After fourteen years of civil war and economic damage, Liberians – particularly women and children – suffer severely from micronutrient malnutrition. In fact, it is estimated to be the root cause of 44% of all childhood deaths in Liberia.
The most recent statistics on iron deficiency indicate a severe public health problem: 87% of children 6 – 59 months were anemic. Among women of reproductive age, 58% of those not pregnant and 62% of those who were pregnant were anemic. Vitamin A deficiency remains an ongoing concern as well, with 53% of children 6 – 35 months suffering from deficiency and 13% of women experiencing night blindness. Additionally, inadequate intake of zinc impacts an estimated 59% of the population.
Understanding Liberia’s Needs
The first step in designing a program for Liberia was to conduct a situation assessment. From January – May 2010, PHC worked with the Liberian Ministry of Health and Social Welfare (MoHSW) and other local agencies to collect data on current national strategies to address malnutrition, local food production, ongoing fortification efforts, cross-border trade flows, and general consumption patterns. In September 2010, PHC and the MoHSW signed a Memorandum of Understanding outlining a broad set of priorities for the development of a national fortification program to improve micronutrient health, including updating micronutrient deficiency data, creating an overarching strategy to guide interventions, raising awareness of the issue, creating a mandate for fortification, and finally, defining and implementing fortification itself.
One of the key activities in this research was the design of a national micronutrient deficiency study led by UNICEF with technical assistance from PHC and other stakeholders. The study began in April 2011 and was completed in June 2011 allowing for an up-to-date nation-wide picture of vitamin and mineral deficiencies.
The most recent FAO food balance sheet (2005) highlights the central role of cassava and rice in the Liberian diet, but points to wheat flour and vegetable oil as potential fortification vehicles based on consumption quantity and what we know about production patterns.
Although cassava and rice are widely consumed, both involve predominantly small-scale local production processes. And although much of the wheat flour available in the country had been imported, domestic production of wheat flour now rivals imported products with one company, Premier Milling, capturing most of the market. While other types of vegetable oils are available, palm oil is by far the most common. And although roughly one-third of rural households consume oil produced at home, all urban households report the purchase of oil.
In order to obtain up-to-date data on consumption patterns, PHC completed an analysis of apparent consumption and coverage patterns for key staple products using data from the World Food Program’s (WFP) 2010 Comprehensive Food Security and Nutrition Survey (CFSNS). The analysis looked at flour, sugar, cooking oil, magi or bouillon cubes, cassava, salt, and rice. Findings indicate population-wide consumption coverage of products to be quite high for five staples: salt (96%), bouillon cubes (94%), sugar (79%), rice (79%) and oil (77%). Based on this data, discussions as to the most appropriate food vehicles to target for fortification began.
Due to the large number of staple product imports that Liberia currently receives, it is important to understand the flow of goods into the country. Virtually all formal imports of staple foods arrive via the Freeport of Monrovia. Liberia’s land borders are porous, however, and there is significant trade with neighboring countries making importer sensitization crucial. Finally, the design and implementation of a strong monitoring and enforcement system will be critical to guarantee standards are met and maintained for both imported and domestically produced products.
Establishing Government Structure
As a central component to any fortification program, a National Fortification Alliance (NFA) provides the platform and organizational structure whereby decisions are made and key stakeholders are represented. In order to ensure there is a guiding body for all future and ongoing fortification efforts, in 2012, PHC supported the creation of Liberia’s first NFA under the leadership of the Ministry of Health and Social Welfare. Including representation from government, the private sector, and civil society, Liberia’s NFA has been critical to ensuring coordination among all agencies involved in the fortification process.
Liberia’s NFA has been instrumental in the creation of a comprehensive National Fortification Guidelines document, a virtual blueprint for the country’s program, that includes fortification regulations and strategy, roles and responsibilities of all stakeholders, inspection and sampling protocols and non-compliance measures, national standards, logo guidelines, and a national fortification budget. This document is currently in the process of being signed by the Ministers of Health and Commerce and Industry before becoming a binding, legal document.
Creating Fortification Standards
In 2013, with technical support from PHC, the NFA of Liberia revised and adopted new food fortification standards for sugar, wheat flour, salt and cooking oil in line with national consumption patterns and harmonized with the Economic Community of West African States (ECOWAS) region in order to preclude any barriers to trade. The drafted Liberian standards have been adopted and gazetted by the Government as mandatory standards (with the exception of sugar, which is currently voluntary) and apply to all domestic producers. Once the National Fortification Guidelines are signed, the mandate will extend to all importers as well.
Engaging and Supporting Industry
In order to assess the capacity of local producers to scale-up for fortification and identify areas of need, PHC, in collaboration with regional experts, conducted individual industry and importer assessments. Liberia’s sole staple food producer, Premier Milling Corporation (producing wheat flour) and the largest importer and bulk re-packager of cooking oil (Fouani Bros.) were assessed. Process line changes required to adopt fortification and proposed estimated costing-models were presented.
In 2013, Premier Milling with equipment and premix assistance from USAID and GAIN began the fortification of their wheat flour. The Fouani Bros. Corporation was given the option of fortifying their re-packaged cooking oil at the Port of Monrovia but later chose to request fortified oil from their supplier instead. Today, three of the largest importers of flour and cooking oil are successfully sourcing fortified products with no impact on consumer pricing. And Premier Milling, whose flour reaches every county within the country, is successfully fortifying their wheat flour product at a level that meets national standard. As a result, you can find Premier Milling’s flour bags displaying the national fortification logo in local markets and bakeries.
Similar to our other country programs, Liberia has adopted a regional fortification logo (an English version of the ECOWAS logo) to be displayed on all fortified products. Logo guidelines have been drafted and incorporated into the national Guidelines document for legal endorsement. Several media campaigns are ongoing including radio spots, a proposed national launch day, mass logo awareness taxicab campaigns, and incorporation into usual health workers and Essential Nutrition Actions (ENAs) educational materials.
Much work is currently being done with the National Standards Laboratory (NSL) in order to establish a strong monitoring system that will ensure coverage and compliance are in line with national requirements. A sampling plan has been drafted based on the need to balance quality data with realistic human resource constraints. Inspector trainings are nearing completion as of July 2016 and most required laboratory equipment has been obtained. The NSL continues to report sampling and compliance information twice a year to key stakeholders.
The program’s priority objective in 2016 is to ensure the National Fortification Guidelines are signed, extending the mandate to all importers. Simultaneously, efforts are being placed on finalizing all inspector trainings, ensuring a system is in place for consistent tracking of national level compliance by the NSL, and continuing consumer advocacy campaigns with the National Consumer’s Council of Liberia.