1. Building the Health Workforce for
Scaling Up Nutrition: Challenges &
Opportunities
• Dr Paul Amuna, RNutr
• Principal Lecturer, University of
Greenwich, Medway Campus, Kent

2. 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. WORLD, DISTRIBUTION OF CAUSES OF
DEATH, 2001
Total 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 conditions
Nutritional deficiencies 9%
Other CD causes 30%
Injuries Cardiovascular diseases
Source: WHR 2002
3
Vilius GRABAUSKA

4. 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% Diabetes
Diarrhoeal 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

5. World Health Statistics 2008

6. World Health Statistics Nutritional
Africa 2008

7. Systematic Shift in Disease Patterns
Type 2
Trauma Diabetes CHD Cancers
Mortality Rates
Infectious diseases
Development

8. Qatar in the 1950s
Qatar in 2010

11. Urban and Rural Population – 1950-2030
Urbanization to accelerate
6
5 actual expected
Assumptions
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

12. World markets and export opportunities
Main import and export regions in world cereal
markets
The 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

13. World markets and export opportunities
Cereal imports of developing countries
The 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

14. Success and failure in fighting hunger
Food and nutrition
Source: FAO, SOFI, 2002
14

15. Direct effects
VETERANS OF THE EARLY MANUTRITION WARS
hunger & poverty

16. Micronutrient Malnutrition…

17. Child mortality stats SA 2000

18. Saloojee & Pettifor, Current Paediatrics (2005) 15, 429-436

19. 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

20. Stroke mortality in adults aged 30-69 years, in nine
selected countries, projections for 2005
Strong K. Lancet Neurol 2007;6:182-7

21. 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
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-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

22. Diastolic Blood Pressure by sex and locality in
Ghana
Men Women
100 100
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

23. Distribution of Blood Pressure by residence
and sex (Tesfaye, 2008)

24. Proportion with BP: measurement & diagnosis
of hypertension by health workers

25. Distribution of adults with hypertension who are
aware and / or are on treatment

26. 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 8.1
Sources: KDHS and GDHS courtesy C. Kyobutungi , 2008

27. 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

28. 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

29. 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.

30. Environmental influences Political/socioeconomic
(MDG7) National food insecurity influences (MDG8)
Water resources management Poverty/ Low Income (MDG1)
Land quality & tenure Poor Education & gender
Natural disasters e.g. floods Household food insecurity inequality (MDG2 &3)
Climate change Unemployment
Drought - crop failures Civil Unrests
Pre-; post harvest losses Negative impact on economic
Loss of fisheries & animal development/Economic collapse
husbandry 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
income
Energy deficits Negative Long term clinical Physical/physiological
Loss of protein and Influences on Outcomes adaptations/manifestations
lean body mass Growth & Oedematous malnutrition ↓energy expenditure
Significant weight Development Growth failure ↓Physical work output
loss Pregnanc y outcome ↑MMR; ↑PNMR; ↑IMR; ↑ rates of stunting (Nutritional
IUGR, LBW, SG A ↑U5MR; dwarfism)
Poor clinical
outcomes Risks of chronic adult Biochemical /metabolic
Nutritional anaemia Nutrition diseases* (obesity, CVD, adaptations
↑ mortality/ morbidity programming* diabetes, hypertension ) changes in hormonal balance
overt micronutrient ↓Prognosis from illnesses ↓Immunity & ↑ susceptibility to
deficiency (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)

31. Lifecycle: the proposed causal links
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32. Prentice et al; 2005

33. Early Nutrition Priorities…

35. SUN PROGRESS REPORT 2012

36. SUN PROGRESS REPORT 2012

37. Challenges & Opportunities

38. Key Findings from ACF Report
Investments 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?

39. 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? !!

40. 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?

41. Approach to the Review
Literature review of institutional members of the
Association of African Universities
1
Selection of institutions fitting the inclusion criteria
2 Creation of database of institutions offering
programmes in nutrition-related subjects
3
Identification of the type, range and nature of
nutrition programmes offered by HEIs
4
Questionnaire on Staffing & Capacity & Assessment of
Curricular against institutional QA & a reference
benchmark set up for course accreditation
5

42. 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

43. 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

44. Table 2: Curricular Assessment of HEIs on AAU
Database running nutrition-related courses
Region of Total No. No. of HEIs Total No. Courses Course which
Africa of HEIs Running of with Good match external
on Nutrition- Nutrition Internal reference
database related Courses QA accreditation
Courses Assessed Structures benchmarks
North Africa 63 11 4 2 0
West Africa 91 23 5 2 1
Central 17 3 0 Unknown Unknown
Africa
East Africa 73 22 16 8 8
Southern 21 13 29 19 10
Africa
TOTAL 265 72/265 54/72
(27.17%) (75%)

45. Summary of Key Findings
72 of 265 (27.17%) offer a range of nutrition-
related courses
1 54 (75%) of courses reviewed with wide
variations in content, focus and targets
2
Quality Assurance standard not uniform and few
measured well against external benchmark
3
Course specifications not standardized & poor
balance between science & Practical aspects
4
Training focus and end points not well defined in
many cases & Training not harmonised within
5
countries or coordinated across the regions

46. 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

47. 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

48. 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?

49. 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?

50. 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

51. Thank You !
p.amuna@gre.ac.uk
p.amuna@gmail.com;