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Changing Nutrition at the National Scale The collective impact approach to achieving mandatory food fortification legislation across east Africa
INTRODUCTION A long-term lack of nutritious foods can result in populations deficient in the essential vitamins and minerals for healthy development. These micronutrient deficiencies affect up to two billion people globally1 and account for one-third of all malnutrition-related child deaths.2 Drawing attention to the issue can be challenging as these health effects can be invisible in an individual; but in a whole country there can be a noticeable difference in terms of social and economic development. While a wellnourished nation is generally healthier and experiences lower morbidity rates, its children are also performing better at school and its population becomes more productive overall. Fortification, or the process of adding essential vitamins and minerals to food, is one of the most cost-effective and direct interventions to addressing malnutrition. While fortification of staple foods is not a guaranteed solution to eliminate vitamin and mineral deficiencies, it has the potential to benefit an entire population with better nutrition. Through boosting the micronutrient content, food fortification can help prevent different micronutrient deficiencies in all, or specific segments, of a country’s population.
Mandatory food fortification occurs
The 2008 Copenhagen Consensus – a
when governments legally oblige food
landmark event in the development
producers to fortify particular foods
sector – ranked micronutrient
or categories of foods with specific
fortification as the 3rd most cost-effective
micronutrients. Especially when
development intervention3. Iodized salt,
supported with an effective enforcement
for example, is considered one of the
system, it delivers a high level of
most widely adopted forms of mandatory
certainty that the selected foods will be
mass fortification. At an estimated annual
appropriately fortified and in constant
cost of USD 500 million, salt iodization
supply. Mandatory food fortification is
would save an annual USD 35.7 billion
considered a cost-effective intervention,
in potential costs associated with iodine
and has a high return on investment,
deficiency4 - the world’s most prevalent,
particularly when a serious public
and preventable, cause of brain
health need for improved nutrition
damage5. For other nutrition strategies,
exists.
annual investments of around USD 4.5
billion would see more than 4.1 billion6
Government backing is essential for the
more people receiving access to other
fortification of staple foods to have a
interventions – at a cost of just over USD 1
national impact on improved nutrition,
per person per year.
and interventions must enhance a nation’s long-term nutrition strategy.
EARLY DAYS Making food fortification mandatory in legislation. Securing mandatory food fortification in
Legislation mandating the fortification
GAIN’s application of evidence and
of all types of flour is currently enforced
broad based stakeholder engagement to
in 64 countries worldwide; 12 of these
policy advocacy - the collective impact
countries in Africa required compulsory
approach to fighting malnutrition - helps
wheat and or maize flour fortification.
ensure food fortification is high on national
More recently, the Global Alliance for
agendas. It brings together influential
Improved Nutrition (GAIN) offered
champions, channels resources and
support to three east African countries
unites stakeholders through a sense of
working to make food fortification
urgency for change. This approach proved
mandatory: Tanzania, Uganda and
successful in encouraging the passing of
Political will, leadership from multi-
Kenya. In this capacity, GAIN supports
mandatory food fortification legislation in
stakeholders and commitment from the
the production of high quality fortified
Tanzania and Uganda.
food industry are all essential factors
foods, using the scientific evidence-base
countries requires commitment and clear leadership from all partners collectively involved in the production of staple foods. Governments, businesses, international organizations and civil society all need to share the common goal to improve nutrition, and work together in partnership to support the passing of legislation.
behind the success of mandatory food
for specific legislation to be approved
In 2011, Tanzania and Uganda passed
through the appropriate government
mandatory food legislation to add
channels.
essential micronutrients to staple foods. By 2013, an estimated 45.6 million people will purchase foods of improved
fortification in Tanzania and Uganda. It is a significant step forward for large-scale improvements in nutrition, but creating the framework and enforcing the compliance of producers with legislation also requires
Wheat flour fortification in Egypt. The story of baladi bread.
nutritional quality. Meanwhile, Kenya is in The foods identified for mandatory
Food fortification has been a standard
Food fortification has an astonishing
legislation are: maize flour, wheat flour
practice in many developed countries
impact on people’s lives; particularly the
and vegetable oil. Universal salt iodization
for a number of decades. In Switzerland,
lives of poorer populations. Egypt started
is already mandatory in all three countries.
for example, salt has been iodized since
its mandatory fortification program in 2008, adding iron and folic acid to wheat flour which is baked into baladi bread; a staple food of Egyptians. Mona Mohamad miscarried twins during her first pregnancy, before wheat flour fortification became mandatory in the country. “The doctor told me my babies were not alive anymore,” she said. Folic acid protects pregnant women from delivering children with brain and spinal cord damage, a condition known medically as neural tube defects. Mona’s second pregnancy went well; she later gave birth to her first baby boy in 2009. It is now estimated that 20 million Egyptians – including pregnant and soon to be pregnant women – have iron and folic acid in their diets through consuming fortified baladi bread.
a parallel effort.
the process of finalizing similar legislation.
1922 to provide iodine to populations at scale; and margarine fortified with vitamin A began to emerge in parts of Europe at the end of the 1920s.
