Business Innovation to Combat Malnutrition Case Study Series 59428 Faire Tache d'Huile: Cooking Oil Fortification in West Africa This case was developed "Whose responsibility is fortification? It doesn't describes the Faire Tache d'Huile initiative with by the World Bank Institute have a natural home in the public sector. At the a particular focus on the coordination issues (WBI) with the support of the Global Alliance for Improved public level, fortification is a multiple orphan: involved and the conditions under which such Nutrition (GAIN), and edited though indirectly relevant to the work of multiple a public-private partnership is likely to succeed by Michael Jarvis (WBI). agencies, it has no explicit parent. While every- (in this case addressing a pressing public health Case development benefited one has a role to play, it's no one's central interest. challenge). from in depth inputs from organizations involved in the It's no one's day job. But given the stakes, it must Faire Tache d'Huile initiative, be everyone's central interest. It must be every- In developing economies, rapid and thorough particularly the staff of Helen one's day job." food fortification for public health worked Keller International. The --Shawn Baker, Vice President and Africa Re- best as a multi-sectoral effort that included contribution of all parties is most gratefully acknowledged. gional Director, Helen Keller International governments, industries, researchers, non- governmental organizations (NGOs), and In May 2007, Helen Keller International other social actors. What made Faire Tache (HKI) announced a new $2.7 million multi- d'Huile nearly unique among such initiatives partner public-private initiative to produce was that it operated not only at the level of vitamin A-fortified cooking oil (oil) in eight individual UEMOA member states, but at the countries in West Africa. These eight coun- regional level as well. This made coordination tries--Benin, Burkina Faso, Côte d'Ivoire, essential to any and all progress. HKI had Guinea-Bissau, Mali, Niger, Senegal, and helped bring together the key private, public, Togo--comprised the West African Monetary and not-for-profit stakeholders with the goal Union (known as UEMOA from its French of achieving mandatory vitamin A fortifica- initials; see Exhibit 1). The program was tion of industrially-produced cooking oil dubbed "Faire Tache d'Huile," literally similar throughout UEMOA. Funding for the initia- to a "snow ball effect" in French, used figura- tive was led by the United States Agency for tively to express the scope and outcomes of this International Development (USAID), which multi-country, multi-partnership approach to contributed $1.3 million. Other financial vitamin A fortification of cooking oil in the partners included the Michael & Susan Dell West Africa Region. The successful implemen- Foundation (contributing $750,000), the tation of this cooking oil initiative catalyzed Government of Taiwan (China) ($300,000), a similar regional initiative on micronutrient the Global Alliance for Improved Nutrition fortification of cereal flour, with the two re- (GAIN, $200,000), and the Micronutrient Ini- gional initiatives declared at the Clinton Global tiative (MI, $173,775). These were investments Initiative as "Fortify West Africa." This case that augmented prior country level funding Copyright © 2009, WBI - World Bank Institute, Washington, DC, United States, and GAIN - Global Alliance for Improved Nutrition, Geneva, Switzerland. The views expressed in this paper are those of the authors only. by MI and GAIN, supporting food fortification in VAD was a public health problem in more than half Côte d'Ivoire and Mali. of all nations, hitting hardest young children and pregnant women in low-income countries, especially By early 2009, three countries in West Africa were in Africa and Southeast Asia (see Exhibit 2 for data fortifying vegetable oil--Burkina Faso, Côte d'Ivoire, on the prevalence and impact of VAD in West Africa and Mali, with Benin and Senegal expected to do so and Exhibit 3 for estimates of economic losses in within the year. Within this initial group, common Africa from all vitamin and mineral deficiencies). language and geographic proximity had made it Worldwide, an estimated 250 million preschool easier than expected to spread practice from one children were vitamin A deficient, and it was likely country to another. However, the collaboration that in VAD areas a substantial proportion of preg- that was emerging at the regional level concealed nant women were vitamin A deficient. An estimated many challenges that had to be overcome in each 250,000 to 500,000 vitamin A deficient children individual country, where industry dynamics and became blind every year, half of them dying within institutional contexts differed. Clear understanding 12 months of losing their sight. Research indicated of the challenges in individual countries could help that even children with mild VAD and no clinical stakeholders wishing to implement food fortifica- symptoms had 25% to 30% higher death rates than tion in other parts of Africa and beyond. those without VAD. VAD compromised the immune systems of approximately 40% of the developing world's children under the age of five and led to the Vitamin A Deficiency in West Africa1 deaths of as many as one million young children each year. Hundreds of millions more were at increased Vitamin A deficiency (VAD) was the leading cause risk of disease and early death. of preventable blindness and visual impairment in children. VAD also significantly increased the risk To successfully combat VAD, short-term interven- of severe illness, and even death, from such com- tions and proper infant feeding had to be backed mon childhood ailments as diarrheal disease and up by long-term sustainable solutions. For deficient measles. VAD increased one's susceptibility diseases children, the periodic supply of high-dose vitamin such as malaria as well. For pregnant women in A in swift, simple, low-cost, high-benefit interven- high-risk areas, VAD occurred especially during the tions had produced remarkable results, reducing last trimester when demand from both the unborn mortality by 23% overall in high VAD populations child and the mother was highest, and typically first and by up to 50% for acute measles sufferers. manifested itself during this period as night blind- ness. The impact of VAD on mother-to-child HIV The arsenal of nutritional well-being weapons in- transmission awaited further investigation. Ade- cluded a combination of breastfeeding and vitamin quate vitamin A in high-risk areas could significant- A supplementation for the youngest victims, coupled ly reduce mortality. Conversely, its absence caused a with enduring solutions such as promotion of vitamin needlessly high risk of disease and death. A-rich diets and food fortification. Since breast milk was a natural source of vitamin A, promoting breast- 1. For more details, please refer to our sources, www.who.int/nutrition/topics/vad/en/index.html, accessed February 7, 2009; WHO country data: www.who.int/vmnis/vitamina/data/en/index.html, accessed March 3, 2009; and, African prevalence of VAD: www.who. int/nutrition/publications/ micronutrents/vitamin_a_deficiency/WHO_NUT_95.3/en/index.html, accessed March 3, 2009. 