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Abstract
Background
Past and present training efforts
Shortfalls in nutrition training efforts
New directions
Advantages of short courses
The role of long-term partnerships
References
Osman M. Galal
The author is a professor at the University of California, Los Angeles, School of Public Health in Los Angeles, California, USA.
In the past, developing countries have faced problems in recruiting and retraining intellectual resources for nutrition education. By now, most developing countries have in place the first of a second-generation cadre of well-educated nutrition scientists who are capable of training nationals in their fields. Many nutrition training programmes are presently run by local personnel. Local cultures and behavioural studies are not always not included in the curriculum, although it is important to include these to enhance the effectiveness of intervention programmes. The need to go beyond descriptive information is evident. The ability to predict changes in malnutrition rates is a skill needed for effective and substantial interventions. Nutritionists from developing countries need to be trained in the basic tools of social science and evaluation research. Developing countries require the cooperation of the developed world to encourage local nutritionists to improve their technological skills. Specific skills can be provided through short courses, workshops, and in-service training. Training also should be coordinated locally, regionally, and nationally. It has been observed that training in nutrition research has not been linked to programme operations. There has been a lack of coordination among nutritionists from the same region, and communities have seldom been involved as partners in training.
A large share of ill health in developing countries is related to nutrition. Data generated by both local institutions and international agencies confirm that malnutrition is a major cause of human suffering, especially in low-income countries in Africa, Asia, and Latin America. One-third of young children in these countries are stunted because of undernutrition. One-half of all deaths among young children are, in part, a consequence of malnutrition. Forty percent of women in the developing world suffer from iron-deficiency anaemia, a major cause of maternal mortality and low-birthweight infants. One in four persons is at risk for cognitive deficits or disease due to iodine deficiency. In many developing countries, the number of malnourished persons continues to grow [I], although great efforts are being made to reduce malnutrition. Most of the burden of malnutrition is at least in part the legacy of the economic conditions and poverty in the households in which these persons live. However, prevention is not only possible, it is often relatively inexpensive.
The traditional response of health planners to malnutrition has been to carry out needs assessments, investigate the current situation, and project goals for the amelioration of the problem. Assessments include gathering information on the nutritional status of the population, factors affecting nutritional status, and the population’s perceptions of nutrition-related health problems. On the basis of these assessments, a country usually designs nutrition training programmes and interventions [2]. However, in many developing countries, institutions of nutritional science face problems in recruiting and retaining trained professionals and in building and monitoring sound physical and technical infrastructures. Further, rapid changes in technology demand a continuous updating of skills at all levels. This is a difficult task. Maintaining infrastructure, research, and administration to equal the task of keeping pace with rapidly changing scientific and communication methods is an area of concern. Unless addressed, these problems threaten to leave nutrition scientists from developing countries almost entirely out of the loop of global scholarly inquiry.
Fundamental needs include trained developing- country nationals to direct core graduate and undergraduate training in their fields; the use of technology to make linkages with researchers from other parts of the world; and the ability to predict future nutritional problems and trends so as to go beyond a mere documentation of the current nutritional status. Training in nutrition traditionally has concentrated on developing the capacity for documentation of nutritional status and use of this information to formulate and influence policy. However, the gap between nutrition policies and the implementation of programmes has not been effectively addressed by institutions in developing countries or through international collaborative work.
Efforts towards improvement in nutrition the world over have not had the desired impact, because scientific knowledge has not been translated into population-specific strategies and interventions. Many national governments have instituted programmes committed to the goal of eradicating malnutrition. To attain this goal, over the years they have sent cadres of young scientists to developed countries for training and have invited skilled expatriates to collaborate with local institutions to upgrade national human resources. Several developing countries now have a second-generation cadre of well-trained nutrition scientists, who are more than equal to the task of directing undergraduate and graduate training in their fields. Even so, their efforts to attenuate the problems of malnutrition have met with little success.
Key reasons for this failure are that an understanding of the culture and behaviour of local populations and the integration of this understanding into programmes and policies often are missing. Until very recently, lessons learned from social and behavioural sciences have not been integrated into nutrition training programmes. Thus, despite the fact that many of these programmes presently are run by local personnel, input from local cultures and behaviour is seldom used to enhance the effectiveness of intervention programmes. The evaluation of the social context of food and nutrition in the community to uncover specific social problems is an essential step to designing problem-oriented approaches to malnutrition [3].
