Act and social grants fall under Social Development, whereas the Department of Basic Education has increasing responsibility for nutrition, through its Early Childhood Development (ECD) mandate. Nutrition cuts across multiple departments, including Health, Agriculture and Rural Development, Trade, Industry and Competition, and the overall purse-string guardians in Treasury.
Responding to Spotlight's queries about what happens next, Presidency Spokesperson Vincent Magwenya revealed that a special task team made up of people from different government departments is being set up to oversee a "targeted action plan" to confront child malnutrition and stunting.
Declaring it a "national priority", Magwenya says the Presidency is taking full charge and is currently coordinated within its Project Management Office. The task team is wide-ranging. It involves relevant state departments, as well as Police, Justice, Home Affairs and Labour, and includes provinces and local government. "It will identify the highest-impact interventions to expand access to nutritious and protein-rich foods; enhance ante- and post-natal care; raise awareness of healthy food choices; and reduce alcohol abuse. Funding for this action plan will be allocated once these priorities have been identified."
The national mission did not emerge out of nowhere; driven through Operation Vulindlela, it followed a network of civil society engagements with the presidency, including three years of work on the National Strategy to Accelerate Action for Children, in which child nutrition finally emerged as a priority.
After firming up leadership, the next step is to borrow from countries such as Peru and Chile, which halved stunting in less than 10 years. These countries have business on board, says Harrison, often pointing out that South Africa's food industry makes billions in profits. "We need an environment where everybody concludes that it is unacceptable for any child to be hungry or stunted. The Presidency needs to urgently convene a gathering of this nature," he says.
Ramaphosa indicated in his State of the Nation Address that funding would be allocated in the Medium-Term Budget Policy Statement later this year.
Harrison has several ideas on how additional government funding to prevent stunting could best be spent.
First, he makes the case for multiple micronutrient supplementation in the prenatal period. He says a single tablet replacing iron and folate with a more effective combination of 15 vitamins and minerals has been shown to reduce low birthweight, preterm birth and early infant mortality.
"We are currently working with the National Department of Health and Reproductive Health and HIV Institute (RHI) at Wits on clinical trials for registration and inclusion on the Essential Medicines List. It could be done by April 2027," says Harrison.
Second, he suggests that social grants could be tweaked to provide more support to pregnant women and new mothers. Beset by delays, financial support during pregnancy has been on the table since 2012, when the Department of Social Development commissioned a feasibility study on the benefits of a Maternal Support Grant (MSG).
There is some research backing such a grant, including an analysis estimating R13 billion in healthcare savings.
The idea has gained some traction. In February, an advocacy coalition pushing for a Maternal Support Grant presented a submission to the SA Human Rights Commission's inquiry into the Food Systems of South Africa. It recommended increasing the Child Support Grant to the food poverty line of R855 -- up from R560 -- and introducing a Maternal Support Grant from the second trimester, through existing SASSA infrastructure.
For urgent implementation, Harrison recommends a simple extension of the Child Support Grant to cover pregnancy, thereby avoiding the complex legislative process required for a distinct Maternal Support Grant.
Conditional grants
Harrison says that "ideally" the extension of nutrition-targeted social security beyond the Child Support Grant should shift from unconditional to conditional direct support.
Conditional grants typically require that people meet certain conditions before receiving a grant. Peru and Chile, for example, make some grants conditional upon attending certain clinic visits and ensuring a child gets their vaccinations. Some critics argue that placing conditionalities creates administrative complexity that can outweigh the benefits. There are also concerns that some people might be doubly excluded - for example, if a grant is made conditional on attending clinic visits, but someone doesn't have the money to travel to the clinic.
Harrison doesn't suggest introducing such conditional grants tomorrow, but he does argue that South Africa should move in that direction. "We are in a particular phase of the nutrition transition, and we don't have the information systems yet, but we need to start incentivising ante-natal clinics and vaccination visits; we need to develop these over the next 10 years," he says.
Grants also shouldn't necessarily come in the form of money.
South Africa faces a dual nutrition crisis of under and over-nutrition, driven by the same root causes. More than 63.5% of households are food insecure, according to the 2024 National Food and Nutrition Security Survey.