2 feeding was the best way to protect babies from VAD. to improve child survival. One high-dose vitamin A However, because breastfeeding was time-limited capsule every six months could help protect a child and the effect of vitamin A supplementation capsules from the death and disease associated with VAD. lasted only 4­6 months, these were but initial steps to- These capsules cost approximately two U.S. cents ward better overall nutrition, not long-term solutions. each and could often be delivered through existing child health programs. However, doing so in West In 1998, the World Health Organization (WHO) Africa was challenged by the gaps in local healthcare and its partners--the Canadian International De- delivery systems; food fortification was seen as a velopment Agency (CIDA), MI, UNICEF, HKI and more direct way to help populations at risk. USAID--launched the Global Alliance for Vitamin A (GAVA). In addition, WHO, UNICEF, and oth- ers subsequently provided support to countries in Vitamin A Fortification delivering vitamin A supplements with the goal of eliminating VAD by 2010. Linked to sick-child visits Fortification of oil products with vitamin A initially and national poliomyelitis (polio) immunization occurred in Europe in the early 20th century after days, these supplements averted an estimated 1.25 rates of VAD there rose as consumers switched from million deaths in 40 countries since 1998. dairy-based butter to new, oil-based margarines. Several years of fortification virtually eliminated An important part of an integrated package of essen- VAD from Europe. Further, in 1944, for example, tial services that promoted child health and stopped margarine fortification with vitamin A reduced preventable deaths, high-dose vitamin A supple- VAD in Newfoundland, Canada, from 48% to 2% of ments were also among the most cost-effective ways the population in four years.2 Table A. Selected vitamin A fortification standards for margarines and oils Country Parts per million (mg per kg) Belgium 6.75­8.1 Brazil 4.5­15.0 Canada 9.9 Chile 9.0 Denmark 7.56 Indonesia 7.5­9.0 Malaysia 7.5­9.0 Peru 9.0 Sweden 9.0 United States 9.9 United Kingdom 7.2­9.9 Food aid standards 10.0­15.0 Source: Commonwealth Regional Health Community for East, Central, and Southern Africa, reprinted in The Micronutrient Initiative, "Sugar and Oil Fortification with Vitamin A," brochure, n.d. 2. Commonwealth Regional Health Community for East, Central, and Southern Africa, reprinted in The Micronutrient Initiative, "Sugar and Oil Fortification with Vitamin A," brochure, n.d. 3 While vitamin A supplements could immediately tion in preventing blindness was a natural con- protect children from VAD for six months, the nection to HKI's mission of eye health, since VAD experience of Europe and Canada suggested that was the leading cause of preventable blindness in programs of vitamin A fortification could eliminate children. To accomplish its cooking oil fortification the problem entirely. Table A shows some of the vi- goals, HKI partnered with industry, government, tamin A fortification standards in place in countries and donors, fostering communication between around the world. Because the production process stakeholders, brokering relationships, and creating and losses from heat and light could reduce the information flow. "HKI's value added is in know- initial amount of vitamin A in fortified foods by up ing the actors," explained Shawn Baker, HKI Vice to 20%, producers typically added somewhat more President and Regional Director for Africa. "We fortificant to compensate. The three primary manu- play the roles of both broker and catalyst. We are facturers of vitamin A fortificant included German not a watchdog." chemical giant BASF, Swiss-based DSM Nutritional Products, and New York's Fortitech. This was hard to do, Baker added: "People talk about partnership but don't realize what it actually takes In addition to the cost of fortificant, MI research to make it happen. It takes commitment, time, and summarized the cost of oil fortification as follows. relationships. Donors don't understand why we Tanks and dosing pumps to combine the vitamin need our number of staff, why we need meetings, A premix with refined oil cost between $20,000 to and why we need time. Look at our cost structure: over $200,000 to procure and install. Chemicals we are more expensive than an NGO that is hiring and equipment for quality control and quantitative frontline health workers, but we need the time to testing could require initial investment between develop relationships and we need the people to put $30,000 to over $80,000 depending on the testing in the time. We are also dealing with a higher level protocols to be used.3 However, every $1 invested of relationship than frontline health and service in vitamin A fortification returned $7 in wages and delivery groups do." decreased disability, according to HKI estimates. The Micronutrient Initiative Players Since 1998, MI had supported semiannual preventa- Helen Keller International tive vitamin A supplementation along with CIDA, HKI, UNICEF, USAID, WHO, and many other HKI was an international NGO, headquartered in organizations in close collaboration with national New York, that fought blindness and malnutrition governments. By 2004, almost 60% global cover- in over 21 countries, primarily by providing exper- age had been achieved. MI and partners in GAVA tise, training, and technical assistance to establish continued working for higher coverage with the nutrition and eye health programs in partnership aim that every child under 5 at risk of VAD could with host countries.4 The role of vitamin A fortifica- receive a high-dose vitamin A supplement every 6 3. Micronutrient Initiative, "Fortifying Africa's Future," (Johannesburg, South Africa: Micronutrient Initiative, 2006), table 4, page 11. 