Building capacity in nutrition for the health workforce
Building the Health Workforce forScaling Up Nutrition: Challenges & Opportunities • Dr Paul Amuna, RNutr • Principal Lecturer, University of Greenwich, Medway Campus, Kent
My Key Focus• Global Health / Disease Statistics and Perspectives• Links to Food Production, availability and MDG 1 (A Glimpse)• The Multiple Burden of Disease in the African Context – Poverty, food insecurity & preventable disease – Developmental links with chronic disease and their relevance to SUN• Proposed Mechanistic links – Proposed Model of interactions – (focus on MDG 1, 4 & 5)• Key SUN and MDG Issues – Challenges & Opportunities – AID FOR NUTRITION REPORT (ACF 2011) – The role of the partnership (MDG 8)• Training and Capacity Needs
WORLD, DISTRIBUTION OF CAUSES OF DEATH, 2001Total deaths: 56,554,000 Other NCDs Respiratory infections Respiratory diseases HIV/AIDS 3% 6% Neuropsychiatric disorders 7% Digestive diseases Perinatal conditions 5% 4% 5% Malignant neoplasms Diarrhoeal diseases 3% 13% Tuberculosis 3% Childhood diseases Diabetes Malaria Maternal conditionsNutritional deficiencies 9% Other CD causes 30% Injuries Cardiovascular diseases Source: WHR 2002 3 Vilius GRABAUSKA
WORLD DISEASE BURDEN (DALY’s), 2001 Maternal conditions Perinatal conditions Respiratory infections Nutritional deficiencies Malaria 6% 7% Other NCDs Childhood diseases 3% Malignant neoplasms 3% 5% DiabetesDiarrhoeal diseases 4% HIV/AIDS 6% Neuropsychiatric 13% Tuberculosis disorders Other CD causes 6% 3% Sense organ disorders 10% 12% Cardiovascular diseases Injuries 3% 4% Congenital abnormalities Respiratory diseases Digestive diseases Musculoskeletal diseases Diseases of the genitourinary system Source: WHR 2002 4 Vilius GRABAUSKA
Urban and Rural Population – 1950-2030 Urbanization to accelerate 6 5 actual expectedAssumptions Billion people 4 3 2 Urban Rural 1 0 1950 1960 1970 1980 1990 2000 2010 2020 2030 Source: UN, World Population Assessment 2002 11
World markets and export opportunities Main import and export regions in world cereal marketsThe world markets for agricultural produce 300 247 187 net exports 200 111 114 100 million mt 25 2 10 0 INDUSTRIAL TRANSITION DEVELOPING -41 -100 -66 -112 -200 -190 net imports -300 -265 1979-81 1999-01 2015 2030 12
World markets and export opportunities Cereal imports of developing countriesThe world markets for agricultural produce 1970-2030 Historical Development Projections 240 East Asia 190 South Asia Near East/North Africa million tonnes Latin America 140 s.S.Africa 90 40 -10 1970 1980 1990 2000 2015 2030 13
Success and failure in fighting hungerFood and nutrition Source: FAO, SOFI, 2002 14
Direct effects VETERANS OF THE EARLY MANUTRITION WARShunger & poverty
Saloojee & Pettifor, Current Paediatrics (2005) 15, 429-436