Households can afford carbs like pap but not protein, Harrison points out. "We don't have an overall food insecurity problem; certainly, only 7% of children are underweight, we have a protein-insecurity problem (and I would add micronutrients in brackets)," he says.
Thus, rather than extending the Child Support Grant by giving people more money, it could potentially be extended by giving pregnant women vouchers that can only be spent on high-protein foods.
A 'cash+care' model project
Something along these lines is already being piloted. A project called Khulisa Care is an initiative between DGMT and the Western Cape Government, with Shoprite as retail partner.
Western Cape Minister of Health Mireille Wenger explained to Spotlight how the project, which started in July 2025, works. Undernourished pregnant women and mothers of low-birth-weight babies receive a monthly R525 voucher for protein-rich foods that support foetal brain development and health. At present, nearly 900 women are enrolled in Khayelitsha, Mitchells Plain, and Breede Valley.
A key element is combining financial assistance with structured support. "Vouchers alone are not enough. The programme also includes regular home visits from trained community health workers who provide breastfeeding support, mental health check-ins and access to health services. Breastfeeding, whenever possible, remains the most nourishing and protective form of feeding for babies, and support from trained health workers can make a significant difference in helping mothers sustain it," says Wenger.
Harrison agrees wholeheartedly about the importance of combining grant support with care. "If I were pressed to name one single most important intervention, it would be conditional income support for high-risk babies", linked to more intensive clinical engagement via community health workers and clinic staff, he says.
If the model proves effective, Wenger says her department would "engage with the Treasury, the private sector and NGOs to explore opportunities for scaling the programme."
There is already good local evidence that grants and keeping children in the system are impactful. For example, a review by Grow Great (a collaborative partnership of government, civil society and funders working to halve stunting by 2030) found that children under two exposed to more than four community healthcare worker visits experienced faster catch-up growth than those with fewer visits. The Thrive by Five Survey 2024 revealed significantly lower stunting rates among children in early learning programmes (7%) compared to those not enrolled (18%). There is also evidence that stunting rates are substantially lower among Child Support Grant recipients than among eligible non-recipients, according to the Closing the Protection Gap policy brief.
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Nutrition support at ECD centres
Once children go to school, they often get meals through the National School Nutrition Programme. Government is now trying to extend similar nutritional support to pre-schools, or Early Childhood Development (ECD) Centres.
Provision has been made for nutrition support to ECD programmes via the Department of Basic Education, though Daily Maverick has revealed that R336 million allocated to the pilot programme has been largely unspent since its inception two years ago.
A complicating factor is that nutrition is a separate add-on from the broader early learning subsidy allocated to ECD centres via the government's new Bana Pele Registration Drive, where accreditation is graded on a status from bronze, silver and gold, depending on meeting health and safety requirements. The two fall under different chief directorates, so Harrison says synergy has been an issue.
Only centres from "silver" status get a full subsidy, says Harrison. This means that even if the ECD subsidy was functional, its reach remains limited, with the most vulnerable children at bronze-registered centres not qualifying.
"If we are serious about early learning development, we need to start in bronze centres - they need it most," says Harrison.
South Africa has been working 'backwards'
Despite children being centre stage in our Constitution and core to Nelson Mandela's democratic vision, South Africa has spent decades playing catch-up on early childhood development, says Harrison.
This blind spot has caused the nation's focus to progress backwards, prioritising 18-year-olds down, rather than supporting children from pregnancy up.
Harrison says he takes personal responsibility for failing to recognise the scale of the "pending explosion" of the HIV pandemic in the early 1990s. Upon realising the gap, he pivoted to co-found LoveLife against youth HIV-AIDS, later joining DGMT in 2010.
Ramaphosa is similarly on record acknowledging past mistakes, expressing regret that early childhood development was not prioritised 30 years ago.
While the dial seems to have shifted, it remains to be seen what concrete change South Africa's children will experience in the coming years.
For his part, Harrison is on alert to ensure the new inter-departmental task team extends to partnerships with civil society and business, a precedent that was set to tackle the country's energy crisis. As Harrison puts it: "It needs to become a long-term institutionalisation of support for the eradication of malnutrition."
