Addressing micronutrients malnutrition in Pakistan with mandatory food fortification by Global Health @ Mott MacDonald

almost 03% percent of its GDP growth annually due to malnu STATEMENT: malnutrition is widespread and serious publi Target Audiences: Policy Micronutrients makers, Government officials, parliamentarians and politica almost 03% EVIDENCE percent of its GDP growth annually due to malnutrition. STATEMENT: Micronutrients malnutrition is parliamentarians widespread serious public health cha • The National Nutrition Surveyand ,2011 survey indicated in in the Target Audiences: Policy makers, Government officials, and political parties P almost 03%EVIDENCE percent of its In GDP growthWomen; annuallyAnaemia due to malnutrition. Pregnant 51.0%; Iron deficiency anaem STATEMENT: Micronutrients malnutrition isVitamin widespread and serious public health for m tA • The Nationaland Nutrition Survey ,2011 survey indicated in challenge, the following D deficiency 86.1%. In Non-Pregnant Women almost 03% percent of its GDP growth Vitamin annuallyAAnaemia due to malnutrition. EVIDENCE In Pregnant Women; 51.0%; Iron deficiency anaemia 25.9%; deficiency 43.1%; Zinc deficiency 41.6%; and Vita • The National Nutrition ,2011 survey in the following micronutrien and Vitamin D deficiency 86.1%.indicated Insurvey Non-Pregnant Women Anaemia 50. • Survey The national nutrition revealed that, 44% of childre EVIDENCE In Pregnant Vitamin Women;AAnaemia 51.0%; Iron deficiency anaemia 25.9%; Vitamin A d deficiency 43.1%; Zinc deficiency 41.6%; and Vitamin D defic deficiency and 40% from vitamin D deficiency; Target Audiences: Policy makers, Government offici • The National Nutrition Survey ,2011 survey indicated in the following micronutrient deficiency l FOOD FORTIFICATION PROGRAMME and Vitamin D deficiency 86.1%. In Non-Pregnant Women Anaemia 50.4%; Iron de • The national nutrition survey revealed that, 44% of children under five •officials, The most recent estimates the United Nations Food and get Audiences: Policy makers, officials, parliamentarians and political partie Target Audiences: Target Audiences: Policy makers, PolicyGovernment Government makers, Government officials, parliamentarians parliamentarians and political andby parties political in parties Pakistan. in Pakistan. In Pregnant Women; Anaemia 51.0%; Iron deficiency anaemia 25.9%; Vitamin A deficiency 48 Vitamin A deficiency 43.1%; Zinc deficiency 41.6%; and Vitamin D deficiency 85.1% deficiency and 40% from vitamin D deficiency; in Pakistan are not receiving proper nourishment. STATEMENT: Micronutrients malnutrition is widespr TEMENT: Micronutrients malnutrition widespread and serious public health challenge, STATEMENT: STATEMENT: Micronutrients Micronutrients malnutrition malnutrition is widespread is widespread serious and public serious health public challenge, health challenge, forunder this reason, for this Pakistan reason and Vitamin D deficiency 86.1%. In•and Non-Pregnant Women Anaemia 50.4%; Iron deficiency anae • The national nutrition survey revealed that, 44% of children five suffered froa •isThe most recent estimates by the United Nations Food and Agriculture Pakistan is losing almost three percent of its GDP growth almost 03% percent of its GDP growth annually due ost 03% percent of03% its GDP annually due to malnutrition. almost 03% almost percent ofpercent its GDPgrowth of itsdeficiency GDP annually growth due annually to malnutrition. due to malnutrition. Vitamin Agrowth deficiency 43.1%; Zinc deficiency 41.6%; and Vitamin D deficiency 85.1% and 40% from vitamin D deficiency; in Pakistan are not receiving nourishment. GDP growth that proper the country is losing to country economy • The national nutrition revealed that, 44% of children five suffered from iron • The most•survey recent estimates byalmost the United Nations Food and Agriculture Organizati Pakistan is three percent of its GDP growth annually due • losing Food fortifications safe under and cost-effective strategy todefic com EVIDENCE DENCEEVIDENCE EVIDENCE deficiency and 40% from vitamin D deficiency; in Pakistan are not receiving proper nourishment. GDP growthUS$0.02 that the per country is losing to country economy and effects capita; The Copenhagen Consensus estimate •following The National Nutrition Survey ,2011 survey indicat he National Nutrition ,2011 survey indicated in the following micronutrient deficie • The National • The Nutrition National Survey Survey survey ,2011 survey indicated inUnited the in the following micronutrient micronutrient deficiency deficiency levels in pregnant levels pr w • Survey TheNutrition most recent estimates by the Nations Food and Agriculture Organization (FAO) sta •,2011 Pakistan is losing almost percent of its GDP growth annually due to malnutri • indicated Food fortifications safe and cost-effective strategy to combat withinmic tothree the economy. In Pregnant Women; Anaemia 51.0%; Iron deficien n Pregnant Women; Anaemia Iron deficiency anaemia 25.9%; Vitamin A deficienc In Pregnant In Pregnant Women; Women; 51.0%; Anaemia Iron 51.0%; deficiency Iron deficiency anaemia anaemia 25.9%; Vitamin 25.9%; A Vitamin deficiency A deficiency 