GAIN’s MODEL
Fortified staple foods available in Kenya, Tanzania and Uganda. Staple food
Added vitamins and minerals
Country
Maize meal
Iron, zinc, folic acid (B9), cobalamin (B12), Vitamin A, thiamin (B1), riboflavin (B2), niacin (B3), pyridoxine (B6)
Kenya (Voluntary since 2003; draft mandatory legislation since 2011)
Wheat flour
Iron, zinc, *folic acid (B9), cobalamin (B12), Vitamin A, thiamin (B1), riboflavin (B2), niacin (B3), pyridoxine (B6)
Kenya (Voluntary since 2003; draft mandatory legislation since 2011) Tanzania (Since 2012) Uganda (Since 2007)
Vegetable Oil
Vitamin A
Kenya (Voluntary since 2003; draft mandatory legislation since 2011) Tanzania (since 2012) Uganda (Since 2007)
Generating political will – driving influential champions. Senior political leaders in Uganda, Tanzania and Kenya had prioritized food fortification in national health strategies as well as in long-term development plans. Acting as key champions for change, their efforts provided the necessary momentum and visibility for mandatory food fortification to be placed high on the political agenda.
*Note: Ugandan wheat flour does not contain folic acid. "It was easy to discuss with our Minister of Health about amending the appropriate act to include fortification standards and the addition of more vitamins and minerals," said Gladys Mugambi, Food Fortification Project Manager at the Ministry of Public Health and Sanitation in Kenya. “Food fortification is a key
strategy in the National Food and Nutrition
officials. The Ministry of Health Nutrition
Policy and is a flagship project for the
Action Plan in Uganda was launched
Ministry of Public Health and Sanitation.”
by the President in 2011 and is also integrated into the country’s overall five-
In Uganda and Tanzania, government
year plan for development. Meanwhile,
perspective towards nutrition also
the Prime Minister in Tanzania drove the
changed with support from high-level
national food fortification agenda forward with public statements and commitments to nutrition.
Building a National Fortification Alliance with a common goal – mandatory food fortification. Bringing together key champions from across sectors strengthens policymaking and can influence, and sustains support for, changes in legislation. GAIN backs the efforts of National Fortification Alliances (NFA) to ensure food fortification programs produce high quality fortified foods that are accepted, and ultimately demanded, by consumers. To ensure broad based sectoral buy-in and that the strengths of all key sectors are harnessed, NFA’s are a coalition of stakeholders - such as government
departments, standards and food regulatory authorities, industry and academics – who work to strengthen fortification policy. They also implement national food fortification programs and build consumer awareness about its importance to the well being of society. In Kenya, Tanzania and Uganda, these committed alliances were instrumental in pushing legislation forward with their ability to educate stakeholders about the need for, and benefits of, food fortification. Their expertise was able to guide work on developing standards and social marketing strategies tailored to a specific country’s needs, and expectations. “The NFA is a committed body that understands the local challenges and how to address them and is able to work successfully across sectors,” said William Ssali, former Vice Chair of Uganda’s National Fortification Alliance and industry liaison on fortification. Nutrition champions at the helm of NFAs have also been a crucial resource. In Kenya, the current Chairman of the National Food Fortification Alliance is the Managing Director of Unga Group, a large East African milling company and a strong advocate for food fortification. His company is one of the leaders in fortification in Kenya and began voluntarily fortifying products in 2003.
GAIN’s role in making staple foods in countries more nutritious.
Commitment from the food industry for change. Working with the food industry itself was essential for moving Kenya, Uganda
An alliance driven by a world without
and Tanzania closer to mandatory food
malnutrition, GAIN supports public-
fortification.
private partnerships to increase access to the missing nutrients in diets
While a small number of businesses,
necessary for people, communities and
including wheat flour millers and
economies to be stronger and healthier.
vegetable oil producers in Kenya and
Established in 2002, it has supported
Uganda began voluntarily fortifying, most
food fortification to key staple foods,
have been reluctant to comply without
including wheat flour, maize meal, salt,
mandatory legislation in place first. In
sugar and vegetable oil. GAIN supports
Tanzania, a number of businesses agreed
the efforts of National Fortification
that there would be limited fortification
Alliances to ensure programs deliver high
done voluntarily as competitors who did
quality fortified foods and supports the
not fortify would have a cost advantage.
drafting of legislation. However, on the flip side, industry
Meanwhile, the Chairman of the Ugandan NFA is the Director General of Health Services. Through his office, the Ministry of Health provides strong support to fortification efforts and promotion of public-private partnerships for improved nutrition.
William Ssali, former Vice Chair of
leaders in these countries have shown
the National Working Group on Food
commitment to moving fortification
Fortification in Uganda, and an industry
forward, encouraging others to follow the
liaison on food fortification. “GAIN has
same path.
been a catalyst and facilitator: Without GAIN’s support, we would not have
“The decision to go in this direction
strengthened our National Fortification
arose partly out of our corporate values
Program in such a short time.”
as well as our commitment to meeting consumer satisfaction,” said Tony Gadhoke, CEO, of Mukwano Group of Companies, a conglomerate in the east and central African manufacturing
sector. Mukwano Group’s company, AK Oils & Fats Ltd, began fortifying a range of its edible cooking oils with vitamin A in 2004. “Through fortification, we give the consumer a product that offers health benefits and also maintains our set standards on quality, taste and affordability”, Mr. Gadhoke added.
