Public health nutrition capacity: The quality of workforce for scaling up nutrition programmes
Summary of research*
What we know: Priority for scaling up multi-sector programmes to tackle undernutrition in LMICs is growing. Public health nutrition (PHN) workforce capacity is critical to programme delivery.
What this article adds: A position paper by the World Public Health Nutrition Association (WPHNA) Capacity Building Task Force describes existing nutrition workforce capacity and potential mechanisms for building capacity (considering workforce size, organisation, and pre-service and in-service training) in LMICs. Nutrition-specific interventions are mostly delivered through health services that depend on decent staff ratios; community health workers are critical for impact. Guidance on multi-sector nutrition programming at scale is scarce, and estimates (where they exist) of PHN workforce numbers suggest they are inadequate. Applicable pre-service nutrition training is mostly clinical and/or food-science oriented; tools for in-service nutrition training largely relate to infant and young child nutrition and food security. Increased priority and funding for building capacity for scaling up nutrition is needed to realise global targets.
Overnutrition and undernutrition problems affect at least half the global population, especially those in low and middle-income countries (LMICs). Programme guidance exists for undernutrition and overnutrition; priority for scaling up multi-sector programmes to tackle undernutrition in these contexts is growing. A position paper by members of the World Public Health Nutrition Association (WPHNA) Capacity Building Task Force outlines the case for and defenes the desirable characteristics of a system for developing the capacity of nutrition workforces for scaling up nutrition programmes in LMICs especially. It uses evidence from the literature and the joint experience of the Task Force to describe the existing nutrition workforce capacity and the potential mechanisms for building capacity. The World Health Assembly (WHA) has urged that member states should include a comprehensive approach to capacity building and workforce development in implementing plans for maternal, infant and young child nutrition, with the capacity indicator being the number of nutrition professionals per 100,000 population.
Key findings on the public health nutrition workforce
Nutrition-specific interventions for reducing maternal and child undernutrition are mostly delivered through the health sector, while nutrition-sensitive interventions are delivered through other sectors such as education, agriculture, water and sanitation, and social welfare. Much less consensus has been created around interventions needed to reduce overnutrition. The importance of employing multi-sector approaches has been widely agreed, but documented experience of how such programmes are implemented is quite rare, with little or no guidance existing on how to develop and manage such programmes.
Many countries report having national, multi-sector nutrition plans, but very few of them are actually being implemented at any scale. Community-based health and nutrition programmes can be very successful, especially if they have the essential elements of community ownership, adequate population coverage, targeting, and central support for supplies and training.
To achieve impact requires a certain level of intensity of effort, with optimal ratios of not more than 20 mobilisers, or community health workers (CHWs) per facilitator/ supervisor and not more than 20 households per mobiliser. CHW volunteers typically receive some locally organised cascade training in order to be able to carry out their work, often from trainers who do not themselves have capacity to train health workers; there does not appear to be any national or international standard for these. Recent reviews confirm that CHWs provide a critical link between communities and health and social services and are effective at implementing evidence-based interventions.
An ideal PHN structure includes a pyramid (see Figure 1), where the specialist PHN manager should have oversight of the delivery of all curative and preventive nutrition interventions delivered through the health system in the district. The delivery of such interventions is typically done by others, including nurses, midwives, dietitians and doctors. They in turn may provide support to other district actors, including CHWs, teachers, agricultural extension workers and social workers.
Figure 1: Multi-layered PHN workforce development1
Few estimates of PHN specialist numbers exist, but all suggest that they are either insuf?cient and/or largely missing in most national nutrition/health workforces. A recent survey of 13 countries in West Africa detected a critical shortage of skilled nutrition professionals in all countries, with limited supervision of nutrition activities, especially at implementation level by front-line health workers. Doctors, nurses and midwives (as well as dietitians in some countries) make up the majority of workers currently entrusted to deliver nutrition interventions globally, but training is particularly poor. For example, Asian regional country case studies (UNICEF and the WPHNA) concluded that the nutritional knowledge of health workers was outdated; their nutrition competencies were limited to more clinical and curative activities; and for nurses and midwives especially, their job descriptions did not include nutrition responsibilities. These findings are not surprising, since even in the USA and the UK the nutrition content of nurses’ and medical doctors’ training is also considered outdated and inadequate.
