Food and nutrition security
With regard to food and nutrition security, participants were more concerned with the accessibility and affordability pillars of food security, as opposed to the availability of food. These barriers were linked to the growing prevalence of overweight and obesity and NCDs in South Africa. These concerns were found to be consistent with research conducted in South Africa which also highlights poverty and lack of income as common causes of food insecurity within an obesogenic environment [11, 12, 16].
Participants stressed the need to focus on sustainable agricultural practices in line with climate change actions to ensure greater food security for the future. Thus, the ongoing research on biofortified crops that are water efficient and resistant to abiotic stressors could be combined with the development of agriculture for nutrition policies. This would allow South Africa, as a water-stressed country, to potentially benefit from sustainable alternative crops which reduce water usage [11,12,13].
Concerning the participants’ apprehension on governments ability to combine policies due to various barriers, it is important to note that stand-alone policies have been found to have a relatively limited impact on food and nutrition security [17,18,19]. A study which investigated drivers for political commitment to nutrition found that low-income countries frequently reported that nutrition and international actor networks, civil society mobilisation, vertical coordination and capacities and resources are essential for driving government commitment for nutrition . These key components for combined policy success are ways in which the mentioned barriers, such as political will, competing priorities and legislation restrictions, could be overcome.
Participants mentioned that sugar cane farmers would have difficulty in switching from their current harvesting practices, to growing fruits and vegetables. To overcome this, participants mentioned utilising the revenue generated from the tax to improve upon rotational crop production in line with nutritious foods. Crop rotation is not commonly practised in the South African sugar cane industry, although it has been shown to benefit maize and wheat crops . A study conducted in KwaZulu-Natal, South Africa, found that soybean and sugar cane crop rotation was beneficial for cane production . Crop rotation has the potential to provide nutritious food to small-scale farmers and surrounding communities, thus combating the potential negative externalities that could arise from the tax.
Participants also recommended that sugar can farmers engage in the biofuel industry as a way of combating the negative externalities and improving livelihoods. However, studies have found that greater government support is needed for sugar cane to be produced for biofuels. Government support will assist in ensuring the viability of biofuels in current markets, as highlighted in the official position statement from the sugar industry .
Overall, perceptions with regard to combining nutrition-specific and nutrition-sensitive interventions to improve the impact on food and nutrition security in South Africa were encouraging. Political will, limited delivery capacity, legislation restrictions and competing government priorities were listed as factors which would make policy combination difficult. Participants from the health, food and beverage industry and finance sector also mentioned that for combined policy approaches to work, research and investigation into these policies within a South African context would need to be done. Moreover, such policies would need to be undertaken with a strategic goal in mind and aligned with other government food and nutrition security policies.
All participants were strongly in favour of utilising the revenue generated from the tax for enhancing and capitalising on nutrition education campaigns. Studies have found that larger education or awareness campaigns would need to be introduced alongside the tax, together with supplementary efforts such as food subsidies or the provision of food vouchers. Education would also assist in consumer choice with regard to substituting SSBs with healthier alternatives .
Of note for future research regarding combined policy approaches and agriculture for nutrition policies, is the need for greater awareness and education about nutrition to improve general understanding and food choices; greater capacity for combined policy-approaches to operate within an obesogenic environment; focusing on the stability of household food supply as an important aspect of food security, and ensuring agriculture for nutrition policies in South Africa focus on minimising food wastage whilst improving the sustainability of crops in the current environmental climate.
Sugar tax, negative externalities and education
Participants expressed concerns over the true motivation for the tax, in relation to the lack of ring-fencing of the funds for health-related initiatives such as health promotion. In terms of government spending in South Africa, it should be noted that the National Treasury allocates funds to each province based on equity. Thus, revenue generated is pooled into the general fiscus and then redistributed accordingly. Exceptions are funds ring-fenced for the Road Accident Fund and Universities South Africa . Therefore, in general, South Africa has a policy against ring-fencing funds, however, greater allocations to the health budget could be made in response to this, as highlighted by the health sector participants. This needs to be combined with clearly outlined plans which illustrate where the additional funds will go in terms of combating the DBM. Specific attention should be placed on youth development and nutrition education programmes as mentioned by the participants.