4. See www.hki.org, accessed May 4, 2009. 4 months. In 2006 alone, MI programs arranged the are a small section. Nutrition and malnutrition are supply of sufficient vitamin A to meet the needs of a social issue for the UEMOA Commission. There is 347 million children in over 70 countries. a quality program in place to set regional standards, but the objective is to develop a common industrial In addition to supplementation, MI explored pos- policy for the region. In all areas, however, UEMOA sibilities to reduce VAD through foods that were is responsible for harmonizing national regula- naturally rich in nutrients, such as red palm oil tions. One objective of regional harmonization is and orange-fleshed sweet potatoes. MI also sup- to break technical and nontariff barriers to trade. ported the fortification of food staples, such as flour, With harmonization, we create the political willing- oil, and sugar, with vitamin A and other essential ness among member states to get involved. With- vitamins and minerals. To this end, MI developed out harmonization of standards, there will be no and maintained the FortAf (Fortify Africa) website result. There is an additional principle: the UEMOA and email newsletter as an information resource Commission should not duplicate what individual and portal focused on African fortification and food member countries can do themselves, but instead processing industries. MI was also a key partner in look for where it can add value." Faire Tache d'Huile. Mawuli Sablah, HKI Regional Coordinator for Faire Tache d'Huile, worked closely with the UC. He UEMOA elaborated, "The UEMOA Commission provides legal backing, legislation, logos, tax exemptions UEMOA was an economic and monetary union of on intraregional trade, direct investment on public West Africa formally created in January 1994, based health grounds, and standards, particularly sur- on the pre-existing West Africa Monetary Union rounding customs and trade. HKI and UEMOA Bank of the CFA franc zone,1 with eight members have an MOU [memorandum of understanding] in 2008, a currency guaranteed at fixed parity to on mandatory fortification of specific multiple food the Euro (CFA 656 = 1), and zone-wide fiscal and products, currently focused on cooking oil and monetary rules, including a common external tariff wheat flour. The issue is how to accelerate results. and free trade among its members. Patterned after Challenges in meeting responsibilities remain." the European Union, the UEMOA Commission (UC) was located in Ouagadougou, Burkina Faso, To set regional standards, the UEMOA secretariat and financed by a share of a one percent levy on all coordinated among member states. If half of the UEMOA imports.5 member states agreed, UEMOA then launched a formal process for setting up a new standard. To According to Adelaide Belemsigri, who headed this end, the UC ran 17 technical committees and NORMCERQ, the UEMOA department in charge coordinated with member state national commit- of all regional standards, product quality, and tees and their national standards organizations. norms: "UEMOA's emphasis is on economic and "Countries can pass their own directives," Belemsigri monetary issues. Social issues [such as fortification] noted. "They can go ahead and do it themselves. But 5. For more details please see http://knowledge.uneca.org/Members/Summermkhululi/observatory-on-regional-integration/regional- economic-commissions-in-africa/uemoa-waemu-westa-african-economic-and-monetary-union/uemoa-waemu-west-african-mone- tary-union, accessed April 20, 2009. 5 when a UEMOA directive is passed, country direc- health standards among ECOWAS countries, and tives need to fit its terms. If not, member states must viewed vitamin fortification as a tangible means to adapt their rules to UEMOA's directive." As of early this end. In 2005, WAHO advanced salt, flour, and 2009, UEMOA had approved nine standards for oil oil fortification, in 2006 passing a resolution for fortification covering such variables as microbio- member MOHs to facilitate mandatory fortification. logical content, chemical content, and the level of This resolution was re-affirmed in the 2008 General vitamin A. The standards would not go into force, Assembly of Health Ministers meeting of the 15 however, unless approved by member state minis- ECOWAS countries. ters. Said Belemsigri, "The ministers have to pass the legal application of these guidelines. Technical documents are ready for use, but we need political AIFO-UEMOA: The Cooking Oil Industry recognition to make it official." UEMOA's Statu- Association tory Council, a group of member state officials, met semi-annually to review such applications. AIFO-UEMOA (AIFO) was a professional associa- tion of cooking oil producers and refiners located in Once approved, member states had three months in UEMOA countries, initially established in 2000 with which to voluntarily adopt the standards. However, 14 member companies primarily in response to the because vitamin A fortification of cooking oil was economic challenges created by UEMOA's deci- deemed a public health issue, UC oil fortification sion to adopt WTO import duties. The opportunity standards would be imposed on a mandatory basis, this created for cooking oil imports was dramatic: with judicial recourse in the event of non-imple- UEMOA import duties fell from 45% on processed mentation. According to Belemsigri, the internal oil and 20% on unrefined oil to 20% on refined oil, legal issues delaying the imposition of mandatory 10% on semi-refined oil, and 10% on unrefined oil. oil fortification would be resolved in 2009, and A November 1999 meeting of UEMOA oil produc- mandatory fortification would be approved or en- ers led to AIFO's formal creation the following July. dorsed in 2010. "We went to the UEMOA Commission to do a big study of our problems," said AIFO founding mem- ber, former president, and current vice president, West African Health Organization Angora Tano. "Also, we went to all the member states to explain the problem and solicit for help to Functional since 2000, the West African Health Or- preserve the oil industry. We were not successful ganization (WAHO) served the public