The Scaling Up Nutrition (SUN) movement. Tanzania and Uganda committed to fight malnutrition. The SUN movement is a global drive to address the challenge of malnutrition in
of food fortification projects are not
the first 1000 days. Uganda and Tanzania
uncommon. In many parts of the
are both committed as SUN ‘early riser’
world, compliance and enforcement of
countries, ready to effectively address
fortification laws remain a challenge.
malnutrition and stimulate social wellbeing and economic growth of their populations. With national policies in place, these countries already respect food fortification as a complementary strategy to improve nutrition. GAIN supports the SUN movement by
Both industry and government must establish quality control systems that ensure foods are fortified according to national standards. In many countries these quality control systems often need to be strengthened.
engaging like-minded private and private sector stakeholders to deliver nutrition interventions. In terms of food fortification, for example, GAIN engages and encourages the private sector, particularly millers, oil and salt producers to join nutrition dialogues.
Bureaus of National Standards in the countries will be responsible for checking that businesses comply with mandatory legislation. Businesses failing to comply will face penalties, and in Uganda, for example, representatives can be imprisoned and their products impounded. In Tanzania, food companies could lose their valuable licenses to operate.
LESSONS LEARNED To overcome this issue of compliance,
Complying with legislation: a key challenge in mandatory food fortification.
GAIN seeks to facilitate the enforcement
A caveat to bear in mind is that the
countries where it intervenes. Maintaining
passing of a law does not, on its own,
compliance is a crucial strategy to
ensure the success of a food fortification
increase the ‘effective coverage’ of
program. Political, social or technical
fortified foods, as well as increasing
barriers to the successful implementation
sustainability of the public health impact.
of food fortification policies, whether they are mandatory or voluntary, in the
Raising awareness of food fortification with social marketing. Public awareness of the benefits of consuming fortified foods and creating demand for fortified foods still need to be improved through behaviour change and social marketing campaigns. “There is still a significant amount of education and communication to be done – the majority of the population does not know what fortification is and is suspicious of it,” said Nick Hutchinson, Managing Director of Unga Group and Chair of the Kenyan National Food Fortification Alliance. Initial efforts have also been made to determine how individual country standards and legislation on food fortification can be better unified across east Africa. The East African Community (EAC) – comprised of Kenya, Tanzania, Rwanda, and Burundi – has embarked on a process to harmonize fortification standards for wheat flour, maize flour, edible oil and salt. They are also investigating the possibility of a unified fortification brand identity, similar to a fortified oil logo in west Africa, as each country in east Africa currently adopts a different design on its products.
Creating a sustainable model. Political will, champion leadership, crosssector collaboration and private sector support are key drivers of mandatory food fortification legislation. “GAIN has been a catalyst and facilitator,” added William Ssali, former Vice Chair
The foundations for a collective impact approach to fighting malnutrition. Champions. The support of high-level champions, such as ministers, is key to provide the necessary momentum to put in place mandatory food fortification. Resources. The formation of National Food Fortification Alliances – coalitions of stakeholders who strengthen fortification policy – provide leadership and drive in the implementation of food fortification programs.
of the National Working Group on Food
The sense of urgency for change. All parties – even those reluctant for change -
Fortification in Uganda, and an industry
must understand the importance of food fortification in the fight against malnutrition.
liaison on food fortification. “Without GAIN’s support, we would not have strengthened our National Fortification Program in such a short time.” GAIN also played a key role in following the various stages of legislation to ensure it maintained momentum through the political process, and in equipping industry with the tools and training to produce high quality fortified foods. Nevertheless, quality control and monitoring compliance must remain a key priority for all stakeholders if the mandatory food fortification is to sustainably deliver public health impact at scale. GAIN HQ Geneva Rue de Vermont 37-39 CH-1202 Geneva Switzerland T +41 22 749 1850 F +41 22 749 1851 E info@gainhealth.org
1. Investing in the future, a united call to action on vitamin and mineral deficiencies, Global Report 2009. Micronutrient Initiative. ISBN: 978-1-894217-31-6 2. R E Black, L H Allen, Z A Bhutta, et al (2008) ‘Maternal and child undernutrition: global and regional exposures and health consequences’, The Lancet, 2008, Jan 19, 371 (9608), 243–60. 3. See: Copenhagen Consensus 2008, http://www.copenhagenconsensus.com/Home.aspx 4. S Horton (2006) ‘The economics of food fortification’, Journal of Nutrition, 136: 1068–1071
5. World Health Organization website, on Nutrition: Micronutrient deficiencies, http://www.who.int/nutrition/topics/idd/en/ 6 World Bank, Scaling Up Nutrition: What will it cost?, 2010, http://siteresources.worldbank.org/ HEALTHNUTRITIONANDPOPULATION/ Resources/Peer-Reviewed-Publications/
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