Chronic disease Mortality rates in three areas of Tanzania and established market economies (women aged 15-59 years) Unwin N, et al, Bull WHO, 2001; 79:947-953
Stroke mortality in adults aged 30-69 years, in nine selected countries, projections for 2005 Strong K. Lancet Neurol 2007;6:182-7
Systolic Blood Pressure by sex and locality Ghana Men Women 170 170 Mean Systolic BP (mm Hg) 160 160 150 150 140 140 Group Group 130 130 Rural Rural 120 120 110 Inner city 110 Inner city N = 57 80 39 114 51 100 26 57 30 36 34 20 N = 54 57 70 137 62 106 48 82 40 33 67 31 30 20 30 40 50 20 40 50 <2 <2 60 60 -3 -2 -3 -4 -5 -2 -4 -5 0 + 0 + 9 9 9 9 9 9 9 9 Age group (y) Age group (y) Agyemang et al. Public Health 2006;120:525-33
Diastolic Blood Pressure by sex and locality in Ghana Men Women100 100 Mean Diastolic BP (mm Hg) 90 90 80 80 Group Group 70 70 Rural Rural 60 Inner city 60 Inner city N= 57 80 39 114 51 100 26 57 30 36 34 20 N = 54 57 70 137 62 106 48 82 40 33 67 31 30 20 40 50 20 30 40 50 <2 60 <2 60 -3 - - - -2 -3 -4 -5 29 49 59 0 + 9 + 0 9 9 9 9 Age group (y) Age group (y) Agyemang et al. Public Health 2006;120:525-33
Distribution of Blood Pressure by residence and sex (Tesfaye, 2008)
Proportion with BP: measurement & diagnosis of hypertension by health workers
Distribution of adults with hypertension who are aware and / or are on treatment
NCD Risk factor prevalence in SSA: Demographic & Health Survey data • in NCD risk factors in sub-Saharan Africa (SSA) Prevalence of overweight & obesity among 15-49 yr females Kenya Overweight Obesity 1993 2003 1993 2003 Rural 14.0 4.4 Urban 26.4 12.3 All 10.9 17.1 2.2 6.3 Ghana Overweight Obesity 1993 2003 1993 2003 Rural 12.2 3.6 Urban 22.4 12.7 All 9.1 17.2 3.6 8.1Sources: KDHS and GDHS courtesy C. Kyobutungi , 2008
Risk factor prevalence –overweight & obesity Quintiles in selected SSA countries Overweight and obesity among women aged 15-49years by SES 2003 Normal Weight Overweight Obesity Underweight Burkina Faso Q1 71.4 1.9 0.4 26.3 Q5 63.4 18.7 8.5 9.4 Ghana Q1 76.7 6.4 1.3 15.6 Q5 50.2 27.4 18.0 4.4 Cameroon Q1 77.4 11.4 1.6 9.6 Q5 52.4 28.9 (28.8) 14.9 (21.3) 3.8 Kenya Q1 68.3 7.3 1.6 22.8 Q5 55.2 27.1 13.2 4.5 Zambia* NE 74.6 4.9 2.0 18.5 HE 56.3 22.3 13.3 8.1 Africa DHS, courtesy, Catherine Kyobutungi, 2008
Self-reported NCD: diabetes selected SSA countries Diabetes On treatment Burkina Faso M 0.5 40.7 F 0.4 26.7 Ghana M 1.0 95.7 F 0.8 79.9 Cameroon M 1.1 74.0 F 1.0 74.0 Kenya M 1.5 36.4 F 1.0 44.0 Zambia M 0.5 23.4 F 0.6 38.4 Courtesy C. Kyobutungi, 2008
Nutritional Programming: Fetal Origins of Adult Disease:“Barker” hypothesis: programming of functionDuring early life, nutrient exposure sets metabolic behaviour and thereby determines the risk of chronic disease during adult life.