health needs with the governments [of the member states], so of the 15 member states of ECOWAS, the Economic we went to UEMOA because decisions adopted by Community of West African States, which included the UEMOA Commission can require the member UEMOA member states as well as Cape Verde, states to change their laws in conformity." Gambia, Ghana, Guinea, Liberia, Nigeria, and Sierra Leone. In 2002, WAHO officially became the The issue was not simply increased competition UEMOA regional health agency as well. Through its from cheaper oil imports. There was also in some annual assembly, WAHO worked closely with mem- instances rampant smuggling, and AIFO sought ber Ministries of Health (MOHs), particularly those greater customs surveillance of UEMOA ports and in UEMOA countries, to help influence national border crossings to at least ensure that import duties, 6 whatever the rate, were being collected. Moreover, the locus of the actual fortification process. National UEMOA imposed upon consumers a value added laboratories and national standards organizations tax on oil of 18­20% that AIFO wanted reduced. certified technical aspects of fortification, and uni- versity laboratories hosted additional testing. MOHs As a collectivity, AIFO had more clout with national typically sought overall responsibility for food forti- customs authorities, for example, than did its indi- fication efforts but lacked the political influence over vidual members. Noted Sablah, "Senegal's main oil policy formulation maintained by their Commerce producer, Suneor, has much more trouble lobbying and Industry counterparts. Moreover, MOHs rarely successfully in Senegal than if AIFO does so as a had staff expertise to take decisions about either oil group. There is unity among the producers in order production or legislation and regulation. to advocate for one's own interests in one's own state." Yet large members often had significant influ- ence in their home countries, and this benefited Individual Cooking Oil Producers AIFO as well by creating focal points around which the expectations and objectives of AIFO and other AIFO reported that its 14 members--the largest players coalesced.6 producers in the UEMOA zone--directly employed some 20,000 people and held CFA 500 billion in cap- Another motivation for AIFO's creation was to ital. There were two main scenarios that governed improve operational efficiencies and secure a stable how industry players might get involved with fortifi- base of raw material supply. Cotton, peanuts, and cation efforts, Baker said: "The government is doing palm were the three primary sources of oils in West its job or producers pressure government to do it. Africa. Improving public health was not part of Companies can go forward without government, but AIFO's agenda until several years after its founding. as long as no legal framework stating that fortifica- tion is good, companies open themselves to risk. Food legislation that allows fortification is not the Government Ministries and Agencies same as legislation that makes it mandatory. Here producers want a mandatory statement, but they are While the MOH was the government agency whose willing to do voluntary fortification. There's a liability mission most closely matched the objectives of food issue and there's a fear that rivals could slam fortified fortification, in practice the participation, assent, products with accusations of poisoning." and coordination of multiple other ministries and agencies were required to prepare for, regulate, and oversee the implementation of food fortification at Getting Started the country level. Ministries of commerce or trade oversaw import duties, customs regulation and Initial Studies enforcement, and regulated wholesale and retail distribution. Ministries of industry regulated the The elements that eventually comprised Faire production and refining of cooking oil, which was Tache d'Huile emerged as early as 2000. MI in 6. On focal points as the implicit locus of decision making and negotiations, see Thomas Schelling, The Strategy of Conflict (Cam- bridge: Harvard University Press, 1960). 7 2000 and 2001 funded population studies to help decision to adopt the lower, WTO tariff rates; (2) identify potential food vehicles for micronutri- the belief that joint action to lobby governments ent fortification. This involved mapping nutrient would be more effective than their individual ef- deficiencies and food consumption patterns to forts; and (3) the desire--at least among the stronger identify commonly consumed, inexpensive, and producers of the region--to capitalize on the pos- centrally produced food vehicles that could be eas- sibilities of intraregional trade created by UEMOA's ily fortified. Cooking oil proved desirable due to customs and monetary union. Recalled Tano, "Our its low cost, daily use in West African cuisine, and productivity was already low because factor costs-- low cooking temperatures (relative to Asia, where energy, logistics, and internal taxes--were high. repeated stir frying at high heat could break down Some taxes in Senegal were as much as 60%. So we the fortificant). MI in partnership with HKI also opposed the idea of reducing import duties." commissioned consultants to undertake industry assessments to determine which food industries To make its case, AIFO proposed that UC staff were capable of doing the fortification work. Pre- attend workshops and seminars on tax policy and paratory work was intense, and was not funded economics. Tano recalled that AIFO's advocacy by GAIN grants but was required from GAIN ap- was rewarded: "UEMOA took our advice and got plicants. Questions that needed to be answered in involved, and we developed a good relationship the preparation phase included: Was food fortifica- with UEMOA. In the process, our organization tion justifiable? Were local industries sophisticated became well known and involved in policy formula- enough to incorporate fortification technology tion. No UEMOA decision could be taken without into their production processes? our knowledge. Getting involved also increased UEMOA's visibility vis-à-vis member states." AIFO Government policy dictated whether and how food did not dictate policy, however. Tano fretted that could be fortified and certified, so any fortification AIFO long wanted to reduce UEMOA's value added initiative required thorough knowledge of the legal tax on oil products, but had no success until 