March 20, 2025

Deploying CHWs to Decrease Severe Acute Malnutrition in South Africa

From 2016 to 2021, the public health department in Limpopo Province, South Africa built a community health worker program that reduced the fatality rate in cases of severe acute malnutrition in children in their first 1000 days from 21.5% to 7.5%. Severe acute malnutrition (SAM) is a major issue across Sub-Saharan Africa and is associated with 30.9% of South Africa’s audited under-five children deaths.

Mr. Daddy Matthews, Deputy Director of Nutrition Services for the Department of Health in Limpopo, South Africa, recognized that Community Health Workers (CHWs) were an underutilized resource in the fight to combat neonatal and child malnutrition. The 1,226 CHW’s in Limpopo Province, primarily tasked with performing HIV/AIDs-related activities, were inadequately trained, not regarded as departmental personnel because they were managed by NGOs, and insufficiently compensated with only a small stipend.

Mr. Matthews recognized an opportunity to both address the high rates of malnutrition and to improve the morale and skills of CHWs in Limpopo Province. First, Mr. Matthews and his team developed an integrated framework to guide their work, the Limpopo Neonatal, Maternal, and Child Health Nutrition Framework. Using this framework, they trained CHWs and NGOs on infant and young child feeding, malnutrition detection, and management of foodborne illnesses. They established teams, known as “children’s clubs,” that were trained in essential skills, including identifying severe acute malnutrition using mid-upper arm circumference (MUAC) tapes, recognizing pregnant women, detecting children with vitamin deficiencies, and connecting mothers with South Africa’s child’s grant. To incentivize performance and boost motivation, Mr. Matthews and his team introduced a competitive element, where teams earned points based on their community outreach success and were awarded prizes. CHWs received formal recognition as Department of Health personnel, receive direct payment and have access to departmental resources. Since implementing this framework, case fatality rates due to Severe Acute Malnutrition have plummeted.

To develop and implement this new framework, Mr. Matthews drew on a number of skills gained through IPPHL, including implementation analysis using theory of change, stakeholder engagement and collaboration, behavioral incentives for program design, and performance assessment to monitor progress and adjust program strategy.