According to Rwanda’s 2015 Demographic and Health Survey (DHS), anemia affects an estimated 39% of children 6 – 59 months and 19% of women of reproductive age (aged 15-49 years). Rural areas tend to be slightly more affected than urban areas (38% vs. 30%, respectively). According to the 2005 DHS, despite a countrywide vitamin A supplementation program, 25% of children under six months of age and 21% of children 6-12 months suffer from vitamin A deficiency. Seven percent of women of reproductive age suffer from night blindness, indicative of vitamin A deficiency. And while 90% of the population has access to iodized salt, the goiter rate among school-aged children is 26%.
Understanding Rwanda’s Needs
The first step in designing a program for Rwanda was to conduct a situation assessment. From April to June 2008, PHC worked with the Ministry of Health and the Rwanda Bureau of Standards to collect data on current strategies to address malnutrition, local food production and market dynamics, ongoing fortification efforts, cross-border trade, and industry structures. In order to identify general coverage and consumption patterns of key staple food products, PHC and the Ministry of Health completed a Food Fortification Rapid Assessment Tool (FRAT) survey.
In 2008, PHC and the Ministry of Health signed a Memorandum of Understanding outlining priorities for the development of a national fortification program including support to create a national strategy to guide fortification efforts, raise awareness on the issue, create a mandate for fortification, institutionalize regular program monitoring, and reinforce the capacity of industry to fortify.
Establishing Governing Structures
As a central component to any food fortification program, a National Fortification Alliance (NFA) provides the platform and organizational structure whereby decisions are made and key stakeholders are represented. In 2010, PHC supported the creation of Rwanda’s first NFA under the leadership of the Ministry of Health to provide strategic guidance on all efforts related to fortification. Including representatives from government, the private sector, academia, and civil society, Rwanda’s NFA has proven critical to ensuring buy-in from all individuals and agencies involved.
In 2010, the Ministry of Health approved a Food Fortification Ministerial Decree drafted by PHC and the Ministry of Health outlining the regulatory framework required to ensure mandatory fortification of identified staple products and imports. Once signed, fortification of identified staple products (namely wheat and maize flour, cooking oil, sugar, and salt) will be required by all in-country producers and importers.
Creating Fortification Standards
With a guiding NFA in place and a decree drafted that would ensure a level playing field for all producers, the next step in Rwanda was to draft country-specific food fortification standards using food consumption data collected through the FRAT survey and current micronutrient deficiency data from Rwanda’s DHS surveys. Results from the FRAT indicate relatively wide coverage in both rural and urban areas of salt, sugar, cooking oil, and maize flour. Although data on wheat flour consumption and coverage was not collected, it was agreed upon in the NFA’s standards creation workshop that coverage was wide enough for it to be considered an appropriate vehicle for fortification. (Coverage is estimated to be ~70% nationwide).
In 2010, PHC along with a group of international and regional experts worked with the NFA to draft country-specific fortification standards that reflect current dietary patterns while allowing for sufficient beneficial impact on health outcomes. The established standards are in line with regional ECSA guidelines precluding any barriers to trade. Standards have been approved by all relevant bodies, made official by the Bureau of Standards, and shared with industry.
A national fortification logo with accompanying guidelines has been adopted to serve as a quality mark to consumers indicating the presence of essential vitamins and minerals needed for proper growth and development.
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 assessments. The assessments, shared with each producer, outlined process line changes required to adopt fortification and proposed estimated costing-models.
In 2013, PHC began working with MINIMEX, Rwanda’s only large-scale maize flour producer, on a fortification advocacy campaign that would reach into every province in the country. The goal was to make consumers aware of the importance of fortified products and to better understand barriers around product uptake. Lessons learned from the campaign are being incorporated into government run advocacy initiatives.
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, and in markets and shops. In April 2013, PHC in collaboration with external consultants, held a comprehensive monitoring trainings for Ministry of Health and Bureau of Standard inspectors. Once deployed, trained inspectors will be responsible for quarterly sample collection and submission to the Bureau for testing and reporting.
In 2016, PHC in collaboration with government staff, adapted PHC’s Fortification-specific Management Information System to the Rwandan context. Key staff will be trained on its use in the coming months. Use of the system will enable effective compilation of monitoring data and ease national compliance reporting allowing for program improvements to be observed and addressed in a timely manner.
PHC efforts are focused intently on final industry scale-up, consumer and policy-maker awareness, and establishing an institutionalized monitoring system. Through 2016, PHC will continue to support appropriate sourcing of equipment and premix; guide appropriate testing, monitoring, and reporting structures within industry and at the government level to track compliance; and ensure the design of a surveillance system to track coverage and ultimately measure the impact of fortification on micronutrient status. We are hopeful that Rwanda’s new Ministry of Health leadership will support the country’s fortification program goals.