Impact of child support grant in South Africa on child nutrition
Summary of research*
Location: South Africa
What we know: Stunting is an indicator of chronic undernutrition and is often linked to poverty-related factors. There is mixed evidence on the impact of cash on reducing child undernutrition in low- and middle-income settings.
What this article adds: In South Africa, the Child Support Grant (CSG) is the largest cash transfer programme targeting children from poor households. A recent paper explored predictors of stunting, including exposure to the CSG, at a median age of 22 months among children from three diverse areas of South Africa. CSG receipt for 18 months or longer was not associated with stunting after controlling for risk factors such as HIV exposure status and low birth weight; higher levels of maternal education had a protective effect on stunting. An association found between mothers’ HIV-positive status and stunting supports previous research findings. Food-price inflation and limited progress in the provision of other important interventions and social services, in the context of high unemployment, have likely limited nutrition impact of the CSG.
In South Africa, child under-five mortality was estimated to be 45 per 1,000 live births in 2012. There has been a significant drop in reported child hunger (from 30% of all children in 2002 to 16% in 2006), but in 2010 three million children were still living in households where hunger was reported. Moreover, 27% of the country’s under-fives were stunted in 2009, a decrease from 33% in 2003.
Existing policy responses to childhood poverty and vulnerability in developing countries include the provision of basic services such as education, healthcare, clean water, in-kind transfers (such as school-feeding schemes and nutritional supplements) and, more recently, cash transfers. The Child Support Grant (CSG) is the largest cash transfer programme in the country and the continent, reaching more than 11 million children from poor households in 2013. The grant is unconditional, means-tested and non-contributory, with a small amount (R320/US$32 per month) transferred by the South African government to children of poor families. However, children living in the poorest households target group still report high rates of hunger (26%) compared with children in the wealthiest households (less than 1%).
Methods
A recent cross-sectional study assessed the uptake and duration of receipt of the CSG and nutritional outcomes in children at two years of age (i.e. median age 22 months) during 2008. The sampling frame was participants from the sites of a multi-country, cluster-randomised, intervention trial undertaken from 2005 to 2008 (the PROMISE-EBF trial to assess the effectiveness of community-based workers in promoting and improving exclusive breastfeeding). After that trial ended (2007), a new cross-sectional study (the present one) was conducted, with participants from the trial traced when the children were aged between nine months and three years. A total of 871 out of 1,148 participants were traced, with 746 participants ultimately included.
The study was conducted in three diverse areas in South Africa:
(i) Peri-urban Paarl, a town with a population of about 130,000 in Western Cape Province;
(ii) Rural Rietvlei, which falls under the Umzimkhulu Municipality in KwaZulu-Natal; and
(iii) Umlazi, an urban township in Durban with a population of 550,000 inhabitants.
In terms of key child-health outcomes, Paarl fares better than the other two sites, with an infant mortality rate of 30/1,000 live birth, compared with Umlazi (68/1,000 live births) and Rietvlei (99/1,000 live births); and an antenatal HIV prevalence of 7% compared with Umlazi’s 47% and Rietlvei’s 28%. Umlazi is the largest township in KwaZulu-Natal Province, with typical township problems, including severe housing shortages, high rates of unemployment and crime and little economic development. Rietvlei is a predominantly rural area where 90% of people live below the household subsistence level, much higher than the national average of 65%.
The main outcome of interest was stunting (height-for-age z score (HAZ) <−2). Grant receipt was defined as mother being in receipt of the CSG on behalf of the index child at any point during the study (12 weeks, 24 weeks and two years). Duration of CSG receipt, the primary exposure, was defined as the age of child (in months) at the two-year visit minus the child’s age (in months) at first reported receipt of the grant.
The researchers extracted baseline socio-demographic characteristics (socio-economic status, mother’s educational level, geographical area, maternal age, marital status), maternal HIV status and exclusive breastfeeding status at 12 weeks of age from the PROMISE-EBF trial data set for the 746 children traced for the present study. Regression analysis was used to assess confounding factors.
Results
Socio-economic characteristics and status varied across the three sites. The mean age of mothers was similar in Umlazi and Rietvlei (23·9 and 24·0 years, respectively) and slightly older in Paarl (24·9 years). The prevalence of HIV amongst mothers was 5.9% in Paarl, 8.1% in Rietvlei and 28.2% in Umlazi. Educational levels of mothers were lower in Rietvlei. Household income also differed across the three sites, with a median US$100 per month in Paarl and Umlazi and US$78 per month in Rietvlei. Most of the mothers in Umlazi were single (85%), as was the case in Paarl (68%), while most mothers in Rietvlei were married (68%). Rietvlei had the highest proportion (70%) of participants who were in the poorest quintile; in Umlazi, no participants fell within that quintile and Paarl had 3%. Paarl had the highest proportion of participants who were in the least poor quintile (34%), Umlazi had 31% and Rietvlei had none.
For two years of child age, Rietvlei had the lowest rates of CSG receipt (28%) compared with Paarl (38%) and Umlazi (34%). High rates of stunting were observed in all three sites, with Umlazi being the most affected (28%) compared with Rietvlei (20%) and Paarl (17%). Duration of CSG receipt had no effect on stunting, after adjusting for confounders. Both HIV-positive status of the mother (adjusted OR=2·30; 95% CI 1·31, 4·03) and low birth weight (adjusted OR=2·01; 95% CI 1·02, 3·96) were associated with more than double the probability of the child being stunted. Completing high school or having a tertiary education was associated with a 58% and 84% reduction in child stunting respectively. Being from Umlazi was associated with a nearly fourfold increase in probability of stunting (adjusted OR=3·89; 95% CI 2·30, 6·59).
Discussion
CSG receipt for 18 months or longer in this study population was not associated with stunting after controlling for important risk factors such as HIV-exposure status and low birth weight, and indicated higher levels of education as having a protective effect on stunting. The strong correlation between stunting and being from Umlazi is likely explained by the high prevalence of HIV in this site. The authors suggest several reasons for the apparent lack of association between CSG receipt and stunting in households. The CSG is often introduced in the context of high unemployment rates, where it becomes the only source of income in many households. The value of the grant has not been keeping up with inflation rates; at US$32 per month, it is a small amount in the context of rising food prices and unemployment. To maximise the potential positive impact of cash transfers, their cash value should be linked to food-price movements and the cost of essential non-food items, and their value adjusted for household size.
The authors conclude that cash transfers need to work in tandem with other poverty alleviation measures such as education, housing and access to quality healthcare in order to maximise their impact on child-health outcomes such as stunting. Findings suggest that in South Africa the effect of the cash transfer on nutritional status may have been eroded by food-price inflation and limited progress in the provision of other important social and environmental services. These findings add weight to calls for changes in the CSG allocation to be pegged to the inflation rate and to be based on the cost of raising a child.
*Zembe-Mkabile W, Ramokolo V, Sanders D, Jackson D & Doherty T (2016). The dynamic relationship between cash transfers and child health: can the child support grant in South Africa make a difference to child nutrition? Public Health Nutrition, 19(2), 356-362. doi.org/10.1017/S1368980015001147.