Environmental influences Political/socioeconomic(MDG7) National food insecurity influences (MDG8)Water resources management Poverty/ Low Income (MDG1)Land quality & tenure Poor Education & genderNatural disasters e.g. floods Household food insecurity inequality (MDG2 &3)Climate change UnemploymentDrought - crop failures Civil UnrestsPre-; post harvest losses Negative impact on economicLoss of fisheries & animal development/Economic collapsehusbandry Individual food insecurity (MDG1) Chronic hunger & ↓food intake Low Productivity & Poor Sub-clinical manifestations Economic Output Micronutrient deficiency Increased risk of disease (MDG6) Vitamins: A, B-complex, C, Impact on mental health (MDG5) Folate etc; Loss of man-hours Minerals: I, Fe, Cu, Se, Zn, K, , Ca, Mg etc.) Clinical manifestations Loss of earnings/reduced family incomeEnergy deficits Negative Long term clinical Physical/physiologicalLoss of protein and Influences on Outcomes adaptations/manifestationslean body mass Growth & Oedematous malnutrition ↓energy expenditureSignificant weight Development Growth failure ↓Physical work outputloss Pregnanc y outcome ↑MMR; ↑PNMR; ↑IMR; ↑ rates of stunting (Nutritional IUGR, LBW, SG A ↑U5MR; dwarfism)Poor clinicaloutcomes Risks of chronic adult Biochemical /metabolicNutritional anaemia Nutrition diseases* (obesity, CVD, adaptations↑ mortality/ morbidity programming* diabetes, hypertension ) changes in hormonal balanceovert micronutrient ↓Prognosis from illnesses ↓Immunity & ↑ susceptibility todeficiency (MDG4) infectious diseases (MDG6) A model of interactions betw een food insecurity human health, nutritional risk and economic output in situations o f poverty and chronic hunger ( Amuna P. & Zotor F. 2008)
Lifecycle: the proposed causal links H ir g he m Ia o r t a m l i t y p i r ed r a te m e n t al d e e n v t el o pm R e du ce d c t a o p ac i ty B Ie a nt b ae y dqu a E ll de r y c b a a r eb Lh c fo ry o w cp Ba i r t th u M d ah lr n ou i se U ie n nt tl a e iy q m u ed / a W e i gh t g r o wt h w ea ni ng Ft rn e qu e R a p i d ic nfo et in s Ie nt ae dq ua Gr o wt h Ie nt ae d qu aIentae dq ua fl o et a f,a ol oh d he t f, o od n utn r i ti o & c ar ehe a lt h& c ar e V b ir e s c s e i at l o y , Ht / i e T s , b Dae C h i l d S td u nt e W o m an R e du c ed M d ah lr n ou i se m e nt a l Py rn e gn a c c a p ac i t y Lg oh wW e i t Ga i n A t d o le es c n Ie nt ae d qu a S td u nt e f,a ol oh d he t & c ar e H ir g he ae R Ie nt dq u a e du c ed m a tl er n a oh m d &e f,a ol het nt a l m o r t al i t y c ar e c a p ac i t y
Key Findings from ACF ReportInvestments in Nutrition Programming & Health Systems• Investment in Nutrition inadequate • Nutrition programmes delivered (only 1% of USD11.8 billion required) mainly through health sector or• 44% of ibvestments in direct interventions allocated to micronutrient via humanitarian crises def. Projects • Few linked to development• 40% allocated to treatment of programmes Malnutrition• 2% for comprehensive programmes for • Aid not necessarily targeted at full direct nutrition interventions MOST NEEDY countries• Fulfilment of donor commitment • Links between health & nutrition variable• 14% to promotion of good nutrition needs better understanding & practice DONOR SUPPORT• Training and education??? • Ques: where is the role of• Workforce development, Research countries themselves in having Training, Capacity Building???? clear, focused policies and programmes?
Some (selected) Key Recommendations• “The contribution that nutrition can make needs to be CLARIFIED by WHO and RECOGNISED by SUN STAKEHOLDERS• “Health System Strengthening must RECOGNISE and INCORPORATE nutrition or be nutrition-sensitive• Ques: Who IS LISTENING OR TAKING NOTE? !!
Questions we sought to learn in a recent survey• Who are we training to do the job?: What is the current capacity for nutrition training throughout the continent? What is the quality of nutrition training programmes in Africa higher education institutions? What is the scope and standard of training and who are the trainees? How is the training curriculum linked to national needs and contexts? How does training fit into national (and regional) nutrition policy agenda, targets and strategies?