There is a lack of a dedicated workforce (especially in the health system) in most LMICs to provide outreach for community-based nutrition services. Scaling up CHWs was considered a crucial part of achieving the Millennium Development Goals (MDGs), but this did not happen.
Organisational diffculties are as great a hurdle to scaling up nutrition actions as the lack of PHN specialists, although the two are interrelated. No programme guidance exists that discusses dimensions of multi-sector nutrition programme governance; e.g. the need for a PHN specialist at all levels – in local government district planning office; in the central unit of each sector to oversee district-level implementation; and in the central unit to help plan, budget and oversee development.
None of the countries studied had in place a unifed nutrition information system that could guide decision-making processes for the double burden of malnutrition across the different sectors and levels of government.
A key challenge for scaling up community-based programmes is institutionalising and mainstreaming community participation. The largest and most successful programme is the Brazilian Family Health Programme, which has integrated 250,000 CHWs into its health services and institutionalised community health committees as part of municipal health services.
There does not seem to be any authoritative source of information (either regional or global) for graduate courses on nutrition. Programmes identifed in a survey of nutrition education in West Africa found that all of them failed to provide a comprehensive coverage of all essential aspects of human nutrition, being heavily oriented to food science (46%), with little emphasis on PHN (24%) or overnutrition (2%).
On-the-job training to develop the workforce to act in nutrition at scale will obviously require new and/or unconventional methods; e.g. a mix of distance learning and periodic coming together with tutors and mentors, which are both economically and logistically feasible.
Considerable material is available for in-service training of health-sector workers in the nutrition actions needed to improve maternal and child undernutrition; e.g. generic tools (such as counselling cards) for programming and capacity development of community-based infant and young child feeding (IYCF) counselling developed by UNICEF. FAO has also developed e-learning courses for professionals working in food and nutrition security, social and economic development, and sustainable management of natural resources.
Continuing professional development is another important area to be considered when developing the PHN workforce. Some universities offer online continuing education courses for nutrition and health-care professionals; e.g. the London School of Hygiene and Tropical Medicine’s distance learning course on multi-sector nutrition programming.
Improved availability of the internet has revolutionised the possibilities for capacity building in PHN. Initiatives include the Public Nutrition Virtual University (still awaiting funding) and the eNutrition Academy, a global nutrition-training platform (courses are still in development). Mentoring, defined as ‘a reciprocal, mutual and supportive learning relationship’, is one more tool that should be used to strengthen workforce development in PHN.
Unless increased priority and funding is given to building capacity for scaling up nutrition programmes in LMICs, maternal and child undernutrition rates are likely to remain high and nutrition-related non-communicable diseases are likely to escalate. A hybrid, distance-learning model for in-service training of PHN workforce managers is urgently needed in LMICs.
*Shrimpton, R., du Plessis, L.M., Delisle, H., Blaney, S., Atwood, S.J., Sanders, D., Margetts, B. and Hughes, R. (2016) Public health nutrition capacity: assuring the quality of workforce preparation for scaling up nutrition programmes, Public Health Nutrition, 19(11), pp. 2,090–2,100. doi: 10.1017/S136898001500378X.
1The pyramid structure represents numbers, not a hierarchical relationship.
More like this
FEX: Tackling the double burden of malnutrition in low and middle-income countries: response of the international community
Research By Alexandra Rutishauser-Perera Alexandra Rutishauser-Perera is a Humanitarian Nutrition Adviser with Save the Children. She has ten years of experience of public...
FEX: Nutrition Exchange South Asia issues on maternal nutrition and complementary feeding
View this article as a pdf Nutrition Exchange (NEX)1 recently developed two regionally focused editions exploring maternal nutrition and improving young children's diets in...
FEX: Scale-up of severe wasting management within the health system: A stakeholder perspective on current progress
View this article as a pdf Summary of report1 This summary was prepared by Brenda Akwanyi who undertook the review together with Philip James, Natascha Lelijveld and Emily...
Resource: Scale-up of severe wasting management within the health system: A stakeholder perspective on current progress
Executive summary Introduction Wasting is a critical issue for child survival and development, with therapeutic treatment of severe cases recognised as an essential...
