UNU/IUNS African Nutrition Leadership Initiative Report

Consultation held in CAPE TOWN, Republic of South Africa 
June 22-25, 1999

Organization of Consultation Organizing institutions

Steering Committee

Editorial committee

Reporter

Summary and Main Conclusions

The Cape Town consultation is part of a global initiative spearheaded by the United Nations University /Food and Nutrition Programme (UNU/FNP) and the International Union of Nutritional Sciences (IUNS), in collaboration with other partners, for enhancing human leadership and organizational capacity to address global nutrition challenges. This initiative is motivated by the growing recognition of the important role of nutrition in human development. The first workshop in this context was held in Manila, the Philippines (see Summary Report); consultations for other regions are planned. For Africa, another two consultations are programmed for the West and East Africa regions.

The UNU/IUNS initiative is based on the recognition that significant work on capacity building is ongoing in many regions, and therefore seeks to build on these efforts, and, where deemed necessary by stakeholders, to help to strengthen them. The Cape Town consultation underlined that in Southern Africa indeed much has been done and that a lot is ongoing, both at national and at regional levels. A good number of programmes and activities are being implemented and many persons have been trained in the field of nutrition. However, although significant improvements have been made, data on health and nutritional problems show a negative trend. It is evident that a number of technical, socioeconomic and demographic factors affect this deteriorating situation. The primary goal of all programmes should be the improvement of the nutritional situation of the people in communities. Adequate investment in human leadership and institutional capacity is seen as an essential mechanism to reach nutrition goals.

In this regard the following issues came up:

There was general agreement that prior action would be needed to improve the situation and in particular to improve leadership and institutional capacity. Action would mainly have to cover the development of new leadership skilled in management, policy analysis and advocacy; client-need driven methods, multidisciplinary training approaches, and better use of existing resources. The meeting discussed several possible models to achieve the wanted action, based on the recognition that there is considerable experience and potency available in the Southern Africa region. The idea of an 'Action Learning Cooperative' that is based on the principles of collaborative partnership, learning together in a noncompetitive way, was positively appreciated by the meeting. However, details such as tasks, membership, funding, structural set-up and mechanism would have to be worked out.

Therefore the meeting proposed an interim approach and decided to:

Prof. Pauline Kuzwayo, who was unanimously nominated by the meeting, accepted to become the interim coordinator of the Nutrition Action Group for Southern Africa.

Part 1: Background, Aims and Scope of the Consultation

Background

The consultation was part of a global initiative spearheaded by the United Nations University (UNU) and the International Union of Nutritional Sciences (IUNS), in collaboration with other partners. This global initiative is motivated by the growing recognition of the important role of nutrition in human development.

The first workshop-convened jointly by UNU and IUNS- was held in Manila, the Philippines in August 1996. The Southern Africa consultation held in Cape Town -specifically focussing on Southern Africa- was the first of three planned consultations for Africa. Two others will be held in West Africa, and in Eastern and Central Africa. Consultations elsewhere are planned for South and Central America, Asia, the Middle East, and the newly independent republics of the former Soviet Union.

This initiative is motivated by the growing recognition of the important role of nutrition in human development. Nutritional problems in the world are rapidly evolving as global socio-economic conditions change, and the interconnected nature of national economies, demographic transitions, and continued population growth pose new challenges to the food system. In the face of these developments, investment in human and institutional capacity to address nutrition -an investment, which has been inadequate and uneven in many regions- must receive priority attention. To be successful, a bold initiative to enhance human and organizational capacity to address malnutrition must be driven by leaders in a particular region. This UNU/IUNS initiative recognizes that significant work on capacity building is ongoing in many regions, and therefore seeks to build on these efforts, and, where deemed necessary by stakeholders, to help to strengthen these efforts.

Aim

The aim of the three-day consultation was to share ideas and build consensus on the need for a concerted effort to strengthen human and institutional capacity to combat malnutrition in Southern Africa and to formulate a bold action plan to make it happen.

Specific objectives 

The specific objectives of the consultation were to:

Programme of the consultation 

The consultation was approached as an action-learning activity. After the start with a wide-ranging exchange of ideas, the discussions became more and more action-oriented and resulted at the end in a concrete proposal. 

In the discussions, plenary and in small groups, participants brought in their ideas and shared their experiences and insights.

The first day focused on developing a shared understanding of the problems and challenges encountered in efforts to institutionalize the response to malnutrition in the region, with particular emphasis on issues related to high-level training and capacity building. Brief presentations were given on

The second day focused on generating organizational and managerial solutions to the issues raised before. Resource persons from within the group of participants had been invited to present their experiences on 'best practices' in capacity building and institutional strengthening for nutrition programme effectiveness. Additionally, some other participants presented 'key ideas' based on their work experience.

