Capacity building has been a major pre-occupation of the Associations leadership since 2006 when the Association formed after the Barcelona World Public Health Nutrition Congress. A major step forward was taken by the Association when we held a workshop during the second World Public Health Nutrition Congress in Porto in September 2010. The workshop initiated a dialogue amongst a working group that set a plan of action that is still rolling out almost 3 years later. During the World Nutrition Congress in Rio 2012, a follow-up workshop was held, with many of the same participants that attended in Porto attending. The workshop reports are summarized below.
Porto workshop 2010
Participants: Barrie Margetts (facilitator), Roger Hughes, John Mason, David Sanders, Sonia Khan, Edna Possolo, Pak Minarto, Elisabetta Recine, Janine Coutinho, Patricia Gentil, Ana Beatriz Vasconcelos, Geoff Marks, Emorn Wasantwisut, and Roges Shrimpton.
Roger Shrimpton reports.
We held this workshop before the Porto congress, as part of our professional affairs work. One of the responsibilities of the professional affairs team is to convene expert groups to carry out tasks such as this. Thus we brought together professionals with relevant experience from different parts of the world and from a range of settings. Our purpose was to identify areas where the Association could provide leadership.
Purpose and method
The overall objective of the workshop was to reach a common understanding of the competencies required by professionals to build capacity at national, provincial and district levels. ‘Competencies’ here means the knowledge, skills and attitudes required effectively to perform in practice. The capacity to be created is primarily to accelerate reduction of maternal and child undernutrition. But the double burden of chronic diseases superimposed on undernutrition now weighs on most lower-income countries, and requires professionals equipped to deal with this reality.
The workshop involved case study presentations by country representatives, followed by presentations outlining rationale, conceptual issues and strategy initiatives related to capacity building, particularly in the context of Association activity, and next steps that we should take.
BrazilAna Beatriz Vasconcelos presented the Brazilian experience, including the revision of the national food and nutrition policy after ten years, which emphasises nutrition in primary health care, the strengthening of procedures for professional qualification, and the ongoing work of strengthening in-service training and support.
IndonesiaPak Minarto described the situation of capacity building for nutrition manpower in Indonesia, including a roadmap for its further development.
MozambiqueSonia Khan and Edna Possolo presented the strengths and weaknesses of the current health system human resources for nutrition in Mozambique, and outlined challenges to be faced.
South AfricaDavid Sanders described some of the challenges as well as ongoing efforts in Africa, including experience gained with distance learning through his own school of public health of the University of the Western Cape in South Africa.
AustraliaRoger Hughes presented Australian experience, and then summarised the Association’s professional affairs team’s work to date in developing international competency standards, and also a certification system for practitioners.
EthiopiaJohn Mason described the scale of the work needed, using Ethiopia as an example. He then also described the potential role of the projected Public Nutrition Virtual University, including curriculum requirements.
Decisions
The workshop concluded with a number of key decisions:
- A comprehensive approach to capacity building is required. This needs to recognise the importance of workforce development, and also leadership development, academic institutional strengthening, organisational development and partnerships
- There is merit in developing international competency standards specific to public health nutrition workforce development that recognise different workforce tiers (frontline, manager, specialist) and different practice contexts (under- and overnutrition).
- There is considerable overlap in the competencies needed by a public health nutritionist in dealing with over- or undernutrition. A core set of competencies are equally valid in either setting, with different emphases depending on the context.
- There is a need for strategic thinking and ongoing dialogue on the process and strategies required to assist capacity development. The role of the Association as a global standard setting body is of critical importance.
- The proposed Public Nutrition Virtual University is a very promising idea. The curriculum it uses would benefit from being linked to and informed by the competency development work.
Discussion papers
It was also agreed that discussion papers be developed by the workshop participants for submission to World Nutrition or Public Health Nutrition. The purposes of these papers include:
- To agree the policy and programme basis for accelerating the reduction of maternal and child undernutrition in countries most affected, while recognising the coexistence with overnutrition.
- To agree the competencies required at different levels in the health system, and to define curricular requirements (including content, learning, teaching and assessment strategies) required for competence at each level. (refer to the competency tab in this section of the website to see progress regarding competencies developed since this workshop).
- To recommend to the Association the next steps, including how we should support the development of required capacity across the many countries that are most affected by maternal and child undernutrition
Rio Workshop 2012
The main purpose of the workshop during the Rio 2012 congress was to case study different countries workforce capacity and capacity determinants, in order to help prioritise the Associations focus regarding capacity building.
The presentations made at this workshop are available below:
A case series of country-level descriptions of existing public health nutrition workforce capacityLessons for future capacity building efforts (PDF)
Consensus on the future core public health nutrition functions and competency requirements of public health nutritionists (PDF)
Oxford Workshop 2014
The WPHNA conducted a follow-up workshop on 7 September 2014 in Oxford, UK, to discuss multisectoral nutrition capacity development. The minutes of the workshop is available here.
Summary of progress to date
Advocacy paper: Capacity building process and strategy
Since Porto the advocacy paper has been discussed and reviewed extensively, and has recently been published in Public Health Nutrition.
A framework is proposed to help shape the capacity needs assessment, which covers four dimensions of capacity development, namely the system, organization, workforce and community levels.
