Micronutrient deficiencies remain a serious problem in Malawi: the 2009 Micronutrient Deficiency Study found 48% of children under five and 25% of women of reproductive age were iron deficient, 40% of children under five and 30% of school-aged children were vitamin A deficient, and 11% of school-aged children had low urinary iodine levels. Although no recent data on zinc or folate deficiency exists, based on the high rates of stunting (40%) and reports of neural tube defects, it can be assumed both remain of serious concern.
Understanding the Situation
Prior to PHC engagement in Malawi in 2009, the government had already initiated efforts to fortify food. A national action plan had been created and a grant application submitted to the Global Alliance for Improved Nutrition (GAIN) in 2006. When funding was not forthcoming, however, progress stalled. Therefore, a key part of the mandate given to PHC by the Department of Nutrition, HIV, and AIDS (DNHA) was to assess and learn from previous efforts. From January – April 2010, PHC worked with DNHA, the Ministry of Health, UNICEF, and other stakeholders to understand past efforts and current national strategies to address malnutrition, local food production, voluntary fortification, cross-border trade flows, and general consumption patterns.
One of the key activities in this research was the analysis of consumption data collected as part of the 2009 National Micronutrient Survey where it was found that the use of centrally processed cooking oil is far more widespread than initially thought. Additionally, despite nsima (maize porridge) being a mainstay of the Malawian diet, only a fraction of the population consumed centrally-processed maize flour. These insights were critical to developing a comprehensive program that effectively balances fortification across multiple food vehicles.
Drafting a Plan of Action
Following presentation of the situation assessment, the Department of Nutrition, HIV, and AIDS asked PHC to help develop not just a fortification program, but also a harmonized strategy to combat micronutrient deficiencies. The plan of action lays out details of five major strategies. These include fortification, supplementation, dietary diversification, crop development / biofortification, and other public health measures. For each, the action plan maps out the steps needed to scale up harmonized implementation over the next five years. The resulting Micronutrient Strategy and Action Plan was circulated for public comment and approved in 2014.
Revising Food Standards
Establishing a comprehensive food fortification program is the foundation of Malawi’s strategy to combat micronutrient deficiencies. The revision of existing food standards to include mandatory fortification is one key step in the plan of action that has already been accomplished. Using the consumption data collected by the 2009 National Micronutrient Survey, PHC worked with the Malawi Bureau of Standards (MBS) and UNICEF to draft standards that reflect current dietary patterns and will have a significant beneficial impact on health.
The revised standards are in line with regional norms and provide sufficient guidance for uniform implementation and monitoring. Final versions for sugar, edible oil, wheat flour, and maize flour were formally adopted as national standards in February 2011 and formally Gazetted in 2015. A formal communiqué from the Ministry of Industry and Trade was circulated establishing a one-year grace period for industry. With this communiqué, standards are now enforceable by the designated food inspectors.
Malawi has a limited number of commercial food processors and several had already been fortifying voluntarily (albeit typically at levels too low to produce a meaningful health impact) prior to the mandatory legislation. The remaining industries expressed willingness to begin provided government can guarantee a level playing field, which now exists.
Illovo Ltd., the country’s sole sugar producer, signed a formal agreement in November 2010 to begin fortifying with vitamin A. Production began in 2011 and currently all sugar samples collected comply with the stated national standard. With the Ministry of Industry and Trade and the National Fortification Alliance (NFA), PHC mapped individual plans of action for each producer. Full compliance from other staple food producers is now dependent upon completed inspections by regulatory monitoring inspectors.
In addition to raising the awareness of government officials such as customs staff, district health officers, and food inspectors, the NFA conducted a significant marketing campaign to educate consumers about fortification. A cornerstone of this effort was the logo developed for use on fortified products. Working with the Consumer Association of Malawi, a group of experts was convened on a panel that aired as a Q&A radio program, a widely broadcast TV commercial was developed, and a series of short radio-spots on the importance of consuming fortified products was aired over a three-week period.
While much of the responsibility for the fortification of food products is given to the industries, the government must ensure that the foods that are being sold in the country meet the standards for safety and quality, including that the right types and amounts of micronutrients are present. To that end, government officials are responsible for monitoring foods that are locally produced and imported at production sites, at borders, in markets and shops, and in households.
At the request of the DNHA in 2010, PHC designed a comprehensive monitoring tool to house all fortification monitoring data at a central location. The monitoring tool, now referred to as PHC’s Fortification-specific Management Information System or Fort-MIS, allows for efficient and effective regulatory decisions to be made and actions taken based upon pooled fortification data from all levels and stages of the national monitoring system. PHC has trained Ministry of Health staff on the use of the tool and initial reports demonstrate that the majority of samples collected comply with national standards.
With Malawi’s fortification program officially handed over to the government, PHC’s focus rests on keeping a pulse on the coverage and compliance of the program by liaising with government staff responsible for maintaining the fortification management information system.