Deficiencies in iron and folic acid are a severe problem in Pakistan: WHO

THE World Health Organisation (WHO)'s reports and statistics revealed that deficiencies in iron and folic acid are a severe problem in Pakistan, with devastating impacts on health and survival, and high costs to national economic development. About 40 percent of women, 65 percent of children, and a substantial number of men suffer from anemia.
An ADB country study under RETA 5944,4 conducted by the Pakistan Institute of Development Economics in conjunction with MOH, estimated that in over 10 years, the more than 22,000 maternal deaths and more than $4.6 billion in lost productivity were caused by iron deficiency anemia, and the estimated 40,000 deaths from heart disease and birth defects were caused by folic acid deficiency.
Global experience of 75 years indicates that within 1 year, flour fortification can reduce vitamin and mineral deficiencies. The high flour consumption by all strata of Pakistani society suggests that the average consumption at the proposed levels of fortification can deliver about one third of WHO's estimated average requirements (EAR) for iron and 10 percent of EAR for folic acid.
The RETA 5944 country study estimates that iron deficiency anemia prevalence may drop by 20 percent among consumers of iron fortified Atta Flour, significantly reducing maternal mortality and enabling productivity gains of more than $800 million over 10 years.
Flour fortified with folic acid was expected to bring down the number of children born with birth defects (neural tube defects) by one third, and rates of coronary heart disease by up to 9 percent. However, these benefits are limited by the inadequate reach of fortified flour from large-scale roller mills. More than half the population, particularly the poor, get Atta mainly from small-scale Chakkis.
Chakki flour fortification remains the best hope for relief from iron and folic acid deficiency for more than half the population. If fortification can be extended to a significant number of Chakkis, protection for the rural poor and highly at-risk populations will rise sharply, and the projected reductions in iron and other deficiencies can be more than doubled.
Dr Zahid Larik, Deputy Director General Health (Nutrition)/National Programme Ministry of Health, Government of Pakistan said that the Government is committed to achieving nation-wide flour fortification to reduce iron and folic acid deficiencies. MOH has endorsed the concept of mandatory legislation of flour with iron 30.0 parts per million (ppm) and folic acid (1.5 ppm).
The Government accepts the concept of mandatory fortification (and the commitments made when it accepted $3 million from Global Alliance for Improved Nutrition (GAIN) for fortification at large roller millers). This will be phased in over the next 5 years. While the legislation does not exist, a proposal has been tabled to modify food standards.
The multi-sectoral team participating in RETA 5944 proposed a 10-year country investment plan to fortify flour nation-wide in two phases. The two-phased approach segments production between large roller mills and small-scale Chakkis.
In phase-1 (2004-2008), more than 700 roller flour-mills will start fortification.
In phase-2 (2009-2013), the programme will expand to small-scale Chakkis.
In 2003, the National Fortification Alliance (NFA), chaired by the minister of health and represented by public and private sector stakeholders, adopted this two-phased plan. In early 2004, the Global Alliance for Improved Nutrition (GAIN) awarded the Government $3 million for phase-1. Extending the benefits of fortification to the remaining 55-60 percent of the population not served by large-scale roller mills is a high priority. Small-scale chakkis and/or villages, however, have little experience in fortification.
The Nutrition Section of the Planning and Development Division, with support from WHO Eastern Mediterranian Regional Office and the Micronutrient Initiative, has developed basic technologies, facilitated the design and fabrication of low-cost chakki -microfeeders in domestic companies, and conducted tests at several pilot chakkis. These technical trials have demonstrated that chakkis can add fortificant mix to flour to produce a safe, homogenous, and acceptable product. However, market-scale implementation is untested and commercial sustainability needs to be addressed.
INNOVATIONS INCLUDE THE FOLLOWING:
NEW BUSINESS ENVIRONMENT
Fortification by chakkis requires adopting new technologies and business procedures and, to some extent, adopting a new role with consumers and new relationships with government and other businesses. Small-scale traditional enterprises such as chakkis do not usually invest in these improvements and innovations. By reducing risk and creating conditions to support improvements and changes in the milling environment, the project will motivate the chakkis to innovate.
NEW TECHNICAL MILLING APPROACHES:
While some technical pilot trials have been undertaken, the project will be the first market-level trial under field conditions to troubleshoot and optimise the accuracy of addition of fortificants and the robustness of chakki feeder technical designs, and to test options for cost effective procurement, storage, inventory, and other critical factors.
The project is expected to identify a number of innovations in technology and milling systems to enable fortification in the communities.