The lead author, Roger Shrimpton, highlighted that efforts to establish a framework for developing nutrition capacity for LMICs began two decades ago at an IUNS meeting in Manila. The concept of a national training pyramid was agreed in Manila, with three types of functions: policy/decision makers; researchers/planners/trainers; programme implementers. UNSCN created a capacity development group in 2000 with UNU and IUNS as chairs established regional task forces. When this group last met in 2008 it was reported that it was difficult to retain young faculty and that there was a lack of enthusiasm among donor agencies for building capacity. Workforce development, whilst central to nutrition capacity development assessment and strategic planning, is not in itself adequate and a broader more conceptual approach is needed.
Evidence from the WHO led Landscape Analysis Country Assessments (LACA) carried out in many low and middle income countries (LMIC) over the last five years, indicates that the capacity to act in nutrition is very often quite limited, both at national and district levels1. Before trying to strengthen nutrition capacity in LMICs, there is a need to have a common understanding of the sort of capacities needed, including an understanding of what capacity exists, what capacity must be developed, as well as what are the challenges, the limitations and the opportunities for doing this. Based on such an assessment a capacity development plan could be established for a country with much greater certainty that all bases are covered. Similarly if other countries in the same geographic region were assessed using the same approach it would facilitate working out regional mechanisms to support nutrition development in a collaborative fashion across the region.
The proposed process for progressing nutrition capacity development follows the traditional action research cycle, or “triple A” process2. Experience has shown that capacity development is best structured as part of a continuous learning and change process that includes empowerment of individuals and organizations, and requires systematic approaches3. Frequently capacity building efforts translate into little more than a one-off training, which unless it is part of a broader initiative, is likely to be merely palliative and not lead to sustained improvements.
Systems-based workforce development must involve:
- understanding the work needed,
- identifying who and at what level can do this work (including quantification),
- training a workforce for these roles,
- supporting this workforce,
- ensuring workforce quality.
This framework has been informed by the analytical framework used for conducting the Landscape Analysis , which includes indicators for assessing the ability to act, which is capacity to do things, as well as those for willingness to act which is more related to the existence of policies, as well as budget allocations and other factors that enable staff to act. The proposed framework has 4 levels, including system, organizational, workforce and community levels, as shown in the table below. While the system level concerns the policy dimensions of capacity, the organizational, workforce and community level dimensions concern factors which more directly influence the ability to act. These levels are in agreement with those proposed by LaFond for mapping capacity in the health sector. It is realised that nutrition capacity has to stretch beyond the health sector alone.
LevelDescription / Key ElementsExamples
SystemLegal Frameworks
Socio-cultural-economic factors
Sectoral policies
Government structures- departments, portfolios.Human Rights Instruments
National Action plans for Nutrition
Health system structure and funding
Health targets and priorities
Workforce quality assurance systems (e.g. registration systems)
Agricultural and export policies and practices
Educational system
OrganizationalNational coordination mechanisms
Workforce size, structure and organisation
Access to information systems
Sector specific interventions
Tertiary education institutionsUniversity nutrition departments, programs and faculty
Number of nutrition personnel relative to population/need, location, distribution, management support and co-location with other disciplines.
Availability of public health intelligence infrastructure and information.
Existing national or provincial nutrition interventions
WorkforceCompetencies (Knowledge, attitudes and skills required to perform in workplace).
Workforce preparationDifferent workforce tiers- Nutritionists and non-nutritionists
Continued professional development
Performance review and evaluations
Professional standards and networks
Training pathways/system.
CommunityCommunity organisations
Social capital
LeadershipCommunity led health services or nutrition programs.
Resources accessed by communities to address nutrition issues.
Social networks and community organisations (e.g. breastfeeding mothers groups)
Facilitation and mobilization
The main conclusions drawn from this paper:
The renewed momentum to act in nutrition among development partners means a new and increased interest in nutrition capacity development in LMICS. Before strengthening nutrition capacity in these countries, there is a need to have a common understanding of the sort of capacity needed: i.e. what capacity exists, what capacity must be developed, as well as what the challenges, the limitations and the opportunities are for doing this. A framework is proposed to help shape the capacity needs assessment, which covers four dimensions of capacity development, namely the system, organization, workforce and community levels. This approach will give an outcome tailored to the current capacity, opportunities and needs for each country. If capacity building efforts only consider the workforce level, without considering the community, organizational, system wide dimensions, the effectiveness and the sustainability of any capacity building efforts are likely to be short-lived. In addition, capacity development initiatives must envisage the double burden of malnutrition, since most LMICs are already experiencing the nutrition transition with overnutrition growing faster than undernutrition decreases.
Next steps
Many of the authors involved in this work have recently been working on a nutrition capacity review in three countries using this framework. The findings of this work will be reported shortly at a workshop in Bangkok.
More news to follow on this page in the near future.
References
1 Nishida C, Shrimpton R, Darnton-Hill I. (2009). Landscape Analysis on countries’ readiness to accelerate action in nutrition. SCN News. 37: 4-9.
2 UNICEF. (1990). Strategy for Improved Nutrition of Children and Women in Developing Countries. New York: UNICEF.
3 UNDP (1997). Capacity Development. Management and Development and Governance Division. Technical Advisory Paper 2. New York: UNDP.