As a result of the predominance of narrowly focused nutritional science training programmes, descriptive presentations of malnutrition have dominated the concerns of strategic planners in developing countries. However, making progress against malnutrition requires not only the provision of adequate descriptive information, but also the abilities to diagnose the causes of malnutrition, predict changes in malnutrition risk over time, identify populations at risk for malnutrition, design effective and sustainable interventions, and evaluate their impact appropriately.
To combat malnutrition effectively, the appropriate institutions in developing countries must generate knowledge about the communities and the individuals who are nutritionally most vulnerable. This knowledge should then be translated into policies and programmes aimed at alleviating malnutrition. With continuous feedback, an interface between action and research can be maintained, and new knowledge can be generated and used to improve programme effectiveness in a dynamic manner. Evaluation should be an integral part of any planned health-care effort and can be integrated easily into nutrition programmes [4].
The crucial nature of the problem of malnutrition argues for practitioners of the discipline to have at their disposal the full array of the tools of the social sciences and of evaluation research. It has been suggested that training models borrowed from engineering be considered [5]. Given the multifactorial and multidimensional origins of malnutrition, we should integrate insights and tools from other disciplines that will clarify the nature of the problem and point to possible solutions.
Although efforts to alleviate malnutrition in the third world have been made for some time, progress has been dramatically uneven. On a worldwide scale, the situation continues to be alarming, despite a number of success stories. The number of malnourished people has increased as the level of poverty has increased in South Asia and sub-Saharan Africa, where it is projected that almost half the children will be significantly underweight by the year 2000 [1]. Several factors constrain our ability to make a greater impact. A partial list includes the following:
Lack of coordination: Institutions of nutrition sciences in both developing and developed countries have not coordinated their efforts. Rather, they compete for resources and may jealously guard their territory. If individual scientists and institutions form regional partnerships to work collectively and exchange ideas and technology, they can make significant contributions to the reduction of malnutrition.
Weak implementation, monitoring, and evaluation: Implementation of nutrition programmes too often has been weak. This is an area where third-world officials have requested help. The response from the developed world has been to focus attention on “nutrition planning,” attempts to systematically diagnose malnutrition problems and delineate appropriate national strategies to solve them. In this way, a nutritional dimension is incorporated into national development planning. Such planning efforts may be important in enabling governments to channel their scarce resources more effectively towards the attainment of nutritional goals [6]. However, despite the progress that has been made in this area, effective implementation demands more than a plan. It requires management, which involves mobilizing, organizing, and directing human and physical resources in programme implementation. Further, the nutrition-planning approach presupposes the stability of governments and institutions, although changes in both are common occurrences.
The incongruence of training and practice: Developing-country nationals who train in the North are often not available to teach others in their countries. The perils of investing disproportionately in government institutes must be considered carefully. Universities also may have their drawbacks in this respect. In some countries, national universities may be effectively closed to foreign-trained intellectuals. The reasons include bureaucratic hurdles, low salaries, hierarchies based on seniority, and professional politics.
Political instability and unavailability of skilled human resources: In some regions of the developing world, training institutions have been destroyed or rendered ineffectual by a lack of political stability. Often, where the need for effective nutrition infrastructure is most critical, the resources tend to be the most limited. This calls for a new approach and may require starting from scratch. Unlike South and South-East Asia and Latin America, much of sub-Saharan Africa does not have first- and second-generation nutrition scientists working in their home countries. In other areas, such as the Palestinian territories. Southern Sudan, and Ethiopia, trained scientists have fled or have been forced to leave and are now scattered throughout the world.
Shortage of funds: Lastly, we are in an era of constricted funding worldwide. The last decade has seen a contraction rather than an expansion of the willingness and interest of the developed countries to invest in the human resources of the South. Despite these difficult times, we should not forget that there are viable centres of excellence in these countries and trained, committed scientists who are willing and able to invest their time and energy in alleviating malnutrition.
