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

Thank You !p.amuna@gre.ac.uk

p.amuna@gmail.com;