2008, framework for fortification policy. In some coun- when rising food costs became a cost of living issue. tries legal permission was required to add fortifi- "Now we are in the process of reducing VAT to 5%," cants to food products, for example. With this in he said. mind, planners needed to consider whether an ap- propriate legal framework was in place for fortifica- A continent away, GAIN was launched in 2002 at a tion to proceed, and if not whether the appropriate United Nations Special Session on Children, with infrastructure could be developed easily. the goal of fighting malnutrition through public- private partnerships in affected countries. In Oc- tober 2002, HKI, MI, UNICEF, and WAHO--four Producers Coalesce NGOs that had already collaborated at country level for several years in preparation for regional food Separately, cooking oil manufacturers and refiners fortification--organized the first public-private sec- in 2000 founded AIFO, an industrial association tor dialogue on food fortification in West Africa in whose members shared (1) an anxiety over their Accra, Ghana to increase awareness of the advantag- individual exposure to cheap cooking oil imports es of food fortification in combating micronutrient from Brazil and Southeast Asia created by UEMOA's deficiencies. A follow up dialogue for countries not 8 attending the Accra meeting was held in conjunc- November 2007 as well as a regional logo for brand- tion with the ECOWAS Nutrition Forum in 2003. ing fortified foods. Separately, HKI's Baker helped catalyze industry interest in oil fortification by asking to present Meshing the Parts to AIFO on the subject once he learned of the group's existence in the course of his work on oil Interests fortification in Mali. At AIFO's general assembly of 2004, Baker gave a presentation on oil fortifica- The main challenge was designing a partnership tion to a receptive audience. The oil industry saw that satisfied the interests of all the various parties. not only the public health benefits of fortification, "These alliances are fraught with tension," noted one but also thought that fortification could success- observer. Sablah explained: "There are public in- fully differentiate their products from the cheap terests in strengthening public health and industry, (and unfortified) oil imports. AIFO moved at the creating jobs. Private interests are corporate social meeting to adopt a resolution supporting the for- responsibility and adding value to their product tification of all oil produced in UEMOA countries. in distinction to foreign imports of unfortified oil. According to the minutes, AIFO "recommended Fortification strengthens the producer alliance, it that the [AFIO] executive office undertake the strengthens UEMOA. The oil industry has a strong necessary steps with policy makers, being the regional association. You have to fortify." This fol- UEMOA Commission and the Governments of lowed the model used for flour fortification being our countries to have vitamin A fortification of oil expanded to ECOWAS. To effect change, a stake- adopted as standard practice within UEMOA and holder explained, "we need strong advocates at the to undertake communication campaigns targeted regional level. We link the cost of VAD and malnu- at the population to promote consumption of vita- trition to investment needs. We are also trying to min A-fortified oils exclusively." Individual AIFO remove import taxes on pharmaceuticals. Vitamin members supported regional norms as a means of deficiencies are no longer just a public health but promoting their products and expand intraregional now an economic issue as well. The Copenhagen trade. As Tano recalled, "I was the managing direc- Consensus made it one of the top issues." However, tor at Cosmivoire, and at the time we saw fortifica- advocacy was more complex in a context of high tion purely as a marketing opportunity, as a way to governmental turnover--when officials changed, promote the brand." the process repeated. In 2007, the second public-private dialogue in Ba- It was important to consider that all players could mako, Mali, saw the creation of a regional alliance also be highly complementary. WAHO's Ismael for food fortification that for the first time included Thiam explained: "The partnership is based on financial partners, a welcome development, noted comparative advantages. HKI have experts on the Baker: "Donors tended to be strongly risk averse ground, they also have expertise in VAD. WAHO and want clear validation of a program's potential tries to catalyze subregional activities. Ministers direct impact before they commit funds." The UC are informed. Our political mandate gives us an expert technical committee on standards approved opportunity to ask for information from Ministries and adopted standards for fortifying cooking oil in of Health. We have to show the private sector what 9 role they can play and that fortification is an oppor- National Fortification Alliances: ANF tunity to add value to their products and expand markets." National fortification alliances (ANFs, from the French acronym) brought together representatives Particular challenges emerged when all partners from public and private parties needed to par- agreed on the benefits of fortification, but were ticipate in fortification to supervise and promote competitors, as was the case for Unilever and Cos- ongoing cross-sectoral dialog on fortification. Only mivoire (more below). Originally Cosmivoire had actors participating in an ANF received support for wanted to fortify sugar, not palm oil, because it was fortification from GAIN. Each country set up its part of a group with a monopoly on sugar produc- ANF differently, often by presidential or ministerial tion in Côte d'Ivoire. Unilever was not involved in decree, or as an NGO. As such, the ANF was usually sugar production there. a multi-stakeholder private-public sector legal entity. However, one observer asserted that "The ANF is At the public sector level, HKI need to get authori- the result of good intentions that pave the way to ties involved and think about tradeoffs. For example, hell. While an ANF gives the private sector an op- the public sector lost money on making fortificant portunity to pressure the government for legislation, tax exempt. HKI and its experts worked to convince for standards, the forums tend to discuss issues government to get involved and accept that losing ad nauseum without taking