Approach to the Review Literature review of institutional members of the Association of African Universities1 Selection of institutions fitting the inclusion criteria2 Creation of database of institutions offering programmes in nutrition-related subjects3 Identification of the type, range and nature of nutrition programmes offered by HEIs4 Questionnaire on Staffing & Capacity & Assessment of Curricular against institutional QA & a reference benchmark set up for course accreditation5
Gaps That need Addressing form the 7-Country ENACT Survey Within Country Standard Well defined targets, Client Uniform standards Groups & Context Contextualisation of training Nutrition Elements of training & levels Training and good balance between theory & practice should equip graduate for Needs professional accreditation Strong emphasis on Training programmes application within should cover other fields community and outside mainstream for national/regional context added value
Where are We Now? Key findings of the 7-Country FAO Study Focus of Nutrition Key issue at interventions on country level fortification/supple Malnutrition mentation NEAC not high on the National agenda and approach Health sector activities Nutrition mainly information, focus on IYCF, no emphasis on Breastfeeding, Polices & practice HIV/AIDS, Nutr Rehab Strategies NEAC remains largely Rare emphasis on uncoordinated btn Food Security initiatives & sectors & not evaluated Source: The Need for Professional Training in Nutrition Education and Communication FAO, June 2011
Table 2: Curricular Assessment of HEIs on AAU Database running nutrition-related coursesRegion of Total No. No. of HEIs Total No. Courses Course whichAfrica of HEIs Running of with Good match external on Nutrition- Nutrition Internal reference database related Courses QA accreditation Courses Assessed Structures benchmarksNorth Africa 63 11 4 2 0West Africa 91 23 5 2 1Central 17 3 0 Unknown UnknownAfricaEast Africa 73 22 16 8 8Southern 21 13 29 19 10AfricaTOTAL 265 72/265 54/72 (27.17%) (75%)
Summary of Key Findings 72 of 265 (27.17%) offer a range of nutrition- related courses1 54 (75%) of courses reviewed with wide variations in content, focus and targets2 Quality Assurance standard not uniform and few measured well against external benchmark3 Course specifications not standardized & poor balance between science & Practical aspects4 Training focus and end points not well defined in many cases & Training not harmonised within5 countries or coordinated across the regions
NEAC / ENACT Capacity Needs: Key Players Needs Assessment How do we e.g. FAO 7-country address Needs? report findings What role (s) can we play as individuals? INSTITUTIONAL & - Advocacy? Training of Trainers – COUNTRY Academic Case? Regional v. Local and / or Online Options CAPACITY NEEDS Economic Case? Any role for National Continental Professional Bodies Professional Bodies e.g. e.g. National FANUS, ANS Nutrition Associations
NEAC / ENACT Capacity Needs: Who are the targets? Undergraduates in As CPD for nutrition, health, Practising agric and allied professionals professions School Teachers: NUTRITION Potential role of Field workers working Teacher Education & with CBOs, NGOs, TRAINING Training Colleges INGOs, International TARGETS organisations Community / Social Medical/Nursing workers dealing Students, Nurses / with clients across Midwifes, Doctors the life cycle
Implementation at Institutional Level: Settings Where? By whom and why? IMPLEMENTAT Who makes the At what level? and how ION decisions and how are they influenced? does it feed into the Curriculum review Focusing on process? - Principles & Practice Is there capacity for What are the Training? institutional Quality Are the resource Assurance Issues? implications?
Questions to Ponder:In the light of these findings which appear to be common across many countries, what do we need to do to build capacity at all levels?How can training programmes be made to fit purpose within the context of national and regional nutritional challenges? What should be the focus of training and how do we make it practical, applicable and adaptable in different settings?What do we need to empower nutrition graduates to transform Africa’s nutrition landscape?How can we measure progress, success and impact? How can we influence the nutrition policy process in respect of the centrality of Nutrition in Development?
Conclusions• There are currently a wide variety of nutritional issues facing the populations in African countries which hamper socio-economic development of the whole continent – across the life spectrum• Academic Institutions and Training & Research are key but (currently non-visible in the ‘SUN EQUATION’• Current funding arrangements are skewed and need to be reconfigured for sustainable solutions• We also know to a large extent what can be done to mitigate these problems and possess the tools for tackling the problems• To address the nutrition and health issues, we need a well trained and motivated health and nutrition workforce competent to transform the nutrition landscape• Such a workforce must be fit for purpose by having the right tools: – sound, fundamental scientific knowledge that underpins their practice – the right skills and competences to enable them operate and – The necessary resources to support their efforts – Practical and relevant skills for translating and communicating messages and supporting implementation of change.• Partnerships between ‘Southern’ and ‘Northern’ Institutions and High level ‘Regional Training Institutes’ needed to advance training, research & practice for development• We also need country nutrition policies that reflect Capacity needs & recognises the place of “Nutrition Educationists” within relevant sectors
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