48.8%; Zinc 48.8%; deficiency Zinc d inAnaemia Pakistan51.0%; are not receiving proper nourishment. GDP growth that the country is losing to country economy and effects on social, US$0.02 per capita; The Copenhagen Consensus estimates that everyh and Vitamin D deficiency 86.1%. In Non-Pregnant nd Vitamin deficiency InNon-Pregnant Non-Pregnant Women Anaemia 50.4%; Iron deficiency and D Vitamin andDVitamin deficiency D86.1%. deficiency 86.1%. In 86.1%. In to Non-Pregnant Women Anaemia Women 50.4%; Anaemia Iron 50.4%; deficiency Iron deficiency anaemia 19.9%; anaemia 19.9% • Pakistan is• losing almost three percent of its GDP growth annually due to malnutrition which is Food fortifications safe and cost-effective strategy to combat with micronutrients the economy. Malnutrition - Women itamin AVitamin deficiency 43.1%; Zinc deficiency 41.6%; and Vitamin Dand deficiency 85.1% AVitamin deficiency A GDP deficiency 43.1%; Zinc 43.1%; deficiency Zinccountry deficiency 41.6%; 41.6%; Vitamin and DVitamin deficiency D deficiency 85.1% 85.1%on Vitamin A deficiency 43.1%; Zinc deficiency 41.6% growth that the isand losing to country economy effects social, human and ec US$0.02 per capita; The Copenhagen Consensus estimates that every $1 spent on The National Nutrition Survey 2011, found he national nutrition revealed that, 44% of children under five suffered from iron • The national • Thenutrition national survey nutrition revealed survey that, revealed 44% that, of children 44% of under children five under suffered five from suffered iron from deficiency, iron deficiency, 54% from 54% vita • The national nutrition survey revealed that, 44% o •survey Food fortifications safe and cost-effective strategy to combat with micronutrients malnutrition to the economy. Malnutrition - Women the following micronutrient deficiencies eficiency and 40% from vitamin deficiency; deficiency deficiency and 40% from and 40% vitamin from DD vitamin deficiency; deficiency; Consensus US$0.02 per capita; TheDCopenhagen estimates that every $1 spent on fortification deficiency and 40% from vitamin D deficiency; The Agriculture National Nutrition Survey 2011, found he most recent estimates United Nations Food and Agriculture Organization (FAO • The most • The recent most estimates recent estimates bythe the United by the Nations United Food Nations and Food Agriculture and Organization Organization (FAO) state (FAO) that state 37.5Nations million that 37. to theby economy. • The most recent estimates by the United Malnutrition Women 1 annually due to a high100 the following micronutrient deficiencies Pakistan is losing 2 -3 percent of its GDP burden of malnutrition which unfortunately has not changed n Pakistan are not receiving nourishment. in Pakistan in are Pakistan not receiving are notproper receiving proper nourishment. proper nourishment. in Pakistan are not receiving proper nourishment The National Nutrition found over the last four decades. National Nutrition Survey (NNS) revealed very high rates ofto micronutrient akistan losing almost three percent ofGDP its GDP growth annually due to malnutrition wh • is Pakistan • is Pakistan losing almost isThe losing three almost percent threeof percent its ofgrowth its2011 GDP annually growth due annually toSurvey malnutrition due2011, malnutrition which isdeficiencies higher which than is higher 2 perce th • Pakistan is losing almost three percent ofMalnutr its GDP - vitamin Women 100 Malnutrition the following micronutrient deficiencies - 51% GDP of pregnant women arecountry anaemic, ironto deficient, 46% deficient in A,and and 69% in vitamin D. The problem DP growth that the country is losing to country effects on social, human a growth GDP that growth the that the is37% country losing is country losing toeconomy country economy and effects and on effects social, on human social, and human economic and economic developme d 80 economy GDP growth thatAthe country is losing to country The National Nutrition Survey 2011, found repeats itself children with 62% of under 5s suffering from anaemia and from vitamin deficiency. 68.9% ood fortifications safe and cost-effective strategy to combat micronutrients malnut • Food fortifications •in Food fortifications safe and cost-effective safe and cost-effective strategy to strategy combat to54% with combat micronutrients withwith micronutrients malnutrition, malnutrition, which costs which anMicr est co 66.8% 1 •estimates Food fortifications safe and cost-effective strateg the following micronutrient deficiencies The lack ofcapita; iron,per vitamins A and DCopenhagen and100 otherCopenhagen minerals limits ability to estimates fight disease, making it every aon major contributor to high chil S$0.02 per The Copenhagen Consensus $1 on US$0.02 US$0.02 capita; per The capita; The Consensus Consensus estimates that every that $1that spent every $1 fortification spent onspent fortification results in fortific results $9 inofben in 80 60 US$0.02 per capita; The Copenhagen Consensus maternal newborn and child death rates. Malnourishment also affects cognitive and physical development, ultimately leading 68.9% o the economy. to the economy. to the economy. 66.8% 51%

