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South African Journal of Child Health

versão On-line ISSN 1999-7671
versão impressa ISSN 1994-3032

S. Afr. j. child health vol.12 no.3 Pretoria Jul./Set. 2018 



The new Road to Health Booklet demands a paradigm shift



Wiedaad SlemmingI; Lesley BamfordII

IPhD, Division of Community Paediatrics, Department of Paediatrics and Child Health, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa and South African Civil Society for Women's, Children's and Adolescents' Health (SACSoWACH), Pretoria, South Africa
IIDrPH, Child, Youth and School Health Directorate, National Department of Health, Pretoria, South Africa and School of Health Systems and Public Health, University of Pretoria, South Africa



Although under-5 mortality rates continue to fall in South Africa (SA),[1] many children fail to reach their full potential, as evidenced by high levels of stunting[2] and sub-optimal educational outcomes.[3]Recent estimates show that 38% of SA children under the age of 5 are at risk of poor development based on their exposure to stunting or extreme poverty, which are both established risks to child development.[5]

In line with the Sustainable Development Goals and the Global Strategy for Women's, Children's and Adolescents' Health, there is a need to shift from focusing on ensuring that children survive to ensuring that they also thrive.[6]

At a national level, the National Integrated Early Childhood Development (ECD) Policy of 2015 assigns responsibility for the provision of a comprehensive package of ECD services for children aged 0 - 2 years to the National Department of Health (NDoH).[7]This calls for a fundamental paradigm shift from the historical focus on vertical, child-survival-focused services. A well-defined and co-ordinated approach to providing integrated services that promote survival as well as nurturing care of young children through the health system has been lacking. Nurturing care embodies the provisions outlined in the ECD Policy, and comprises five essential elements, i.e. health, nutrition, early learning, safety and security and responsive caregiving.[8]

To address this, the Road to Health Booklet (RtHB) has been redesigned (Fig. 1). The process was led by the Child, Youth and School Health directorate within the NDoH, with support from partners who have experience in ECD, child health and communication. The partners included the South African Civil Society for Women's, Children's and Adolescents' Health (SACSoWACH), as well as academic, multilateral and private foundation partners.



The RtHB is at the centre of the U5 child health campaign, known as the Side-by-Side campaign, which aims to ensure that young children have access to the full range of nurturing care services at health facility and household levels. Side-by-Side describes the supportive relationship between a child and their caregiver, as well as the relationship between healthcare workers and practitioners who support and advise the caregiver. Side-by-Side aims to convey the concept of partnership and togetherness, and speaks to the shared child-rearing journey that caregivers embark on with their children and all those who help and support them.

The demand side of the campaign speaks to caregivers with its central message that 'You are central to your child's nurturing, care and protection - and their lifelong health outcomes. Your health worker is there to support you!' Each theme (also known as pillars) has a set of messages (Fig. 2).



RtHB health-promotion messages are aligned with those received by mothers/caregivers registered on MomConnect, a mobile phone service though which women receive messages during pregnancy and until the child is 1 year old.[9] Plans are underway to extend the messaging to when the child is 5 years old, and will be provided to caregivers through a RtHB App. The RtHB health-promotion messages are available in all official languages, and supportive materials for health workers are being developed. To promote societal awareness, the rollout of the RtHB and Side-by-Side campaign will be supported by a radio drama, which will be broadcast each week from September on eleven regional radio stations in nine official languages. Ensuring optimal use of the RtHB remains an important and ongoing challenge, particularly for services and interventions that are not currently provided at scale, such as developmental monitoring.

Including these interventions in the RtHB and creating societal awareness of the five pillars will drive demand for currently under-prioritised services. All child health consultations (both at primary level facilities as well as community health worker visits to households) should be structured around the five themes, and health workers are expected to address each of these pillars at every contact.

The majority of SA children grow up in adversity, and unless we ensure that they overcome these challenges and maintain a positive developmental (as well as health) trajectory, we are likely to perpetuate the cycle of poverty, inequality and poor developmental outcomes. The first years of a child's life, when the effects of risk and plasticity are most profound, are a critical window for early intervention, but also for promotive interventions that can benefit all children.

There will be ongoing efforts, over the next 3 - 5 years, for the RtHB and Side-by-Side campaign to provide a platform for implementing nurturing care, and expanding and strengthening the package of services provided to young children through the health system in SA.



1. Dorrington R, Bradshaw D, Laubscher R, Nannan N. Rapid Mortality Surveillance Report 2016. Cape Town, South African Medical Research Council, 2018.         [ Links ]

2. National Department of Health, Statistics South Africa, South African Medical Research Council (SAMRC), ICF. South African Demographic and Health Survey 2016: Key Indicators. Pretoria, South Africa and Rockville, Maryland, USA: NDoH, StatsSA, SAMRC and ICF, 2017.         [ Links ]

3. Spaull N. Schooling in South Africa: How low-quality education becomes a poverty trap. In: De Lannoy A, Swartz S, Lake L and Smith C, eds. South African Child Gauge 2015. Cape Town: Children's Institute, University of Cape Town, 2015.         [ Links ]

4. Countdown to 2030 Women's, Children's & Adolescents' Health. Country Profiles for Early Childhood Development. Geneva: Countdown to 2030, 2018. (accessed 25 July 2018).         [ Links ]

5. Walker SP, Wachs TD, Meeks Gardner J, et al. Child development: Risk factors for adverse outcomes in developing countries. Lancet 2007;369(9556):145-157.        [ Links ]

6. Every Woman Every Child. The Global Strategy for Women's, Children's and Adolescent's Health (2016 - 2030): Survive, thrive, transform. New York: Every Woman Every Child, 2015. (accessed 26 July 2018).         [ Links ]

7. Ntoimo LFC, Odimegwu CO. Health effects of single motherhood on children in sub-Saharan Africa: A cross-sectional study. BMC Public Health 2014;14(1):1145.        [ Links ]

8. Black MM, Walker SP, Fernald LCH, et al. Early childhood development coming of age: Science through the life course. Lancet 2017;389(10064):77-90.        [ Links ]

9. Barron P, Peter J, LeFevre AE, et al. Mobile health messaging service and helpdesk for South African mothers (MomConnect): History, successes and challenges. BMJ Glob Health 2018;3(Suppl 2):e000559.        [ Links ]

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