decisions." Although some tax revenue is worth the gains made by fortifi- cross sectoral discussion could be done without cation. Many issues such as legislation, competition, the ANF as an intermediary, the ANF facilitated taxes, and tariffs were addressed by different depart- introductions and relationship building before ments whose staff and leaders needed to be enrolled actors interacted directly. Conflicts were never far and subsequently informed. "We need a common away. Oil producers could see the budget figures for view," a stakeholder explained, "which will lead to a fortification projects and therefore knew what to bid common understanding of the problem if we are to to win deals. make progress." Another potential lever was consumer associations. Launching Fortification: "We used to bring consumers associations to come in The Experience of Selected Countries order to have them sensitize consumers about the ex- istence and value of food fortification," Thiam noted, With an estimated average of 31% of its 235 million "so that they will look for and register the meaning of people living in towns of over 10,000 inhabitants, the logo. Consumers associations met in the Bamako West Africa was more urbanized that eastern and meeting of 2007. But consumer associations didn't do southern Africa.7 In 2005, West Africa produced 1.2 enough. At the country level, they don't know what million tons of palm oil. Average consumption was role to play. We are even involving the press." 7. "Africapolis: Urbanization Trends in West Africa 1950-2020," Agence Française de Développement, 2008, www.afd.fr/jahia/Jahia/Afri- capolis, accessed July 2009. 10 1.7 million tons, with average per capita consump- cost of fortification passed on to the consumer was tion of 6.3 kilograms per year.8 This compared to not high, about 5 CFA cents, or 1 U.S. cent, per collective 33 million tons produced by Indonesia, liter. Nevertheless, communications were key. The Malaysia, and Thailand in 2006.9 "At one point in communications component ranged a gamut of time Asia could not compete with West Africa," formats from formal advocacy, to elevator talks, to a Tano pointed out. "Now, in one week Asia out-pro- concerted media campaign, in West Africa on radio duces West Africa." and television in that order, as low literacy levels precluded the effectiveness of print media in the See Exhibit 4 for an overview of the state of imple- areas and populace most affected by VAD. mentation in francophone West Africa and Exhibit 5 for the state of oil fortification in West Africa According to David N'Dri, HKI Adbidjan, there outside UEMOA. Baker felt that Senegal should be were three major strategies: advocacy, social mar- the farthest along with fortification. "The industry keting, and communication/mobilization. Social is ready to produce," he explained, "but the bu- marketing was marketing the cause, not selling a reaucracy is glacial." Thiam agreed: "Advocacy of product. "We are selling a cause," he explained. "We fortification is facing a big bureaucracy in Senegal. use traditional marketing strategies such as TV, So far, the bureaucracy is winning." On March 5, radio, and commercials, as well as mixed marketing 2009, however, Senegal's president signed a decree tools and community participation and mobiliza- for mandatory fortification such as existed in Côte tion to raise the awareness on the benefits of forti- d'Ivoire and Mali. According to MI's Banda Ndiaye, fied foods." Selling a case required advocacy at many "In Senegal, we hope fortification will start within levels, N'Dri explained. "At the institutional level it three months. We also want to evaluate imports. We takes time for ministries to come to agreement and want to do a baseline survey too, to assess existing execute on their areas of responsibility. Typically, vitamin A and iron coverage, and we await funding the MOH took the lead in approaching the others for lab analysis." and urged them to get involved. Coordination also required discussions in the UEMOA Ministerial Examination of the fortification process in Mali and Council with heads of state as a Ministry of Health Burkina Faso follows a deep dive into the process agenda item. It involved the development of train- and outcome in Côte d'Ivoire, one of the most ing workshops for regional directors of health and advanced countries in terms of oil fortification, regional district directors, and finally an effort to beginning on page 14 below. reach social opinion leaders. A common logo for the fortified product was Telling the Story in the works. A West African logo would help consumer awareness about fortified foods and Regardless of location, consumer adoption was key their benefit to the health of children and moth- to the effort bearing fruit. It helped that additional ers. The target group would be the population at 8. Micronutrient Initiative, "Fortifying Africa's Future," (Johannesburg, South Africa: Micronutrient Initiative, 2006), p. 26. 9. United States Department of Agriculture, Foreign Agricultural Report, "Indonesia: Palm Oil Production Prospects Continue to Grow," Commodity Intelligence Report, December 31, 2007, www.pecad.fas.usda.gov/highlights/2007/12/Indonesia_palmoil/, ac- cessed May 11, 2009. 11 large and specifically those in the rural areas and ergistic rather than conflicting. One advantage of at greatest disadvantage. At the time of the case, regional effort was the ability to set out a regional the Côte d'Ivoire logo (see Exhibit 6) was adopted standard for practice, legislation, and certification. with some modifications for application on a Another was the ability to work directly from the regional basis. However, a number of obstacles start with regional institutions and a region-wide made its immediate use problematic. These ob- industry association to accelerate fortification stacles were in the process of resolution in order within individual countries and the region. A third to make the logo available for branding fortified was the impact of harmonized standards. The foods by the industry. challenge was in managing a large number of ac- tors all moving at a different pace. The advantage National governments tended to promote logos of national level effort was its easier focus and the their industries use, Baker explained, but it became ability to bypass the idling that regional coopera- clear at the regional level that myriad logos might tion typically entailed when