Although participants were apprehensive about the ability of the tax to result in improved overweight and obesity outcomes at a ground level, they did note that the tax is still relatively new and that a longer timeframe would be required to assess the effects. These perceptions are consistent with a study that explored food taxes and their impact on competitiveness in the agri-food sector. The authors argued that changes in industry and consumer consumption patterns and subsequent health outcomes would take time to materialise and that some outcomes, such as the potential health effects, may require more time .
Participants were also concerned about the substitution effect, whereby consumers would likely switch to another beverage or food product that may not necessarily be healthier. The substitution effect in South Africa, in relation to fiscal policies such as the sugar tax, is largely unknown. Consumers may not substitute with a healthier alternative, unless larger education or awareness campaigns are introduced alongside the tax, together with supplementary efforts such as subsidising healthier food options or providing food vouchers . Participants recognised these supplementary efforts as potential areas for ring-fencing the revenue generated by the tax on SSBs, in line with agriculture for nutrition interventions. Further research in a South African context is needed to understand consumer reaction in a local setting .
Future research on SSB tax could also look at the link between industry adaptation and health benefits. Participants attributed likely health benefits to industry adaptation of SSBs rather than reduced consumption. Industries have adapted their products by reducing the size of SSBs and reformulating by replacing sugar with alternative sweeteners .
This section highlights the overall perception that fiscal policies such as the tax on SSBs, should be implemented with side-along campaigns aimed at changing consumer behaviour. A combined policy approach is more likely to offset the negative externalities mentioned by participants, as well as create an opportunity for greater multi-disciplinary interaction and collaboration.
Double burden of malnutrition
Participants perceived the DBM to be a concerning public health burden which places growing strain on economic growth, healthcare and social and youth development. Existing research highlights the global concern for the DBM in low-middle income countries . Limited research is available on the overburdened public health system in South Africa; however, undernutrition and overnutrition are seen as public health crises globally [29,30,31].
A qualitative study on the attitudes and perceptions of urban South Africans in relation to the tax on SSBs highlighted similar perceptions to these study participants . Both perceived the tax to be a solitary, income-generating mechanism used to enhance government funds rather than being focused on improving the DBM in South Africa.
An innovative suggestion from the consumer interest sector is having an independent, government-facilitated consumer movement group in South Africa. Research shows that civil society and media can contribute towards pressuring for ownership and accountability regarding malnutrition interventions. This includes following up on government commitments and ensuring that funds are well planned and accounted for . This would give the consumer with lower socioeconomic status greater representation and voice when it comes to implementing fiscal policies such as the taxation on SSBs and any prospective combined policy. In future, when planning and implementing combined policy approaches, governments would do well to consult and work closely with communities and civil society organisations to ensure greater clarity, stakeholder commitment and support.
Overall, participants were generally in favour of combining the policies to improve the DBM. This would need to be a holistic approach which takes into consideration the need for education and market access of small-scale farmers as previously mentioned. Such approaches would allow for product distribution and behaviour change to take place, thus improving the ability of the nutrition-sensitive intervention to result in positive nutrition outcomes.
Government function and scaling up nutrition-sensitive agricultural interventions
Participants frequently highlighted that before the tax on SSBs could be combined with a nutrition-sensitive agricultural policy, government would need to ensure that basic services are scaled up and run optimally. In light of the current government debt and mismanagement of government spending, the feasibility of combining these policies was though to be unlikely.
The need to create a demand for healthy foods within a market-based economy was mentioned as the next important step after ensuring there are effective basic services. Government, together with PPPs, needs to facilitate an effective value chain by ensuring proper infrastructure, services, awareness and education. Over and above this, government needs to ensure that small-scale farmers have market access and good product distribution in areas where populations need it the most. This would include distribution to street vendors and informal convenience stores or spaza shops.
A study by Gittelsohn, Laska, Karpyn, Klingler and Ayala  explored key areas to increase healthy food access in informal convenience stores. The main themes identified were, establishing relationships with stores and between stores and customers. Another study  investigated strengthening accountability systems to create healthy food environments to reduce global obesity. This study found quasi-regulatory approaches to be the most effective in combating industry opposition and government reluctance. Agriculture for nutrition policies can combine these insights into future interventions, to effectively function in a market-based economy.
