building capacity in nutrition for the health workforce
TRANSCRIPT
Building the Health Workforce for Scaling 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
3
3%3%
5%5%
7% 3% 6%4%
13%
30%9%
WORLD, DISTRIBUTION OF CAUSES OF DEATH, 2001
Total deaths: 56,554,000
Cardiovascular diseases
Diabetes
Malignant neoplasms
Digestive diseasesNeuropsychiatric disorders
Respiratory diseasesOther NCDs
InjuriesOther CD causes
Nutritional deficienciesMaternal conditions
MalariaChildhood diseases
TuberculosisDiarrhoeal diseasesPerinatal conditions
HIV/AIDS
Respiratory infections
Source: WHR 2002
Vilius GRABAUSKAS
4
6%
6%
4%3%
3%7%
5%
13%
3%
10%
4%3%12%
6%
Cardiovascular diseases
DiabetesMalignant neoplasms
Digestive diseases
Neuropsychiatric disorders
Other NCDs
Injuries
Other CD causes
Maternal conditions
MalariaChildhood diseases
Tuberculosis
Diarrhoeal diseases
Perinatal conditions
HIV/AIDS
Respiratory infections
Respiratory diseases
Nutritional deficiencies
Sense organ disorders
Diseases of the genitourinary system
Musculoskeletal diseases
Congenital abnormalities
WORLDDISEASE BURDEN (DALY’s), 2001
Source: WHR 2002 Vilius GRABAUSKAS
World Health Statistics 2008
Africa NutritionalWorld Health Statistics 2008
Systematic Shift in Disease PatternsM
orta
lity
Rate
s
Infectious diseases
Development
TraumaType 2
Diabetes CHD Cancers
Qatar in the 1950s
Qatar in 2010
11
Urban and Rural Population – 1950-2030
Source: UN, World Population Assessment 2002
Urbanization to accelerate
0
1
2
3
4
5
6
1950 1960 1970 1980 1990 2000 2010 2020 2030
Bill
ion
peo
ple
Urban
Rural
expectedactual
Assu
mpti
ons
12
Main import and export regions in world cereal markets
111
-41-66
114
2
-112
187
10
-190
247
25
-265-300
-200
-100
0
100
200
300
INDUSTRIAL TRANSITION DEVELOPING
mil
lio
n m
t
1979-81 1999-01 2015 2030
net exports
net imports
The
wor
ld m
arke
ts fo
r agr
icul
tura
l pro
duce
World markets and export opportunities
13
Cereal imports of developing countries1970-2030
-10
40
90
140
190
240
1970 1980 1990 2000 2015 2030
mill
ion
tonn
es
East AsiaSouth AsiaNear East/North Africa
Latin Americas.S.Africa
Historical Development Projections
World markets and export opportunitiesTh
e w
orld
mar
kets
for a
gric
ultu
ral p
rodu
ce
14
Success and failure in fighting hunger
Source: FAO, SOFI, 2002
Food
and
nut
rition
Direct effects
hunger & poverty
VETERANS OF THE EARLY MANUTRITION WARS
Micronutrient Malnutrition…
Child mortality stats SA 2000
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
Strong K. Lancet Neurol 2007;6:182-7
Stroke mortality in adults aged 30-69 years, in nine selected countries, projections for 2005
Systolic Blood Pressure by sex and locality Ghana
31338210613757 674048627054N =
Women
Age group (y)
Mea
n S
ysto
lic B
P (
mm
Hg)
170
160
150
140
130
120
110
Group
Rural
Inner city20365710011480 343026513957N =
Men
Age group (y)
Mea
n S
ysto
lic B
P (
mm
Hg)
170
160
150
140
130
120
110
Group
Rural
Inner city
Agyemang et al. Public Health 2006;120:525-33
Diastolic Blood Pressure by sex and locality in Ghana
31338210613757 674048627054N =
Women
Age group (y)
60+50-59
40-4930-39
20-29<20
Mea
n D
iast
olic
BP
(m
m H
g)
100
90
80
70
60
Group
Rural
Inner city
20365710011480 343026513957N =
Men
Age group (y)
Mea
n D
iast
olic
BP
(m
m H
g)
100
90
80
70
60
Group
Rural
Inner city
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)
1993 2003 1993 2003Rural 14.0 4.4Urban 26.4 12.3All 10.9 17.1 2.2 6.3
1993 2003 1993 2003Rural 12.2 3.6Urban 22.4 12.7All 9.1 17.2 3.6 8.1
Overweight Obesity Ghana
Overweight Obesity Kenya
Sources: KDHS and GDHS courtesy C. Kyobutungi , 2008
Prevalence of overweight & obesity among 15-49 yr females
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 function
During early life, nutrient exposure sets metabolic
behaviour and thereby determines the risk of chronic disease during adult life.
