World Vision Malawi’s
Micronutrient and Health (MICAH) Program
SMALL SCALE FORTIFICATION
at a Rural Hammermill
Submitted by:
Kimberly Baldwin Radford, MPH
B.P. 130 • Toamasina 501 • MADAGASCAR
[email protected]
Submitted to:
World Vision Canada
1 World Drive • Mississauga, Ontario L5T 2Y4 • CANADA
TABLE OF CONTENTS
TABLE OF CONTENTS.................................................................................................. 2
ACRONYM LIST and GLOSSARY................................................................................. 3
INTRODUCTION............................................................................................................. 4
BACKGROUND .............................................................................................................. 5
SMALL SCALE FORTIFICATION at a RURAL HAMMERMILL .................................... 6
Overview of Small Scale Fortification................................................................................. 6
Description of MICAH’s SSF Process................................................................................. 6
Logistics and Infrastructure ................................................................................................ 7
Premix Details ...................................................................................................................... 8
PERCEIVED IMPACT BY BENEFICIARIES .................................................................. 8
MICAH Beneficiaries Respond ............................................................................................ 9
APPENDIX A: MICAH Malawi Program Map & Target Population .... Error! Bookmark
not defined.
APPENDIX B: MILLING PROCESS & HAMMERMILL DIAGRAMS..... Error! Bookmark
not defined.
APPENDIX C: FORTIFICATION MONITOR JOB DESCRIPTION.. Error! Bookmark not
defined.
APPENDIX D: SAMPLE SMALL-SCALE MILL MOU ....... Error! Bookmark not defined.
APPENDIX E: EXCERPT/NIGEL MOTT’S REPORT ........ Error! Bookmark not defined.
APPENDIX F: FORTIFICATION OFFICE & HAMMERMILL ............ Error! Bookmark not
defined.
APPENDIX G: MICAH SSF IEC ACTIVITIES..................... Error! Bookmark not defined.
MICAH Small Scale Fortification
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ACRONYM LIST and GLOSSARY
ADP
Area Development Program
CIDA
Canadian International Development Association
Hb
Haemoglobin
HH
Household
IEC
Information, Education & Communication
kg
Kilogram
Likuni Phala
“Thin” porridge usually made from blended maize and soya
flour; used as a complementary food for children.
LOP
Life-of-Project
MICAH
MICronutrient And Health (Program)
MoA
Ministry of Agriculture, Irrigation & Food Security
MoH
Ministry of Health
NGO
Non-governmental organization
nsima
Thick porridge made from ground maize; dietary staple
SSF
Small scale fortification
U5
Under-five
WRA
Women of Reproductive Age
WVC
World Vision Canada
WVM
World Vision Malawi
MICAH Small Scale Fortification
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INTRODUCTION
In 1995, World Vision Canada began the CIDA-funded MICronutrient And Health
(MICAH) program in five African countries: Ethiopia, Ghana, Malawi, Senegal and
Tanzania. MICAH’s purpose is to use integrated health and nutrition strategies to
reduce micronutrient malnutrition.
The overall goal of MICAH is “to improve the nutrition and health status of women and
children through the most cost effective and sustainable interventions.”1 The three main
objectives and key activities include:
1. Increasing “intake and bioavailability of micro-nutrients (e.g., iron,
iodine and vitamin A)” via supplementation, fortification, and dietary
diversification and modification, including exclusive breastfeeding,
home gardens, fruit trees, fish ponds, solar-dried foods, etc.
2. Reducing “the prevalence of diseases that affect micronutrient status”
via water and sanitation improvements, immunization, malaria control,
and worm and parasite treatment (e.g., hookworm and schistosomiasis).
3. Building “local capacity for delivery systems to improve micronutrient
status” via equipping labs, training staff, and influencing policy issues.2
As part of its efforts in fortification, World Vision Malawi initiated the small scale
fortification (SSF) of maize at a select number of rural hammermills. The objective of
SSF activities has been a) to provide essential micronutrients to those at high risk of
malnutrition in rural areas through a village-level fortification program; b) increase
access to fortified foods and c) decrease micronutrient malnutrition.
MICAH SSF activities were initiated in 1998 through the establishment of the Domasi
Fortification Unit, the commercial site that manufactures the fortification preblend
described below, as well as likuni phala. Village-level SSF activities began in June
2001. SSF currently reaches at least 22,600 households via 11 community mills3
spread throughout Malawi’s three regions (north, central and south). This report is a
description of small scale fortification activities at a representative hammermill in
rural Malawi.
See Appendix A for MICAH program map and target population breakdown.
1
World Vision Canada, MICAH Phase 1 Results 1995-2001, p. 8.
Points 1-3 from MICAH Phase 1 Results 1995-2001, p. 8.
3 The number of participating mills has varied throughout the LOP due to infrastructure and ownership issues un-related to WVM.
2
MICAH Small Scale Fortification
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BACKGROUND
According to the World Bank (2004), 84% of Malawi’s population reside in rural areas.
Maize is the principal food crop and dietary staple4, with Malawians consuming on
average over 100 kg per person per year.5 This
The Maze of Malawian
reliance on maize creates a lack of dietary diversity -Maize Terms
a significant contributing factor to micronutrient
(a sampler)
deficiencies in Malawi. “Maize flour in rural areas of
Malawi is processed with a combination of hammerLikuni Phala: mixture of soy and
maize flours; made into a thin
mill technology and several stages of pounding by
6
porridge (usually for children)
hand, soaking, washing, and drying.” The textbox at
Mgaiwa: unrefined maize meal,
right highlights several types of maize flour/meal and
used for making nsima, especially
their uses in the Malawian diet.
during the lean season
Nsima: staple dish; thick (hard)
porridge, usually made from
maize
Ufa Woyera: refined white maize
flour, used for making nsima
(preferred)
In 1996, MICAH’s baseline survey showed that 56%
of Malawian children under-five (U5) were stunted
(HAZ<-2SD), while anaemia affected 84% of U5’s
(Hb<11.0g/dL) and 59% of pregnant women
(Hb<11.0g/dL). The 2003 Malawi National
Micronutrient Survey7 confirmed the high levels of
stunting (53%) and anaemia in children (80%), and further showed that 13% of adult
men also suffer from anaemia.
In its natural state, maize is a good source of vitamin B1 (thiamine), B2 (riboflavin), and
niacin. However, most of these nutrients are concentrated in the outer layers of the
grain, thus a significant proportion is lost during the milling process. The fortification of
maize flour replaces micronutrients lost in processing and increases the intake of other
essential micronutrients. The most notable is iron, consumed in relatively low quantities
in the average Malawian diet.
Maize fortification has the potential to reduce anaemia, benefiting all members of the
family. Community-level fortification presently costs about US$0.29/beneficiary/yr,
making it an extremely cost-effective intervention. The cost per beneficiary continues to
drop due to increased demand.
4
Ellis, F., Kutengule, M. & Nyashu, A. Livelihoods & Rural Poverty Reducation in Malawi (draft), Ladder Working Paper No. 17, July 2002, p. 4.
Smale, M. & Jayne, T.S. Maize in Eastern & Southern Africa. p. 3.
6 Ibid, pp. 6, 7.
7 UNICEF/MoH/CDC 2003 Malawi National Micronutrient Survey
5
MICAH Small Scale Fortification
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SMALL SCALE FORTIFICATION at a RURAL HAMMERMILL
Overview of Small Scale Fortification
“Small Scale Fortification (SSF) is defined as the addition of micronutrients to the milled
cereal products in mills with a capacity of less than 1 metric ton per hour using a diluted
premix or ‘preblend’ format, with or without special dosing or blending equipment.”8
In the case of MICAH SSF, the diluent is maize flour (the carrier).
Cereal flours and foods can be fortified on a small scale by adding a
micronutrient premix to the grain during milling or to the flour/meal after
milling. This is achieved by using:
(a) A calibrated scoop/spoon to measure an amount proportional to the
weight of grain, or
(b) A sachet, containing an amount appropriate for a set weight of grain, or
(c) A small dosifier that dispenses an amount proportional to the weight of
grain flow.9
How do hammermills work?
Hammermills are one type of
single-stage milling that convert
cereal grains into flour using
simple equipment. They were
introduced to Africa in the 1920s
(footnote #5, p. 6).
“Hammermills consist of swiveled
metal blades that grind the grain by
smashing it against a metal screen.
These mills run at very high speed
and the fine meal is forced through
the screen by air due to the high
speed of the hammers.” Diagram,
Appendix B.
MICAH’s small scale fortification activities add the
micronutrient premix during the milling process (see
diagram, Appendix B) and use a calibrated scoop to
measure the quantity of preblend.
Description of MICAH’s SSF Process
MICAH’s SSF at rural hammermills involves three
“players”: The customer (usually a woman); the mill
fortification monitor (partially financed by MICAH); and
the mill operator (usually a man who may or may not
be the mill owner).
The job description of the mill monitor (Appendix C)
and the memorandum of understanding between the
mill owner and World Vision Malawi’s MICAH program
(Appendix D) illustrate the responsibilities of each
Fortification Handbook Vitamin &
party. Prior to starting SSF at a mill, the miller is
Mineral Fortification of Wheat Flour
& Maize Meal, p. 25
trained by MICAH on the prevalence and impact of
micronutrient deficiencies, the role of food fortification,
premix ingredients, how to properly add the fortificant, and business planning and
marketing.
MICAH’s fortification process is as follows:
8
9
The Micronutrient Initiative, Fortification Handbook, June 2004, p. 66.
Ibid, p. 69.
MICAH Small Scale Fortification
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1. The customer arrives at the mill with her sack or basket of maize – usually presoaked and dehulled. Most women walk from <30 minutes up to an hour to reach a
mill site. In some areas, women may walk over two hours for milling.10
2. The mill monitor weighs the maize using a hanging scale.
3. The monitor records the following data in the MICAH fortification registry: Family
name; village; type of maize (whole or de-hulled); total kilograms; and how many
scoops of pre-mix to be added based on total weight of maize. The monitor also
records the acceptance rate (women have the option to refuse the fortification
service), noting the reason if fortification is refused.
4. The fortification pre-mix -- stored in a plastic bucket with lid -- is measured onto a
tray using a pre-measured scoop (150 g. plastic cup). The current proportion is one
scoop of pre-mix per five kilograms of maize (soon to be adjusted; see below).
5. Customer pours maize into mill hopper; mill monitor adds pre-mix into hopper.
Occasionally the miller adds the pre-mix depending on the number of customers and
the layout of the mill.
6. Customer collects finished product at the discharge end of machine.
7. If the quantity of maize is less than one kg, maize is not fortified. Any “millable” item
will be fortified (as desired by customer) if it is ≥ 1 kilograms. If an individual brings
less than 5 kgs, half the scoop is added, if it is less than 1 kg, nothing is added.
8. The ground maize may be dried again on a mat at home, then stored or prepared
per usual cooking method.
In the case of Malawi hammermills, payment is in cash, not in-kind. There is currently
no extra charge for fortification, except for a few sites that have voluntarily raised the
milling fee in anticipation of MICAH’s program close-out, and want to be able to
continue SSF post-MICAH (e.g., Ekwendeni).11
Logistics and Infrastructure
The diluted premix is manufactured at the Domasi Fortification Unit, a commercial plant
near Zomba in southern Malawi, begun as part of MICAH program activities. Preblend
is packed in 50 kg bags and delivered to participating mills by MICAH. At each mill,
MICAH has built or rehabilitated a small fortification “office” accessible to World Vision
staff, the mill monitor, and the mill operator/owner.
The building generally consists of a locked storage room for the bags of pre-mix
10
Mvula, P. & Munthali, A. Evaluation of the Food Fortification Programme, July 2004, p. 35.
Consultant Nigel Motts provided a business perspective of Malawi hammermills, including a description of MICAH SSF activities, in his Aug
2003 report, Malawi: Case Study of the Workability of Fortification via Service Hammer Mills (draft). See excerpt, Appendix E.
11
MICAH Small Scale Fortification
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(stacked on pallets) and a small office with a desk to hold the various reporting
forms/record books required by MICAH for quality assurance/quality control. Preblend
has a shorter shelf-life than the more concentrated premix (approximately one month
vs. one year). No more than 200 kgs of preblend are stored per mill, minimizing the risk
of contamination, infestation, deteriorating product and theft. An example of a typical
MICAH fortification unit office, Malawi hammermill and maize processing photos are
depicted in Appendix F.
Premix Details
Throughout the life of the MICAH program, two premix formula have been used.
Changes have been made due to local dietary needs and cost considerations. The mix
that is currently being used (as of May 2005) is as noted below. When the current stock
of premix has been depleted, the program will begin using the second formula, reducing
costs as the quantity of maize flour carrier is less.
Current premix (until stock depleted): IS-254, supplied by Roche Products, South Africa:
1:200 ratio of premix to maize (0.15 kg of premix added to 30 kg. of maize) to create
preblend; 150 grams of preblend fortifies 5 kg. maize.
Nutrients
Thiamine Mononitrate
Riboflavin
Pyridoxine HCl
Nicotinamide
0.78 mg
0.52 mg
0.77 mg
5.85 mg
Zinc Oxide (Zn)
Iron (reduced > 95% through 325 mesh)
Folic Acid
Vitamin A (palmitate)
3.74 mg
2.86 mg
0.11 mg
1415 IU
Revised Premix (to begin distribution approximately June 2005): IS-353, supplied by
DSM (formerly Roche), South Africa: 1:50 ratio of premix to maize (0.15 kg of premix
added to 7.5 kg. of maize) to create preblend; 37.5 grams of preblend fortifies 5 kg.
maize.
Nutrients
Thiamine Mononitrate
Riboflavin
Pyridoxine HCl
Niacin
2.21 mg Zinc Oxide (Zn)
1.70 mg Iron - Electrolytic (Fe)
3.13 mg Folic Acid
25.00 mg Vitamin A palmitate
Calcium
15.06 mg
35.00 mg
0.91 mg
6,953.04 IU
80.00 mg
PERCEIVED IMPACT BY BENEFICIARIES
Maize fortification initially met with resistance by MICAH beneficiaries. There were
many misconceptions about the purpose of fortification, the most pervasive being that
the preblend contained poison or contraceptives and was a “plot” to limit family size.
MICAH staff used many varied strategies to help educate and inform the target
population, including radio, posters, role plays/drama, Q&A sessions, song, community
MICAH Small Scale Fortification
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role models/leaders, peer education, football (soccer) team sponsorship (the Domasi
Fortifiers), taste-testing/demonstrations, social marketing and other information,
education and communication (IEC) strategies. See Appendix G for IEC highlights.
MICAH’s IEC strategies made significant inroads into the myths about fortification.
Monitoring results at participating mills show nearly 100% utilization. A 2003 evaluation
of WVM’s food fortification programme showed similar results:
Figure 1: Community member awareness and
utilization of fortification services
100%
80%
60%
40%
20%
0%
Mzimba
Lilongwe
Zomba
Chiladzulu
(n=100)
(n=98)(n=149)
(n=96)
Fortification Area
Knowledge
Utilization
Problems cited
MICAH Beneficiaries Respond
The stories below highlight MICAH beneficiaries’ perceptions about SSF and fortified
foods based on interviews held in Malawi in April 2005. (See related PowerPoint
presentation for photos of interviewees.)
Story #1: Mrs. Galisomo, mother of five, Kabudula mill
Mrs. Galisomo is the mother of five children. When MICAH came to her village in 2001,
she didn’t know anything about fortification, but she heard that it was connected to
family planning. Now she can tell you that fortification means adding vitamins and
minerals to her maize to reduce anaemia. Several times a month, Mrs. Galisomo and
other women walk to the local hammermill to have their maize ground. There a MICAHprovided blend of maize flour, vitamins and minerals is added to their grain as it is
milled. Mrs. Galisomo had her last two children, ages 4 and 1½, since the family has
begun eating the fortified maize. The last two are healthier and stronger than her other
children at the same age and have not been sick as often. Mrs. Galisomo has noticed a
difference in her own health, as well: “My blood tested higher [Hb] after using the
fortified maize flour. I used to be thin, but now look at me – I’m healthy and strong!”
Story #2: Lorine, 16, and her son, Sylvester, 1½ years old, Tengo Village
Lorine became pregnant while still a student. Wanting to hide her pregnancy and
remain thin, she ate very little. By the time Lorine was ready to deliver, she was very
MICAH Small Scale Fortification
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malnourished; her baby boy, Sylvester, was born underweight. Lorine had no
breastmilk for her son for the first four months of his life. The local hospital told her that
she couldn’t breastfeed and shouldn’t even try because she was so emaciated.
When Sylvester was four months old, a neighbour helped Lorine contact MICAH staff.
MICAH provided both mother and baby with fortified maize and soybean flour to be
eaten as porridge (likuni phala). Mother and baby put on weight and within two months,
Lorine began producing breastmilk and was able to breastfeed. Sylvester is now a
healthy one-and-a-half year old, walking and still breastfeeding. Lorine thanks both God
and World Vision for giving her the chance to breastfeed and provide for her baby.
The women of Tengo nod in agreement: fortified flour made the difference for this young
mother and baby. Since MICAH came to their village, they sing: “We don’t want to go
backwards. What about you?” But the women also have a request: “We walk around 7
kms to get our maize fortified. Please start a fortification project closer to our village.
The fortified maize gives us smoother skins and healthier bodies.”
Story #3: Janet Takoma, Village near Domasi
Fortification means mixing vitamins and minerals with maize flour. When we first heard
this message, it was very strange to us. We thought it was family planning, but a
woman who was using the fortified flour became pregnant and gave birth.
Vitamins and minerals are very important. They reduce anaemia in children and
provide body protection. Now I know that there are vitamins in different types: Vitamins
A and B; folate; zinc and iron. After starting fortification, we have healthy bodies. Even
though our bodies are small, they are physically fit.
Story #4: Janet Phiri, near Domasi
I failed to go and get my flour fortified at first. When I saw others go, their bodies were
healthy and they gave birth, so I started going, too. I eat fortified maize with my whole
family. After we started eating, we are all healthy – I even gave birth! We appreciate
the fortification because we have good health here. Our children are not malnourished
and have good haemoglobin. Our eyes see far at night and our skin is smooth.
The women in her village believe that fortification has made the biggest positive
difference in their health and that of their families.
Other SSF Anecdotes
Village chiefs and traditional leaders:12 We see what’s happening in other villages
and want MICAH fortification help, too.
12
MICAH Data Review Workshop, as related by MICAH staff and partners; April 6, 2005.
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Sometimes fortification is attributed some unlikely benefits that encourage its
consumption:
• “The birth rate has increased. Men can marry three women! Consuming fortified
flour has contributed to their strength.”13
• “Fortified maize satisfies and stays longer in the body.”
• “After starting fortification, we have… eyes that can see far.”
13
Ibid.
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