What, then, is the solution? How can nutrition training be improved in a manner that will make a tangible difference? A more targeted approach to the problem of malnutrition is clearly required. Third-world institutions should assess their own strengths and weaknesses relative to their tasks. Each institution should examine its financial, human, political, and organizational resources. This assessment of capabilities may reveal key weaknesses. The institution can then evaluate the relative capabilities of other institutions in carrying out such tasks, their policies, and their willingness to help, and can formulate strategies to obtain assistance from other organizations or institutions. To build such capacity internally without any external support is a major task for third-world institutions. The resources and expertise of centres of excellence in the developed countries should be utilized to accomplish these goals. Such a strategy also promotes the development of centres of excellence throughout the world.
Nutrition training institutions and programmes need to develop self-evaluation techniques. However, the biggest problem for many institutions in the third world often is competition over resources with other institutions. Third-world nutrition training institutes will continue to require external funding assistance. Funds from developed countries should be used to build the capabilities of third-world institutes rather than to finance the formal education of a few individuals from the developing world at institutions in the developed world, as is commonly the case at present. The latter strategy has several disadvantages: it is more expensive, and personnel trained abroad over a long period of time may not fit well into the existing systems upon their return to their home countries and, in some cases, may not even return.
Developing countries require the cooperation of the developed world to upgrade the skills of nutrition experts from developing countries in the use of technology and to encourage these experts to use data from their own countries in training. Specific skills often are provided best through short courses, workshops, and in-service training. Unlike formal education, short-term training is flexible, emphasizes experiential learning, and is more responsive to changing nutritional needs and problems. Such training can be accomplished by concerted, collaborative efforts of local, regional, and international institutions. The local efforts should include training in data management and analysis and the dissemination of specific skills and technologies. Regional efforts require cooperation between institutions within and among developing countries to facilitate and promote the exchange of information and skills. At the international level, institutions in the developed world may upgrade the skills of nutritionists from the developing world or send experts to developing countries to train local nutritionists and other professionals in allied fields. The training institutions in developed countries will continue to attract degree candidates from abroad. Ideally, even nutritionists from the third world who pursue formal degrees in developed-country institutions should be encouraged to use data from their own countries in their training to assess and evaluate local nutritional conditions.
Short courses lasting from a few days to several months, workshops, apprenticeships, distance-education courses, and in-service training are well suited to a number of specific needs:
» They can provide added skills to a cadre of workers at any level;» They can upgrade knowledge and skills at low cost and form a ready link between research development and practice;
» They can be used as bridges to more extensive training, providing a “levelling” to compensate for past inequality of opportunity;
» They can provide networking opportunities for professionals;
» They can offer the astute manager of human resources alternative strategies to restructure the work force and improve its efficiency;
» Most importantly, they are very cost-effective; this is especially the case if such activities are conducted locally.
However, to be successful, short-term training should be made attractive to those in the best positions to provide it and those who are most likely to use it. This would ensure programmes of a high quality.
Short-term courses are the best medium for initiating and implementing innovative approaches, such as distance learning, courses on the Internet, and the provision of continuing education intermittently to a group of nutrition leaders over a prolonged period of time. This is because, unlike the traditional degree-granting institutions, they are less restricted by conventional bureaucratic and academic barriers. By tailoring training activities to the needs of the developing countries and providing certification that not only will be recognized by the home country, but also will fit into the career structure of the country in question, programmes can be made more attractive and effective.
Long-term partnerships between institutions or centres of excellence in developing and developed countries have proved particularly beneficial. They are flexible and can thus cater to the changing needs of the developing-country institution over time, enhancing research and training activities in both institutions. Furthermore, they can provide a resource for regional assistance and training that is superior to that which either of the centres could provide alone.
Such partnerships, however, are extremely difficult to fund and maintain over long periods of time. The ebb and flow of development programmes and donor priorities, focused often on a project-by-project basis, militates against the maintenance of such relationships. However, long-term alliances are worth nurturing. They work best in the mode of full partnerships that have the breadth and depth to survive administrative changes in both institutions, avoiding the problems inherent in “technical assistance” models in which consultants make periodic short-term visits but are not an integral part of the programme from start to completion.
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