The third day focused on the action to be taken. Based on the identified problems and 'good practices' in the days before, the meeting focussed on possible solutions, as well as on the mechanism for the needed implementation of the proposed actions.

Andre Zaaiman and Piet Human of the Goree Institute, based in Senegal, West Africa, facilitated the consultation.

Participants 

Participants were selected on the basis of their experience and involvement with capacity building. They did not represent organizations and/or countries. They brought in a mix of professional experience such as research, training/education and programme planning and implementation in the field of nutrition and related fields such as agriculture and health.

Part II: Nutrition and Capacity Building in Southern Afriac

Opening remarks on the UNU/IUNS initiative

Cutberto Garza

The overall aim of the global initiative that comprises a series of workshops/meetings in diverse regions, is to asses what type of nutrition training is needed throughout the world in order to develop human and institutional capacity to address malnutrition. Past meetings showed that most countries have a fairly good basis, but mainly focussing on the biomedical dimensions. Now it is time to give attention to the integration of social and programmatic aspects in training.

As for Africa, and in particular Southern Africa, it is obvious that a lot is going on in the field of nutrition in the different countries, and certainly also at regional levels. But also, Africa is still facing a lot of problems. The idea behind this consultation is to help accelerate the development of human and organizational capacity. The consultation is to be seen as a brainstorming opportunity: to discuss on the basis of an assessment of experiences and constraints how to move forward. The outcome should be a strategic vision and a plan with clear priorities, with indicators where to go and mechanisms how to reach the goals.

Participants of this consultation take part on a personal base. They were invited because of their experiences with and/or involvement in human capacity. Most of them have a leadership role in Africa. They are expected to liaise with the outside world and to bring the agenda-as developed during this consultation- to the implementation phase.

Goals of the global initiative are: 

The overall outcome of the global initiative is a global plan for nutrition capacity building.

UNU and IUNS play a broker's role in the enhancement of human capacity for nutrition.

Dr. Barbara Underwood underlined the importance of this meeting and expressed on behalf of IUNS her appreciation for this joint UNU and IUNS initiative.

The nutrition situation in Africa 

Olivia Yambi and Milla McLachlan

Over the last three decades the region has witnessed a lot of activity in the field of nutrition. This included: 

The above exemplify efforts for a systematic approach against malnutrition and the region has documented success stories on reduction of malnutrition especially covering the period of the 1980's, e.g. Zimbabwe, Tanzania, Kenya and other successful small scale projects. The challenge has been in going to scale, or allowing the positive experiences to mushroom, and to have sustained reduction of malnutrition. While we all want to see that half-full glass signifying the success and achievements, we are aware of the recent deterioration as we watch the water pouring out and that glass getting emptied. Malnutrition levels are rising in several countries and so are the numbers of malnourished children. The fact that rates of malnutrition remain high in many countries is a reflection of violation of the right to nutrition.

Sub-Saharan Africa has taken pride in having an underweight prevalence that is half that of South Asia. Nevertheless, still about one in three children under the age of five is underweight. In three countries the prevalence of underweight is over 40%, approximating the levels in South Asia. There are also large disparities within countries. For example Zimbabwe with an underweight prevalence of 16%, below the average for sub-Saharan Africa, have 3 provinces with prevalence of over 20%. South Africa average prevalence of 9% hides the high prevalence in the Northern Province, for example.

Governments in the region can take pride in the success achieved in the area of universal salt iodization, a strategy pursued especially in the mid 1990's for reduction of iodine deficiency disorders. As shown on the map, in about one third of the countries in Eastern and Southern Africa over 80% of the households have access to iodized salt. Further efforts are required to improve the quality of iodized salt, address problems of small producers and ensure access to iodized salt in countries in conflict (e.g. Ethiopia used to receive 80% of its domestic iodized salt requirement from Eritrea). The success in increasing access to iodized salt can be attributed to a clear strategy, mobilization of resources, partnership between government and the private sector, among other factors.

Another area in which the region has had relative success is that of control of Vitamin A deficiency. The map shows clearly that Vitamin A deficiency is still a problem in most countries of the region. Most countries have included vitamin A supplementation m their country strategies and recognize the importance of multiple, strategies to prevent vitamin A deficiency. Until recently, coverage rates for supplementation were quite low and only a few countries e.g. Zambia and Malawi, had achieved reasonable coverage with routine EPI contacts. At the start of the National Immunization Days (NIDS) for polio campaign, the regional coverage of vitamin A supplementation was only 24%. About 25 countries in Sub-Saharan Africa have included vitamin A supplementation in NIDs and the coverage has doubled. It is estimated that 60% of young children received at least one high-dose vitamin A capsule in 1998. But adequate supplementation means two doses over a twelve-month period, so further effort is required. Countries are also pursuing dietary promotion and health intervention but the effectiveness of these approaches has not been adequately assessed. Fortification is also being pursued with Zambia leading the way with sugar fortification.