National food insecurity
Individual food insecurity (MDG1) Chronic hunger & ↓food intake
Environmental influences (MDG7) Water resources management Land quality & tenure Natural disasters e.g. floods Climate change Drought - crop failures Pre-; post harvest losses Loss of fisheries & animal husbandry
Negative Influences on Growth & Development Pregnancy outcome IUGR, LBW, SGA Nutrition programming*
Physical/physiological adaptations/manifestations ↓energy expenditure ↓Physical work output ↑ rates of stunting (Nutritional dwarfism) Biochemical /metabolic adaptations changes in hormonal balance ↓Immunity & ↑ susceptibility to infectious diseases (MDG6)
Sub-clinical manifestations Micronutrient deficiency Vitamins: A, B-complex, C, Folate etc; Minerals: I, Fe, Cu, Se, Zn, K,, Ca, Mg etc.)
Long term clinical Outcomes Oedematous malnutrition Growth failure ↑MMR; ↑PNMR; ↑IMR; ↑U5MR; Risks of chronic adult diseases* (obesity, CVD, diabetes, hypertension) ↓Prognosis from il lnesses
Household food insecurity
Energy deficits Loss of protein and lean body mass Significant weight loss Poor clinical outcomes Nutritional anaemia ↑ mortality/ morbidity overt micronutrient deficiency (MDG4)
Clinical manifestations
Low Productivity & Poor Economic Output Increased risk of disease (MDG6) Impact on mental health (MDG5) Loss of man-hours Loss of earnings/reduced family income
A model of interactions between food insecurity human health, nutritional risk and economic output in situations of poverty and chronic hunger (Amuna P. & Zotor F. 2008)
Political/socioeconomic influences (MDG8) Poverty/Low Income (MDG1) Poor Education & gender inequality(MDG2&3) Unemployment Civil Unrests Negative impact on economic development/Economic collapse
WomanMalnourished
AdolescentStunted
PregnancyLow Weight
Gain
ElderlyMalnourished
ChildStunted
BabyLow Birth
Weight
Higher maternal mortality
Inadequate food, health &
care
Inadequate food, health
& care
Inadequate food,
health & care
Reduced mental
capacity
Reduced mental
capacity
Reduced capacity to
care for baby
Inadequate foetal nutrition
Higher mortality
rateImpaired mental
development
Untimely / inadequate weaning
Frequent infections
Inadequate food, health
& care
Inadequate catch up growth
Visceral obesity, H/T, Diabetes
RapidGrowth
Lifecycle: the proposed causal links
Lifecycle: the proposed causal links
Prentice et al; 2005
Early Nutrition Priorities…
SUN PROGRESS REPORT 2012
SUN PROGRESS REPORT 2012
Challenges & Opportunities
Key Findings from ACF Report
Investments in Nutrition• Investment in Nutrition inadequate (only
1% of USD11.8 billion required)• 44% of ibvestments in direct interventions
allocated to micronutrient def. Projects• 40% allocated to treatment of Malnutrition• 2% for comprehensive programmes for full
direct nutrition interventions• Fulfilment of donor commitment variable• 14% to promotion of good nutrition
practice• Training and education???• Workforce development, Research
Training, Capacity Building????