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Addressing micronutrients malnutrition in Pakistan with mandatory food fortification

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Food Fortification - Benefits

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Global research findings discovered that, since most poor populat year of sustained consumption – without changing eating habits. Fortification is also cost effective, with the in this context, food fortification is a practical and inexpensive alt findings discovered that, since most poor populations do not fications safe and cost-effective strategy Food fortifications Food fortifications safe and cost-effective safe andofcost-effective strategy Global strategy Copenhagen Consensus panel economists findingresearch a with malnutrition, which costs an tomicronutrients combat with to combat micronutrients with micronutrients malnutrition, malnutrition, which costs which an costs an incostPakis in this context, food fortification is a practical andof inexpensive alternative for return on investment of $8 for every $1 invested in the MESSAGE: We urge that, fortification staple foods is safe, US$0.02 per capita; the Copenhagen Consensus estimated US$0.02 estimated per US$0.02 capita; the per Copenhagen capita; the Copenhagen Consensus Consensus 2 Global research findings discovered that, since most poor populations do not have access case of iron fortification . When costs are passed onto malnutrition status of the whole population; conomists found a economists return on investment panel of economists panel of found a return found on a investment return on investment ofof $8$8 of $8

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in this context, food fortification is a practical andofinexpensive alternative for poor popula MESSAGE: We urge that, fortification staple foods is safe, cost-effective an 1 invested infor the case of iron fortification. for every $1 invested every $1 in the invested case of in the iron case fortification. of iron fortification. Food fortifications safe and cost-effective strategy