NEX South Asia Editorial
Nutrition Exchange (NEX) is a long-standing ENN publication that captures the different experiences of countries in preventing and treating malnutrition. The focus of NEX has...
FEX: The Lancet series on the double burden of malnutrition
View this article as a pdf Research snapshot1 The double burden of malnutrition (DBM) is the coexistence of overnutrition (overweight and obesity) alongside undernutrition...
Providing maternal nutrition services at sub-national level in Punjab Province, Pakistan
View this article as a pdf Dr Khawaja Masuood Ahmed is the National Coordinator for Nutrition and for the National Fortification Alliance in the Ministry of Health, Pakistan....
FEX: Bottleneck analysis for the integrated management of acute malnutrition services in Somalia
View this article as a pdf Lisez cet article en français ici By John Ntambi, Madina Ali Abdirahman, Dorothy Nabiwemba, Pramila Ghimire, Sayed Ezatullah Majeed,...
Integration of maternal nutrition into Nepal’s health service platforms: What’s happening?
View this article as a pdf Bhim Kumari Pun is the Senior Integrated Nutrition Programme Manager in the Suaahara II programme. Khim Khadka is Provincial Health Director,...
FEX: FEX 65 editorial themes
View this article as a pdf Dear readers, A warm welcome to the 65th edition of Field Exchange. This edition features a range of programming issues that unfortunately reflect...
FEX: Nutrition in health response in emergencies: WHO perspectives and developments
By Zita Weise Prinzo, Adelheid Onyango, Dr Ferima-Coulibaly Zerbo, Hana Bekele, Dr Ngoy Nsenga and Adelheid Marschang View this article as a pdf Lisez cet article en...
View this article as a pdf Dear Field Exchange readers, Welcome to the 64th edition of Field Exchange. We are delighted to kick start 2021 featuring a special section on...
FEX: Community management of acute malnutrition in Mozambique
By Edna Germack Possolo, Yara Lívia Novele Ngovene and Maaike Arts Edna Germack Possolo is Chief of the Nutrition Department of the Ministry of Health, Republic of Mozambique...
FEX: Scale-up of IMAM services in Afghanistan
By Ahmad Nawid Qarizada, Piyali Mustaphi, Jecinter Akinyi Oketch and Shafiqullah Safi View this article as a pdf Lisez cet article en français ici Ahmad Nawid...
Scaling up a community-based nutrition package in Afghanistan to improve complementary feeding practices in children 6-23 months of age
View this article as a pdf Click here to listen to an interview with the author on the ENN podcast channel Dr Mohammadullah Noorzad is the Senior Officer for the Community...
FEX: Addressing acute malnutrition in Cameroon during an emergency: Results and benefits of an integrated prevention programme
View this article as a pdf Lisez cet article en français ici By Eveline Ngwenyi, Mica Jenkins, Nicolas Joannic and Cécile Patricia Eveline Ngwenyi is a...
FEX: SUN Movement experiences in Indonesia
By Nina Sardjunani and Endang L. Achadi Lisez cet article en français ici Nina Sardjunani is the SUN Lead Group member and was previously Deputy Minister of Ministry...
FEX: Prevention of child wasting in Asia: Possible role for multiple micronutrient supplementation in pregnancy
View this article as a pdf Lisez cet article en français ici By Kristen M. Hurley, Endang L Achadi, Clayton Ajello, Sufia Askari, Madhavika Bajoria, Kalpana...
FEX: A review of the humanitarian nutrition response in North-East Nigeria
This is a summary of a Field Exchange field article that was included in issue 64. The original article was authored by Alison Donnelly, Joanne Chui and Arja Huestis. Alison...
FEX: Transforming media coverage of nutrition in Kenya
By Titus Mung'ou Lisez cet article en français ici At the time of writing, Titus Mung'ou was the Advocacy and Communications Manager at Action Against Hunger (ACF) and...
Reference this page
Shrimpton, R., du Plessis, L.M., Delisle, H., Blaney, S., Atwood, S.J., Sanders, D., Margetts, B. and Hughes, R. (). Public health nutrition capacity: The quality of workforce for scaling up nutrition programmes. Field Exchange 53, November 2016. p26. www.ennonline.net/fex/53/qualityofworkforceforsunprogrammes