some members were be counterproductive. Branding was important and less prepared or capable than others. should be considered at a pan-national level, he said. The topic was discussed at a conference in Dakar in Patrice Bosso in HKI's Abidjan office elaborated: February 2009 that brought together the UC and "The community based process is very slow. Oil WAHO plus technical representatives from UEMOA fortification started in 2007 and is to be completed member countries. "The UEMOA wanted a stan- by 2010. However, it took one year to develop the dard logo to be applied to any fortified product, re- regulatory framework. Member countries have gardless of industry or place of manufacture," Baker the ability to go faster, but once adopted at the explained. The conference was discussing what stan- regional level, it becomes compulsory for each dard to agree to. In addition to adopting a regional member country to adopt. The dilemma is whether logo to allow consumers to easily identify fortified to wait on adoption regionally or move early at the food products, it was proposed that UEMOA create national level." an additional mark indicating conformity with food fortification standards. Industry players were also Broadening HKI's regional efforts to the 15 interested in the use of the broader regional logo, ECOWAS states would follow, Baker added: Baker believed. "Working with the UEMOA Commission as a first step in the regional effort is ideal for moving the fortification agenda more easily to the broader Ongoing Challenges ECOWAS level." This was because a memorandum of understanding existing between the UEMOA Regional versus National Fortification Efforts and ECOWAS Commissions stipulated that ECOWAS would adopt standards established by Among the most vexing challenges HKI faced UEMOA. However, this meant harmonizing UE- was the complex question of whether and to what MOA standards with existing national standards extent to forge national effort into a regional level in Anglophone countries, such as Nigeria and initiative, and conversely how to use a regional ini- Ghana, ultimately facilitating intra-regional trade, tiative to accelerate national efforts. Helpfully, HKI with likely adverse consequences for the smaller viewed regional and national efforts as mostly syn- national level players. 12 Cross-Border Trade and Harmonization food producers bore in developing countries and help provide credit lines. Development banks, for The next big challenge for further efforts across the example, could be contacted for discussion on the region but also the broader continent was border establishment of a fund to support lines of credit for control. "There are 100 land border crossings in the cereal flour milling and vegetable oil industries West Africa," Baker explained, "versus a strategic and other private sector players. Banks could enter number of ports. This is the advantage of a regional a partnership with GAIN or HKI to establish such a approach: you don't have to police the land bor- funding mechanism for the private sector's fortifica- ders with anything like the same level of scrutiny tion effort. The major concern of the private sector as otherwise." Common external tariffs could for was carrying an inventory of micronutrients that example limit smuggling and impose more stan- tied up cash flow at a time when working capital dards. The borders, however, remained porous and was particularly tight. enforcing such standards tenuous. "The big issue is import control of competing fortified products," Baker explained. "When I first arrived five years ago, global premix procurement facility village markets in Senegal mostly carried Senegal- produced oils and palm oil producers were more Micronutrient fortificant (premix) was the largest local. Today we see products from other countries." recurrent input cost for large-scale mass food fortifi- cation programs. Procuring this premix was not Furthermore, for uniformity it was recommended without complications: access to suppliers; inflated that all countries use the same units of measure- prices; access to upfront capital for large purchases; ment in their fortification standards, preferably lack of quality assurance and monitoring of deliv- mg/kg, since vitamin A premix was measured in ered products; and, often, the lack of funds. those units. As part of the harmonization, it was also important that the fortified products be labeled Some observers suggested that GAIN had a strong with the same units--either mg, IU, or RE (retinol comparative advantage in designing, managing and equivalents)--to indicate the levels of added nutri- operating a Global Premix Procurement Facility. ent included. This would make comparison of nutri- The food fortification efforts that GAIN supported ent levels in products from the different countries were already establishing large new markets for easier. Even as a result of the harmonization, in the premix industry and would continue to do setting standards for vitamin A, the other sources of so with the addition of a new Infant and Young vitamin A in the diet of particular country had to be Child Nutrition Program and the GAIN­UNICEF taken into consideration. Universal Salt Iodization Partnership Project that supported the creation of a revolving credit facility to local millers and vegetable oil refineries to access Making Things Easier fortificant. The cost of micronutrients premix corre- sponded to US$1.00 to US$5.00 per ton of fortified a credit line food and generally represented between 0.5% and 2% of the cost of the final product. However, for Some observers believed that proponents of food companies fortifying large amounts of food, premix fortification should assume some of the risks that cost could hamper cash flow. 13 Developing such a facility would require identify- for their brand: "The fortification idea came from ing milling and refinery production capacity and HKI. We at Cosmivoire saw it as a marketing op- market size; analyzing the cost of purchasing food portunity. At first it was a question of marketing, a fortificant relative to each producer's productive way to promote the brand. But it has been a process capacity; assessing the capacity of GAIN suppliers of development. The common market was not yet to meet the demand for fortificants in each targeted implemented and [producing oil fortified with] country; and reviewing distribution channels and vitamin A cost slightly more. At the time