Can fortification be implemented in rural African communities where micronutrient deficiencies are greatest? Lessons from projects in Malawi, Tanzania, and Senegal

Abstract

Background. Fortifying common foods with micronutrients is an effective strategy for decreasing micronutrient deficiencies at a population level. National fortification initiatives often do not impact remote communities that are unreached by commercially produced food. The feasibility and sustainability of small-scale fortification as a mechanism to overcome this barrier are not well documented. Objective. To document the process and assess the feasibility of implementation of community-based fortification of staple grains in rural communities in Malawi, Tanzania, and Senegal. Methods. In the late 1990s, World Vision piloted community-level fortification within a large-scale, multicountry, integrated nutrition and health program. The exploratory approach focused on developing appropriate community-based methods and processes for flour fortification. An external review in 2012 documented the implementation process, identified barriers and enablers for sustainability and effectiveness, and evaluated the potential for replication and/or scale-up of the intervention. Results. Strong advocacy influenced national policy and legislation for mandatory national-level fortification of staple grains. Piloting community-based fortification led to community acceptance of the consumption of fortified foods; however, lack of realistic funding mechanisms limited sustainability. Conclusions. Despite the complexity and challenges of community-based fortification, it demonstrates great potential to address unmet needs for micronutrients in vulnerable populations. Further work is needed to determine contextually feasible and sustainable mechanisms for premix supply, quality control, and cost recovery. Incorporating community-based fortification into national fortification frameworks is recommended for countries where a significant proportion of the population may have very limited access to commercially fortified foods.