There has been less success in the prevention and control of anemia. Up to 50% of women are anemic during pregnancy and anemia is affecting up to 60% of preschool children in some countries. In most countries though, programmes focus on anemia of pregnancy and the problem in pre-school children and the implications on the development of the child goes unrecognized. The most common intervention is iron and folic acid supplementation during pregnancy. This intervention is inadequate because women present to health facilities too late in pregnancy and health workers are not reaching out into communities. Some attention is starting to be given to the problem of anemia recognizing its multiple causes. Several countries are now conducting assessments and hopefully more comprehensive programmes will be implemented.

Protein energy malnutrition remains a major threat to development in the region. The maps show clearly that most countries have a Low Birth Weight rate of over 10%, signifying a serious maternal health and nutrition problem. As pointed out above, about one in three children under the age of five years is underweight in sub-Saharan Africa. If we look at countries of Eastern and Southern Africa, about half of the countries report stunting prevalence of over 40%. The average underweight prevalence had stagnated at around 35% between 1990 and 1997, and several countries are now reporting deterioration. Preliminary results of the analysis for the 4th World Nutrition Situation Report (ACC/SCN) show that Sub-Saharan Africa will have underweight prevalence of around 35% in year 2000, a rate similar to that observed in 1975. The harsh reality is that for this indicator the region will be where it was 25 years ago.

The deterioration of the nutrition situation measured by underweight prevalence is accompanied by deterioration in other indicators like infant mortality rate and under 5 mortality rate. For example, the recent Demographic and Health Survey results for Kenya show that IMR has increased by about 40% between the late 1980's and the mid 1990's, and is continuing to worsen.

Among the factors contributing to declines in nutrition status and increase in IMR and U5MR is the HIV/AIDS pandemic that has hit the region hard. Discussion on the nutrition situation in the region would therefore not be complete without reflecting on this. Countries affected by armed conflict and HIV/AIDS have worsening situations in general. For example in Zambia, over 90% of severely malnourished children in Lusaka are HIV-positive. The statistics for HIV/AIDS in the region are grim indeed.

By the end of 1998, Sub-Saharan Africa comprised 22.5 million or two-thirds of the world's total population living with HIV/AIDS, including one million children. The graph showing total cases of HIV/AIDS clearly shows where the burden is, e.g. 34 million people in sub-Saharan Africa have been infected since the start of the pandemic compared to a world total of 47.3 million There have been 11.5 deaths in Africa, out of 13.9 deaths world wide. A quarter of these deaths are children. Eastern and Southern Africa is the worst hit region with an estimated 70% of sub-Saharan Africa's or 50% of the world's total people living with HIV/AIDS. Adult infection rates have reached 25% of the sexually active population. In South Africa, for example, the infection rates reported from antenatal clinics are 26.9% in KwaZulu Natal and 22.6% in Mpumalanga compares to a national average of 17%. By the end of 1998, over 6 million children under the age of 15 years lost their mother to AIDS in Eastern and Southern Africa, 70% of the world's orphans.

The implications of HIV/AIDS for nutrition are far reaching. Households are being left without primary care givers and young children are left without option but to care for the siblings without the capacities to do so. Household food security is affected, as is the ability to access services. Household and community resources that could potentially be used for improving nutrition have to be used for care of the sick and funerals--5,500 of them a day! The nutrition community is being faced with different challenges in areas of infant feeding. Guidelines for infant feeding in cases of HIV/AIDS have been prepared and countries are struggling to put these into practice against a background of most mothers not having an opportunity to know their HIV status.

Other factors to be considered as attributing to the trend in nutrition status are emergencies, drought, floods and wars, increasing poverty, and reductions in social sector spending. As emergencies are becoming a permanent feature in the region, programmes have to factor these into their planning such that adequate response is provided. It is important to recognize malnutrition as a cause of poverty.

As the focus of this meeting is about capacity building, there is a need to ask the question "whose capacity?" Our development paradigm recognizes people as key actors in addressing their problems including the nutrition problem. It is also recognized that households and communities play a key role in caring for their children. It is therefore important that systematic efforts are made to strengthen the capacity of households and communities to address nutrition problems. Such capacity will make the assessment, analysis, action and the learning process for better assessment, analysis and action more efficient. Those who will facilitate such a process themselves need to be better equipped to do this. The needs at the household and community level have to inform the process of capacity building at other levels.

Institutional capacity building in the area of food and nutrition in Southern Africa; lessons learned 

Pauline Kuzwayo

Introduction 

There has been international concern about the lack of significant progress in improving the food and nutrition in the developing world. Available data indicate that one in every three children under six years in sub-Saharan Africa is underweight. It is the only region in the world in which poor nutritional status and poverty are stagnant or worsening. A few countries such as Zimbabwe and Tanzania have achieved substantial progress in nutrition improvement under difficult conditions:

This review is not meant to be exhaustive, but to merely highlight some experiences of institutional capacity building in parts of Africa.