Most participants were in favour of scaling up nutrition-sensitive agricultural interventions and mentioned that government can focus on not only agriculture but the consumer. The participants agreed that there is a need for greater policy coherence and stakeholder involvement to improve implementation, monitoring and evaluation. This is consistent with research which identified poor coherence among South Africa’s numerous food and agricultural policies . Incoherence was related to unclear or conflicting goals and objectives of the policies and lack of accountability of responsible parties .
A policy review by Hendriks and Olivier  found that South African agri-food policies require greater coherence between policies, ‘power players’ and independent actors – especially when making, implementing, monitoring and evaluating agri-food programmes [36, 37]. The United Nations Standing Committee on Nutrition (UNSCN) identified similar challenges which impede the success of nutrition-sensitive agriculture for nutrition policies .
Past research has found mixed and inconclusive evidence on agriculture for nutrition interventions, due to the use of multifaceted nutritional indicators. Recommendations were made for governments to focus on identifying and agreeing on key indicators to more effectively measure the impact of these interventions [6, 39]. Thus, the composite indicators identified by participants can be used in the monitoring and evaluation of agriculture for nutrition interventions in future. The indicators assess the impact of these policies on health and nutrition across the value chain. The indicators mentioned by participants are production indicators, purchasing patterns, consumption and dietary diversity patterns and health status indicators.
Collaboration and enabling environments
For government to scale up nutrition-sensitive agricultural policies and combined policy approaches, government needs to create an enabling environment for intersectoral collaboration, PPP and community and stakeholder engagement. Improving intersectoral collaboration and PPP is one of the pillars detailed in the National Policy on Food and Nutrition Security . Currently, the coordination mechanisms to align the response and goals of various sectors and government departments remains underdeveloped and unbudgeted for.
An enabling environment and enhanced collaboration will also ensure a greater commitment towards a Health in All Policies approach whereby the improvement of health is incorporated into collaborative decision-making across sectors and policies .
The recurring notion of nutrition champions was highlighted as being essential for creating enabling environments. Ample literature supports the notion of nutrition champions. According to the Scaling Up Nutrition movement, a nutrition champion raises awareness about nutrition and assist in placing nutrition-related issues on the political agenda [41, 42]. Different levels of nutrition champions exist, from high-level to working-level and grassroots champions such as teachers and community leaders [41, 42]. For nutrition champions to be effective, they need to be well-connected and trusted within informal and formal social networks .
Research shows that nutrition champions can transfer information, resolve conflicts and positively change perceptions in favour of a nutrition agenda. This is linked to their extensive knowledge of and experience in nutrition and their ability to develop relationships with different stakeholders . The identification of potential champions through stakeholder mapping is important as it ensures the selection of context-appropriate champions. Champions should be aware of their roles and responsibilities and be provided with support to ensure long-term commitment to assigned policies and interventions [43, 44]. Therefore, nutrition champions would be crucial in the development of combined policy approaches, especially in driving the alignment of nutrition-sensitive and nutrition-specific policies and programmes. In particular, nutrition champions could assist in driving such combined policy approaches linked to the taxation on SSBs in South Africa.
Participants believed that combining nutrition-sensitive and nutrition-specific policies would assist with job creation and improve youth development and overall health and productivity. However, this would need serious government commitment to be effective. Government would need to consider other competing priorities, and in the case of ring-fencing funds for agricultural interventions, would need to consider factors such as education, awareness and opposing market forces.
A recent study conducted in Mexico which researched employment changes associated with the tax on SSBs found no significant changes in employment . More research in a South African context will be required to assess the impact of the sugar tax on the broader economy. No literature is available on potentially combining the tax on SSBs with a policy aimed at nutrition-sensitive agricultural interventions as a means to prevent job losses and improve food and nutrition security. This research underlines the potential for combining the current tax on SSBs with an agriculture for nutrition policy to offset the potential negative externalities which may arise from the tax. Whilst allowing for benefits across the value-chain, from the small-scale farmer to the consumer, when combined with mass education campaigns and monitoring and evaluation.
Many feasibility issues to combined policy approaches in South Africa were voiced by the participants. Ongoing research around such approaches in other developing and developed countries would provide further insight into the barriers and feasibility of combining nutrition-sensitive and nutrition-specific policies in the future, especially with regards to the tax on SSBs and agriculture for nutrition policies.