Programming & Health Systems• Nutrition programmes delivered
mainly through health sector or via humanitarian crises
• Few linked to development programmes
• Aid not necessarily targeted at MOST NEEDY countries
• Links between health & nutrition needs better understanding & DONOR SUPPORT
• Ques: where is the role of countries themselves in having 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? !!
• 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?
Questions we sought to learn in a recent survey
Approach to the Review
2
Literature review of institutional members of the Association of African Universities
Selection of institutions fitting the inclusion criteria
Creation of database of institutions offering programmes in nutrition-related subjects
Identification of the type, range and nature of nutrition programmes offered by HEIs
Questionnaire on Staffing & Capacity & Assessment of Curricular against institutional QA & a reference benchmark set up for course accreditation
3
4
5
1
Gaps That need Addressing form the 7-Country ENACT Survey
Nutrition Training Needs
Within Country Standard Uniform
standards Contextualisation of training
and good balance between theory & practice
Elements of training &
levels should equip graduate
for professional
accreditation Training programmes should
cover other fields outside mainstream
for added value
Strong emphasis on application within
community and national/regional
context
Well defined targets, Client
Groups & Context
Where are We Now? Key findings of the 7-Country FAO Study
National Nutrition Polices
& Strategi
es
Key issue at country level Malnutrition
NEAC not high on the agenda and
approach mainly
information, no emphasis on practice
Health sector activities focus on
IYCF, Breastfeeding, HIV/AIDS, Nutr RehabNEAC remains
largely uncoordinated btn initiatives & sectors
& not evaluated
Rare emphasis on Food Security
Focus of Nutrition
interventions on
fortification/supplementa
tion
Source: The Need for Professional Training in Nutrition Education and Communication FAO, June 2011
Region of Africa
Total No. of HEIs on database
No. of HEIs Running Nutrition-related Courses
Total No. of Nutrition Courses Assessed
Courses with Good Internal QA Structures
Course which match external reference accreditation benchmarks
North Africa 63 11 4 2 0
West Africa 91 23 5 2 1Central Africa
17 3 0 Unknown Unknown
East Africa 73 22 16 8 8Southern Africa
21 13 29 19 10
TOTAL 265 72/265 (27.17%)
54/72 (75%)
Table 2: Curricular Assessment of HEIs on AAU Database running nutrition-related courses
Summary of Key Findings
2
72 of 265 (27.17%) offer a range of nutrition-related courses
54 (75%) of courses reviewed with wide variations in content, focus and targets
Quality Assurance standard not uniform and few measured well against external benchmark
Course specifications not standardized & poor balance between science & Practical aspects
Training focus and end points not well defined in many cases & Training not harmonised within countries or coordinated across the regions
3
4
5
1
NEAC / ENACT Capacity Needs: Key Players
INSTITUTIONAL
& COUNTR
Y CAPACITY NEEDS
How do we address Needs?
What role (s) can we play
as individuals? - Advocacy?
Academic Case?
Economic Case?
Training of Trainers –
Regional v. Local and / or Online OptionsContinental
Professional Bodies e.g.
FANUS, ANS
Any role for National Professional Bodies
e.g. National Nutrition Associations
Needs Assessment e.g. FAO 7-
country report
findings
NEAC / ENACT Capacity Needs: Who are the targets?
NUTRITION
TRAINING
TARGETS
As CPD for Practising
professionals School Teachers: Potential
role of Teacher
Education & Training Colleges
Field workers working with CBOs, NGOs,
INGOs, International organisations
Medical/Nursing Students, Nurses / Midwifes, Doctors
Community / Social workers dealing
with clients across the life cycle
Undergraduates in
nutrition, health, agric
and allied professions
Implementation at Institutional Level: Settings
IMPLEMENTATIO
NFocusing on
- Principles & Practice
Where?
Who makes the decisions and how are
they influenced?
At what level? and
how does it feed into the Curriculum
review process?Is there capacity
for Training? Are the resource
implications?
What are the institutional
Quality Assurance Issues?
By whom and why?
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?
Questions to Ponder:
• 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
Conclusions