Historical experience in institutional capacity-building 

For the past decades several national, regional and international initiatives have drawn attention to the need for institutional capacity building in the area of food and nutrition, with a specific focus of developing countries. Since the establishment of the UNU in 1975, it has given highest priority to capacity building, especially south of the Sahara.

A joint UNU and ACC/SCN working group convened in 1984 to address the strengthening of institutions concerned with food and nutrition. The working group recommended high priority is awarded to the development of capacity of institutions that have potential to become centers of excellence. The issue was further discussed at the IUNS meeting held in Seoul, South Korea during 1989 and the very subject on institutional capacity building was a title of a workshop held by the UNU and IUNS in 1996.

By 1997, it was reported that over 600 researchers and young scientists, over 40% of the UNU fellowship awarded, had received post-graduate training in the area of food and nutrition.

The results of institutional building in Africa are a cause of great concern as generally the initiatives have not been successful. Despite the reported fact that almost 27% of the UNU nutrition fellowships were awarded to people from Africa, only 1,5% of the fellowships were implemented at UNU associated institutions in Africa. In 1988, a joint UNU and AAU (African Association of Universities) was initiated aimed at strengthening national capacity in food and nutrition involving seven African countries. The initiative was terminated in 1994, because an evaluation done indicated limited impact on strengthening capacity for research and advanced training.

The Swedish International Development Agency (SIDA) has been involved in the strengthening of a number of food and nutrition institutions in Africa, for example, the Ethiopian Health and Nutrition Institute, Zambian National Food and Nutrition Commission, the Tanzanian Food and Nutrition Centre, and the National Nutrition Unit - Zimbabwe Ministry of Health and Child Welfare. The outcome of the Zimbabwe and Tanzanian's experience has generally been considered positive in some aspects of the capacity building process.

The Applied Nutrition Programme (ANP) of the University of Nairobi was launched in 1985 with support of the Deutsche Gesellschaft fur Technische Zuzammarbeit (GTZ), the German agency of technical cooperation. Nearly 100 individuals from Kenya and other countries in Eastern, Central and Southern Africa have gone through the MSc Applied Nutrition programmes trained by high-level expert faculty. The ANP serves as a good example on how to support build- up institutional capacity.

The East, Central and Southern Africa Food and Nutrition (ECSAFAN) Cooperation, established in 1979 by the CRHCS/ECSA Health Ministers conference is the oldest networking institution aimed at addressing food and nutrition problems in the ECSA region. It was only in the mid 1990's that the CRHCS/ECSA intensified the effort of institutional capacity building in collaboration with other institutions within the region (University of Zimbabwe, Pan-African Institute for Development East and Southern Africa (Zambia) and international universities (Wageningen Agricultural University- the Netherlands, Emory - USA and Southampton - UK).

In the context of the European Union Programme NATURA-NECTAR, that was carried out by three European universities and coordinated by the Wageningen Agricultural University, five 2-4 week modules on different nutrition subjects have been developed in partnership with universities from Benin, Ghana, Kenya, South-Africa, Tanzania, Zimbabwe and the Ethiopian Health and Nutrition Research Institute.

While generally the efforts of institutional capacity building in Africa have not been successful, the initiatives in Latin America and Asia have been relatively successful. In these regions a number of key regional and national institutions have been established, for example the Institute of Nutrition of Central America and Panama in Guatemala, the Institute of Nutrition and Food Technology in Chile, and the Institute of Nutrition at Mahidol University in Thailand, to name a few.

A number of lessons can be distilled from the experience of institutional-building or strengthening. The fundamental, lesson learned has been that political will must exist. Govemment support is indispensable for any capacity-building to be successful. The other key lessons learned include: a) development of a multiple skilled core group of well-trained and highly motivated professionals; b) a critical mass of well-trained people, with a good, strong and visionary leader and long-term budgeting commitment from both the member countries and external financial assistance.

As much as successful institution-capacity building initiatives are of different forms, it seems that in Africa initiatives implemented at academic institutins are more likely to be successful than at government institutions.

Some guiding principles in institution building 

Any approach to institutional building should be based on a thorough situation analysis, with a clear goal of promoting institutional structures and capacity. The situation analysis would gather information on institutional capacities and identify areas that require strengthening, determine the level of knowledge and skills of their staff, financial support and physical assets.

The effectiveness of food -and nutrition institutions requires good management, financial sustainability and the process of phasing-out support should be planned for -at the beginning of the process.

Challenges 

The unacceptable situation of lack of institution capacity is a challenge for food and nutrition specialists and related practitioners both at national and regional level. From the key challenges, strategies about ways of taking the African nutrition challenges into the new millenium can be identified: