Large-scale food fortification efforts in Haiti
By Ruth Climat, Yves-Laurent Régis and Chrisla Joseph
Ruth Climat is a medical doctor with a Master’s degree in human nutrition. She has been working in the medical and nutrition field for more than 10 years in Haiti. She is currently Technical Director of the RANFOSE project for Partners of the Americas.
Yves-Laurent Régis has over 30 years of experience in the management, monitoring and evaluation of programmes for development and humanitarian organisations. He is currently the Chief of Party for the food fortification project implemented by Partners for Americas and the Global Alliance for Improved Nutrition (GAIN).
Chrisla Joseph is a specialist in monitoring and evaluation with over 10 years of experience in managing and assessing food security and development projects. She is the project coordinator of the RANFOSE project.
The Ranfòse Abitid Nitrisyon pou Fè Ogmante Sante (RANFOSE) project is funded by the United States Agency for International Development (USAID). Successes achieved were made possible thanks to the contribution of the Ministry of Health and the industries fully involved in food fortification in Haiti (Les Céréales d’Haïti, Les Moulins d’Haïti, Carribex, HUHSA, DEKA Group and Bon Sèl d’Haïti).
What we know: Large-scale food fortification of regularly consumed staple foods can significantly improve the nutritional status of children and of pregnant and lactating women.
What this article adds: Micronutrient deficiencies are widespread in Haiti. Food fortification has been shown to be a safe and cost-effective intervention. In 2017, a panel of experts identified that the fortification of wheat flour with iron and folic acid ranked second among 85 interventions that could have the most social, economic and environmental benefits in Haiti. The same year, the Parliament passed a law making it a requirement to fortify wheat flour with vitamin B1, B2, B3, folic acid, iron and zinc, salt with iodine and edible oil with vitamin A. The RANFOSE project is supporting the implementation of the food fortification law by providing technical assistance to the Government of Haiti to create a legislative and regulatory environment that supports the production and importation of fortified foods, to make fortified foods that meet national standards available and accessible, to establish a system of quality assurance, quality control and monitoring of sustainable fortified foods and to raise consumers’ awareness to understand and accept the benefits of fortified foods. As a result of these and other efforts, fortified products are increasingly replacing unfortified products on the Haitian market despite constraints such as missing legal application texts to enforce the law, the lack of adoption of a unique food fortification logo and the low capacities of the national testing laboratory.
Malnutrition and micronutrient deficiencies in Haiti
Deficiencies in micronutrients (vitamins, minerals and trace elements), also known as ‘hidden hunger’, have devastating consequences on populations, the clinical signs of which often only become visible after the deficiency has caused major, often irreversible, internal damage. These deficiencies are directly associated with a significant increase in the risks of morbidity and mortality and have consequences not only for those affected but also for families, health services, education systems and societies in general. Despite the scarcity of complete and/or recent data, micronutrient deficiencies are considered to be a public health problem in Haiti. According to the latest Demographic and Health Survey (DHS) of 2016/2017, iron deficiency anaemia was present in 49% of non-pregnant women of childbearing age and in 66% of children aged 6 to 59 months (Figure 1) (IHE & ICF, 2018). Furthermore, nearly 35% of the Haitian population are considered to be exposed to the risk of zinc deficiency (Wessells & Brown, 2012) and 2006 survey data showed that 32% of children were vitamin A deficient and 25% of children aged 6 to 12 years were iodine deficient (MSPP & UNICEF, 2006).
Figure 1: Prevalence of anaemia in children by department, Haiti
Source: 2016/2017 DHS (IHE & ICF, 2018)
Micronutrient deficiencies occur alongside other forms of undernutrition in Haiti. A January 2020 Standardised Monitoring and Assessment of Relief and Transitions (SMART) survey revealed that nearly one in four children under five years of age (22.7%) suffered from stunting and 6% were wasted. Sub-optimal infant and young child feeding practices in the country contribute to poor nutrition status. The results of the 2016/2017 DHS showed that only one in four children under six months of age in Haiti was exclusively breastfed and only 25%, 40% and 11% of children aged 6 to 23 months achieved minimum diet diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD) respectively (IHE & ICF, 2018). The consumption of foods rich in micronutrients such as vegetables and nuts (28 to 62%), dairy products (42 to 35%), meat (14 to 38%), eggs (6 to 7%) and food rich in vitamin A (23 to 39%) is uncommon (Ayoya et al., 2014). Chronic food insecurity restricts access to a healthy, diversified and balanced diet and contributes to low diet diversity. According to the latest report from the National Food Security Coordination (CNSA, 2020), nearly four million Haitians are acutely food insecure (Figure 2).
Figure 2: Haitian population in acute food insecurity, September 2020
Source: IPC analysis, September 2020 (CNSA, 2020)
Ongoing interventions to address micronutrient deficiencies
UNICEF introduced the use of multiple micronutrient powders (MNPs) in Haiti in 2010 to improve the nutrient quality of complementary foods for children aged 6 to 23 months and since that time the Ministry of Public Health and Population (MSPP) has adopted their use in its national nutrition policy (Ayoya et al., 2014). Several other interventions, including vitamin A supplementation, prenatal micronutrients distribution to pregnant and lactating women and nutritional education, have also been ongoing in Haiti for decades. Unfortunately, however, the coverage and impact of these interventions remains low. According to the latest DHS, only 7% of children had received iron supplements in the previous seven days, 30% had received a vitamin A capsule in the six months prior to the survey and less than half of women of reproductive age (43.2%) reported receiving iron tablets during their last pregnancy (IHE & ICF, 2018). Although no studies have been undertaken to clearly identify the reasons behind these poor performances, poor access to health services and the disruption of inputs to health facilities are commonly reported.
The state of food fortification in Haiti
Several interventions are capable of reducing micronutrient deficiencies but food fortification, as a complement to other interventions, has been shown to be the safest in terms of the least side-effects and to have the most significant cost-benefit ratio. Worldwide, the benefits of fortifying staple foods with iron and salt with iodine are estimated to be USD7.2 billion per year (Horton et al., 2010). Evidence of measurable improvements in the micronutrient status and health outcomes in women and children in low- and middle-income countries through food fortification are also reported (Keats et al., 2019).
In 2017, applying the Copenhagen Consensus method, a panel of experts identified that the fortification of wheat flour with iron and folic acid ranked second among 85 interventions that could have the most health, social, economic and environmental benefits in Haiti. According to the report, spending HTG331 million1 to fortify 95% of wheat flour would prevent 140 deaths from neural tube defect and more than 250,000 cases of anaemia each year, with profits of HTG7.9 trillion (HaïtiPriorise, 2017). At the same time, it was estimated that USD34 million and USD37 million could be saved each year by improving iodine and iron status respectively (Dieneet al., 2014). As a result, the MSPP adopted food fortification among the five strategic objectives of the national nutrition policy and pushed for the drafting of a law to make food fortification mandatory in the country. This work finally paid off in February 2017 when the Parliament passed legislation making it a requirement to fortify wheat flour, salt and edible oil imported or produced locally throughout the national territory. Wheat flour would be fortified with vitamin B1, B2, B3, folic acid, iron and zinc, salt with iodine and edible oil with vitamin A.
To support these efforts, in July 2017, the United States Agency for International Development (USAID) in Haiti launched the Ranfòse Abitid Nitrisyon pou Fè Ogmante Sante (RANFOSE) project. This project is implemented by Partners of the Americas and the Global Alliance for Improved Nutrition (GAIN) in collaboration with the MSPP, the private sector and other partners in order to:
- Create a legislative and regulatory environment that supports the production and import of fortified foods in Haiti;
- Make fortified foods that meet national standards available and accessible;
- Establish a system of quality assurance, quality control and monitoring of sustainable fortified foods;
- Educate consumers to understand and accept the benefits of fortified foods.
The following activities have taken place in support of these efforts.
Creating an enabling environment
In March 2018, the RANFOSE project launched a Food Fortification Working Group (FFWG) made up of members of the private sector including wheat flour mills, oil bottling companies, the country’s iodised salt plant and various major importers of commodities as well as civil society, United Nations agencies, government entities and consumer associations. Members of the FFWG meet on a regular basis to discuss the challenges and progress of fortification. An action plan of the FFWG was developed that includes a set of activities to coordinate and mobilise all sectors and organisations for the reduction of micronutrient deficiencies and gives directives for quality control, the promotion of fortified foods, measurement of progress and accountability of all stakeholders.
Provision of technical support
Following the launch of the RANFOSE project, assessments of the flour industry and salt and oil plants were carried out and technical support provided to local businesses and importers to identify needs and ensure compliance with the fortification levels recommended by MSPP and the Ministry of Commerce and Industry.2 Working sessions are organised on a regular basis with the relevant competent state authorities such as MSPP, the Ministry of Trade, the Ministry of Economy and Finance, Customs and the Ministry of Agriculture with the objective of strengthening their involvement in the implementation of food fortification in Haiti. In addition to the technical support provided to companies, the members of the working group were connected to the GAIN premix facility for the acquisition of good quality premixes.
Promotion of food fortification
Several activities have been organised with different actors in coordination with MSPP to promote food fortification. Advocacy and awareness-raising materials were developed and a radio and television communication campaign was launched in July 2020 to raise awareness among the population and industrial users of fortified products about the consequences of micronutrient deficiencies and the benefits of fortified foods. To help customers make an informed choice, a food fortification logo to be affixed to fortified products was developed and is awaiting final approval from the Department of Health before it can be deployed.
Achievements of the programme to date
The strategies used to support and expand fortification in Haiti have brought about some successes to date. Today, all locally produced foods targeted for fortification are available in a fortified version in the local market and some imported versions are also fortified. The number of importers who market fortified products is steadily increasing, as described in the next section. Figure 3 below presents the availability of fortified products (wheat flour, oil and salt) before and after the implementation of the RANFOSE project.
Figure 3: Availability of foods fortified in Haiti before and after 2018, in metric tons
Wheat flour is consumed in several forms in Haiti including in soups, porridge, pasta, bakery products and pastries and snacks (bread, candies, cookies, pâtés and other sweet or savoury fried dough). According to the Famine Early Warning Systems Network (FEWS NET), in 2018 the annual consumption of wheat flour was 14kg/person on average, or nearly 240-300,000 metric tons of wheat flour per year, 72% of which was produced in Haiti (FEWS NET, 2018). Two companies fortify local flour and some imports are fortified, although adjustments are still underway to adapt the levels of fortification to meet the recommendations of the MSPP. Currently, over three quarters of the flour available on the Haitian market is actually fortified. Two local companies share a total production of fortified flour of 217,100 metric tons per year and a major player imports nearly 12,000 metric tons of fortified flour per year. In August 2020, another local flour mill officially started production of fortified wheat flour and is intending to supply the aforementioned main importer who will therefore replace the imported flour with locally produced flour.
Two oil mills are bottling imported oil in Haiti and have been fortifying this with vitamin A since October 2018. One of these mills decided to also enrich the butter and margarine that it produces as well. These two oil mills represent roughly 50% of the Haitian market share with a total of 6,500 to 8,500 metric tons received in bulk per month. At the same time, several major importers have also taken the step to import fortified oil. Today, seven brands of oils are fortified with vitamin A.3 We can therefore estimate that nearly 80% of the oil available on the Haitian market is fortified.
The vast majority of iodised salt available in Haiti is imported and contains potassium iodide. According to MSPP, this chemical form is not recommended for a tropical country like Haiti and instead industries should use potassium iodate. One local factory does produce iodised salt that complies with the MSPP recommendations. This factory produces approximately 300 metric tons of iodised salt per month in the form of both coarse salt and fine salt. In August 2020, a new player joined the programme to commercialise locally produced iodised salt. This new distributor has the potential to help improve the availability of appropriately fortified salt which currently represents slightly over 16% of the salt market.
Despite the fact that the population has historically preferred locally produced non-iodised salt for household use, which is cheaper, sales of locally-produced iodised salt have increased recently. This is likely as a result of the promotional efforts of the MSPP particularly around the use of iodised salt in school canteens, supported by RANFOSE, and the promotion of its use via other organisations such as Fonkoze4 or Projet Santé5.
Challenges to food fortification in Haiti
In spite of the successes of the national food fortification programme in Haiti, there have been major challenges to its progress as a result of the prolonged political crisis in the country, often accompanied by violent street demonstrations and roadblocks as well as fuel shortages which have regularly hindered the transporting of fortified products throughout the country. In addition, frequent changes in government have affected planning and coordination with public entities and the deterioration of the economic situation has limited the population’s access to fortified foods. This situation has been exacerbated by the impacts of the COVID-19 pandemic which have led to a further slowdown of the economy and interruptions to the food supply chain. These external factors have led to major delays in the implementation of activities linked to food fortification efforts. For instance, although the legislation regarding food fortification was enshrined in law almost four years ago, some essential pillars of the legal framework are still not yet in place, for example legal texts specifying the modalities of the application of the law, food fortification standards, rules and guidelines and a logo to clearly identify fortified products for consumers.
Another challenge is that companies that voluntarily adopt fortification and absorb the associated costs do not receive any kind of support or incentive from government authorities while those who do not fortify their products are not penalised. In the absence of effective control and sanctions, company adopters may lose motivation to continue enriching their products. This needs to be addressed. A final challenge is that, currently, the quality assurance and control system is poorly harmonised and inefficient. Some entities of the quality control system are not yet involved in food fortification due to the lack of publication of application texts. Furthermore, the capacities of the national laboratory need to be strengthened to provide appropriate quality control testing.
Large-scale food fortification of regularly consumed staple foods can significantly improve the nutritional status of children and pregnant and lactating women. Fortification, if well implemented, has the capacity to reach the most vulnerable populations in communities that other interventions cannot reach. Efforts in recent years by the government, supported by the RANFOSE project, have considerably improved the availability of micronutrients in oil, salt and wheat flour in Haiti. The food vehicles selected for fortification are widely consumed by the entire population, fortified products are increasingly replacing unfortified products, routed through the same distribution channels, and since no price increase has been recorded following fortification, we expect that these efforts will lead to greater availability of micronutrients for the population throughout the national territory.
Targeted efforts are needed to overcome challenges to ensure the full and sustainable rollout of food fortification. To this end, RANFOSE will continue to advocate for the publication of technical legal texts by the Haitian government, improved quality control and collaboration between industries and laboratories to guarantee a sustainable food control system and the development and dissemination of norms and standard operating procedures for fortification. RANFOSE and its partners will also continue to invest in communication campaigns to raise the population’s awareness of the importance of fortified foods to maintain demand and project sustainability towards achieving improved health and nutrition throughout the country.
For more information, please contact RANFOSE at firstname.lastname@example.org.
1 The ‘gourde’(HTG) is the national currency of Haiti
2 Since October 2020 it has been mandatory for importers of wheat flour, salt and vegetable oil to obtain a certificate of compliance with fortification issued under the Ministry of Commerce and Industry.
3 This latest estimate includes a new company that has been importing fortified oil since November 2020.
4 Fonkoze is both a financial service (micro-finance) and a non-profit foundation that provides development services and programmes to support the ultra-poor, working to secure financial and technical support for its Haitian partners. The Fonkoze Foundation is implementing the USAID-funded “AKSYON” project which builds on their network of community health stores to decrease the number of women and children under five years of age who suffer from malnutrition.
5 Projet Santé is a USAID-funded project providing integrated maternal and child healthcare, including nutrition services and HIV care, in the hospitals and communities of Haiti.
Ayoya, M A, Heidkamp, R, Ngnie-Teta, I, Mamadoultaibou, A, Daniel, E F, Durandisse, E B, Saint-Fleur, J E, Beaulière, J M, Koita, Y, M'mbakwa, B E, Stoltzfus, R J, Pierre, J M (2014) Précis of nutrition of children and women in Haiti: analyses of data from 1995 to 2012. Ann N Y AcadSci;1309:37-62. doi: 10.1111/nyas.12373
Coordination nationale de la sécurité alimentaire (CNSA) (2020) IPC acute food insecurity analysis. Haiti: Acute Food Insecurity Situation August 2020 - February 2021 and Projection for March - June 2021. http://www.ipcinfo.org/ipc-country-analysis/details-map/en/c/1152816/
Diene, S, Eveillard, R, Kovach, T, Lêlio-Joseph, M, Moses, P, Oot, L, Ralph, B, Sethuraman, K, Sommerfelt, A E (2014) Reducing Malnutrition in Haiti: Estimates to Support Nutrition Advocacy – Haiti PROFILES 2013. Washington, DC : FHI 360/FANTA and Ministeère de la Santeé Publique et de la Population, Haiti.
FEWS NET (2018) Haitistaple food market fundamentals, March 2018. Famine Early Warning Systems Network (FEWS NET). Available at: https://fews.net/central-america-and-caribbean/haiti/market-fundamentals/march-2018
HaïtiPriorise (2017) HaïtiPriorise Eminent Panel Findings. Port-au-Prince, May 3 2017.https://www.copenhagenconsensus.com/haiti-priorise/haiti-priorise-eminent-panel-findings
Horton, S, Shekar, M, McDonald, C, Mahal, A and Krystene Brooks, J (2010) Scaling Up Nutrition: What Will It Cost? The World Bank, Washington, D.C.
Institut Haïtien de l’Enfance (IHE) et ICF (2018) Enquête Mortalité, Morbidité et Utilisation des Services (EMMUS-VI 2016-2017) Pétion-Ville, Haïti, et Rockville, Maryland, USA : IHE et ICF.
Keats, E C, Neufeld, L, Garrett, G, Mbuya, M N N and Bhutta, Z (2019) Improved micronutrient status and health outcomes in low- and middle-income countries following large-scale fortification: evidence from a systematic review and meta-analysis. Yearbook of Paediatric Endocrinology. 10.1530/ey.16.13.17.
Ministère de la Santé Publique et de la Population & UNICEF (2006) Enquête sur la prévalence de la carence en vitamine A et de la déficience en iode en Haïti. Port-au-Prince, Haïti. Ministère de la Santé Publique et de la Population & UNICEF.
Wessells, K R and Brown, K H (2012) Estimating the global prevalence of zinc deficiency: results based on zinc availability in national food supplies and the prevalence of stunting. PloS one, 7(11), e50568. https://doi.org/10.1371/journal.pone.0050568
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Ruth Climat, Yves-Laurent Régis and Chrisla Joseph (). Large-scale food fortification efforts in Haiti. Field Exchange 65, May 2021. p30. www.ennonline.net/fex/65/foodfortificationeffortshaiti