NEW LOCAL BUSINESS SERVICES:
In the low-technology milling environment, adding the fortificant requires a diluted fortificant mix, blended with local flour at a projected rate of 1:20. This means that a typical market area of 500-700 chakkis needs 330-350 MT/year. Given this volume and the need for frequent delivery, key challenges would be transport and its costs in rural areas. Delivery of the fortificant concentrate to the districts and subdistricts is estimated at $2/kg, and a pre-diluted fortificant would presumably cost about 20 times that. A key innovation would be lowering the costs of (i) blending fortificants in the districts; (ii) support services, including timely maintenance services; and (iii) spare parts supply for feeders.
New links among district, provincial, and national agencies and research institutions
At a time of increased decentralisation of many government functions, including health and food control services, local implementation will be the key to monitoring by the Government.
Controlling food safety and quality in the chakki market requires sampling, analysis, and communications capacity at the community level. The project will link the union council, district inspectors, and health personnel to provincial and national agencies and national technical institutions to develop collaborative systems for food control and nutrition surveillance.
Local agencies can sample and undertake qualitative testing (ie, spot tests for iron) and co-ordinate with provincial or national counterparts for capacity building, technical guidelines, and more sophisticated food and statistical analysis.
COMMUNITY MOBILISATION TO RAISE CONSUMER AWARENESS AND DEMAND:
Rural and low-income communities have few traditional channels for marketing new products. Literacy is low and traditional media outlets are scarce, limiting opportunities to educate consumers and create a perception of added value for fortified atta flour. Therefore, a key project objective is to develop new processes for social marketing and community mobilisation to reach consumers of chakki flour via non-traditional community based and face-to-face channels as well as traditional media. A key advantage of small-scale fortification is that it promotes not only a product that is healthier but also locally produced. Local ownership is key to motivating sectors of the community that might otherwise not be involved.
In this operational research phase, the project will address a number of questions about chakki fortification, such as (i) actual costs, (ii) how these costs can be brought down, (iii) how much of the increased costs-if not all-can the consumer be convinced of paying an additional price, and (iv) what the most effective areas or minimum thresholds for public subsidy are.
The project will clarify these issues so that realistic, innovative strategies for sustainable chakki flour fortification can be developed.
SUSTAINABILITY:
While protecting 150,000-175,000 people for 2 years is a worthwhile activity in itself, it is not the project's ultimate aim. The goal is to define the conditions, capacities, and resources needed for the sustainable expansion of chakki fortification to as many as 100 million Pakistanis-mainly the poor and vulnerable. To sustain traditional, large-scale fortification, consumers are required to pay for all, or at least a significant part, of the fortification costs.
However, fortification will be more expensive for the chakkis than for large-scale enterprises because the relative costs for plant and product improvements are higher (in large mills the cost increase is below 1 percent, in chakkis, 3-5 percent).
Although this is affordable given the fluctuating price of bread, it hinders consumer adoption and financing. To overcome this barrier, public financing may be justified, given the high benefits and effective targeting of chakki flour fortification. However, the level of public resources, the specific channels of assistance, and the transition to sustainable consumer financing need to be carefully defined.
The project's central thesis is that building local public and private sector capacities will not only make small-scale fortification technically possible, but also lower incremental costs and increase local ownership to create consumer demand and sustainable production. The project will test and evaluate strategies to make investments in fortification more attractive to the chakki miller and fortified atta more affordable and attractive to the consumer.
To reduce the risks to local chakkis and businesses, a number of public investments and support activities are planned to enable start-up, including a temporary "introductory period" when the consumer will not be required to pay incremental costs.
The project outcomes may or may not suggest the possibility of fortifying all chakkis within the 5 years of the national flour fortification programme's phase-2. However, the project should define conditions under which small-scale fortification is sustainable and how phase-up and expansion will be initiated. This will enable external funding agencies and the Government to understand what kind and scale of public investments are needed to create sustainable small-scale milling fortification that will be extended to the most vulnerable people in Pakistan. It should be noted that small-scale mills in Africa (eg, Malawi, South Africa, Zambia, and Zimbabwe) have been cost-effective and sustainable, and people bought fortified flour at a higher price.
PARTICIPATORY APPROACH:
Because the chakki millers and their customers are dispersed throughout Pakistan, this project needs to be implemented by communities. While typical fortification technology is a centralised, top-down intervention, the success of small-scale milling depends on community production, action, and support. While taking advantage of centralised services whenever possible, ultimately production, control, marketing, and monitoring of small-scale fortification need to function in a decentralised community environment, and to engage local government, business, and NGOs.
Project inception, launch, implementation, and evaluation involve participatory planning workshops and other activities to build joint and supportive strategies among local partners. The project will improve a local product (wheat flour) and service (milling), enhancing the quality of local nutrition. These innovations and improvements come from the communities and will be facilitated by a participatory approach.