Global research findingsmalnutrition discovered that, since most poor populations do not have access status of the whole population; to combat with micronutrients malnutrition, which coststo anadequate in this context, food fortification is a practical and inexpensive alternative for poor populations. MESSAGE: We urge that, fortification of staple foods is safe, cost-effective and sustainab estimated US$0.02 per capita; the Copenhagen Consensus 1 Repositioning Nutrition as Central to Development. A Strategy for Large-Scale Action. World Bank 2006 http://web.worldbank.org/archive/website01363/WEB/ panel of economists found a return on investment of $8 malnutrition status of the whole population; STATEMENT: Improving micronutrients malnutrition through f IMAGESNUTRITIO.PDF for every $1 invested incost-effective the case of ironand fortification. MESSAGE: We urge that, fortification of staple foods is safe, strategy toD of Pakistan can achieve its ambition to sustainable meet the Sustainable 2 Micronutrient Fortification (Iron and Salt Iodization). Sue Horton, Venkatesh Mannar & Annie Wesley. Copenhagen Consensus Centre, 2008. malnutrition status of the whole population; STATEMENT: Improving micronutrients malnutrition through food fortifica

What is being done?

A number of initiatives are already in place to reduce malnutrition in Pakistan. Vision 2025 envisages a hunger free Pakistan, providing safe food and adequate nutrition for the whole population. A multi-sector nutrition strategy for Pakistan is underway and provincial multisector nutrition strategies have been developed but have yet to be developed into plans. A revitalised National Fortification Alliance is in operation, and all provinces have constituted Provincial Fortification Alliances. However more policy measures are urgently required in order to meet UN Sustainable Development Goal No.2

to “end hunger”. Government commitment is required to ensure that significant progress is made in addressing Pakistan’s micronutrients malnutrition crisis through mandatory food fortification initiatives. The Pakistan Government’s commitment to tackling malnutrition provides a platform to build on. Other important fortification efforts on which FFP will build include the Micronutrient Initiative’s work on Universal Salt Iodisation (USI) and the work of World Food Program and GAIN, which have been supported by donors including USAID and Australian DFAT.

Existing food fortification regulatory environment in Pakistan

Existing industry barriers to food fortification

1) Mandatory legislation relating to food fortification in Pakistan There is no mandatory legislation on wheat flour fortification in any of the four provinces, and only Punjab has started making progress. Although legislation exists for fortifying edible oil/ghee with vitamin A, there is a lack of adequate enforcement and regulatory mechanisms with the result that the vast majority of edible oil is either unfortified or inadequately fortified. Levels of vitamin D deficiency revealed by the NNS 2011 require fortification with vitamin D as well as A.

Barriers for industry include non-availability of fortificant (premix), lack of quality equipment (micro-feeders) and lack of demand from consumers due to lack of information and knowledge about the benefits of fortified foods.

2) National Standards The Pakistan Standards and Quality Control Authority (PSQCA) has issued Pakistan Standard Specifications for fortified wheat flour and edible oil/ghee. 3) Government commitment to enforcement Multi-sector nutrition strategies are in place in every province of Pakistan. The Punjab strategy includes legislating for mandatory wheat flour fortification with iron and folic acid by 2016 and enforcement one year after enactment, demonstrating a commitment to fortification. It also refers to the need to raise awareness about the importance of fortified food products. Food authorities are established in Punjab, Khyber Pakhtunkhwa Province (KPK) and Baluchistan while Sindh Province is planning to establish food authorities.

What needs to be done? 1. Harmonise national food fortification standards across all provinces of Pakistan through PSQCA. 2. Develop mandatory legislation for the fortification of wheat flour with iron, folic acid and other essential micronutrients and edible oil/ghee with vitamin D (in addition to A). 3. Develop regulations and mechanisms for enforcement of the legislation. Mechanisms should be in place to ensure that standards are followed. 4. Ensure that all required human and financial resources are in place and food inspectors and laboratories are resourced to undertake systematic, quality assured testing to sustain food fortification.

Food Fortification Programme supporting role to government and industry The Food Fortification Programme is a five-year investment by the UK Government and aims to support government at federal, provincial and district level and to support the wheat flour and edible oil/ghee industries through technical assistance. FFP will launch communications campaigns in districts to build consumer demand and generate evidence based data through research studies to improve the implementation of food fortification in Pakistan.

Food Fortification Programme 4th Floor, Din Plaza, Jinnah Avenue, Blue Area, Islamabad, Pakistan