we gave it the capacity to receive fortificants on a regular basis two years, one year to convince, one year to imple- to meet production levels. ment." The goal was to be able to provide 80% of the population with access to fortified oil by 2008. A Country Case Study: Côte d'Ivoire Public Participation: Setting and Running the Côte d'Ivoire, with about 19 million people sharing ANF (Association Nationale de Fortification) 322,462 km2, bordered Liberia and Guinea to the west, Mali and Burkina Faso to the north, Ghana Patrice Bosso, HKI Abidjan, elaborated: "Cos- to the east, and the Gulf of Guinea and the Atlantic mivoire had a marketing concept: cholesterol free Ocean to the south. The economy relied heavily on cooking oil. No social dimension existed in their agriculture, with smallholder cash crop produc- thinking, it was just a marketing strategy. And tion being dominant. Côte d'Ivoire was prescient in there was no public participation." The idea of pub- pushing for food fortification. Salt iodization had lic-private collaboration in the region was raised by begun in 1985, for example, and a 1998 a presiden- WAHO and HKI at Accra's 2002 first public-private tial decree mandated that oil be fortified. The Ivoir- sector regional dialogue on food fortification. ian standard for oil fortification is 25-30 interna- There was also an opportunity: in 2003 the Ivoirian tional units (IU) per gram, which provided 30% of MOH tendered bids to raise funds for fortification recommended daily allowance of vitamin A. of oil and flour at the national level. HKI supported the proposal and approached GAIN in 2005 for its support. As a result, Côte d'Ivoire received money The Players for the food fortification in what was called the PIPAF project. Unilever began voluntary fortification of oil in 2001, well before other AIFO producers. However, Public actors also converged in the creation of the both Unilever and Cosmivoire (Côte d'Ivoire's two Ivoirian ANF in 2003 as part of GAIN's first round leading oil producers) participated in the 2004 of fortification funding to developing countries. It AIFO general assembly where Baker presented. The was important to note that GAIN did not suggest meeting changed their view: fortification was no nor mandate that ANF be set up. "They gave us longer seen as a pure business situation. Even so, conditions for GAIN funds to be released for man- despite the enthusiasm at the AIFO level, Tano re- agement by the ANF," ANF Secretary General Pierre membered that he and his colleagues at Cosmivoire Gagne said. "GAIN told us how the funds were to did not see fortification as a public health benefit. be managed: for funds to be released, the country Rather, they viewed fortification as a marketing tool needed to create a forum of government, industry, 14 civil society, and development partners (WHO, on capitalizing the achievements to date. "When UNICEF, World Food Program). The forum should we created the fortification logo we made sure the elect a general assembly and establish a structure to alliance would take ownership and take it to others. conduct operations. We decided on a structure. The Alliance members presented the logo at a UEMOA government expressed willingness to reduce tax on meeting, for example." Finally HKI helped make fortificant. We elected the MOH to head the ANF, members responsible for action. unanimously. All the members were busy in their own businesses but we needed structure in charge According to ANF Secretary Pierre Gagne, Côte of matters on a daily basis." The ANF decided that d'Ivoire's ANF general assembly met every six months HKI should be implementing the project under the to discuss the status of fortification implementation. supervision of GAIN. In the process, GAIN picked In some instances, extraordinary meetings might be HKI to manage the money so that HKI wore a called as had been the case to consider, design and double hat in Côte d'Ivoire, as implementing agency approve the "caravan," a truck that traveled through- and manager of GAIN funds. Bosso, from HKI out Côte d'Ivoire presenting information on food Abidjan, actually saw three roles for HKI in Côte fortification to out of the way inhabitants. d'Ivoire: legal framework, capacity building, and coordination of action. The general assembly usually considered two items, namely the daily operations of the ANF and HKI's Headed by a political appointee from the MOH, implementation status, and was the body that made few believed the ANF had reached its full potential. major decisions. If a newcomer wanted to join However, it was very hard for anyone to withdraw the ANF general assembly, the assembly decided from the group, as doing so created the impres- based on the recommendation of the Scientific and sion that the withdrawing party has no concern Technical Committee. In terms of reporting, Gagne for public health. "We get in touch with each ANF and the Minister of Health signed general assem- member to make sure they respect their com- bly minutes for submission to GAIN and approval mitments. Also studies and experience is shared," of HKI reports. GAIN usually did not ask for the HKI's David N'Dri explained, "and so are studies report but worked via HKI to make their audit or from different countries. We've supported alliance gather information. "GAIN is supposed to report members to attend conferences on fortification. to ANF on meeting with the implementing agency," The major idea was to maintain alliances. Also, it's Gagne pointed out, "but they never have. HKI will a way to show that all players will gain something. tell us that GAIN is here in Côte d'Ivoire. We won't To do the organizing, we started advocacy to get otherwise know." in touch with the various organizations relevant to the alliance. We also convinced the public authori- The ANF permanent secretariat had a structure ties to issue a decree to establish the ANF." This with technical and scientific committees, among required one on one meetings to convince all others, which brainstormed issues once a month. partners to join the alliance; HKI created these HKI funded them per the agreement. "If we wait for opportunities. "The more they meet, the more the government to fund it would never happen," Gagne alliance is alive. HKI capitalizes." HKI also helped explained. "On paper we have 12 people but only 4 identify international events and get members actually exist. We have no fuel. Government lacks interested in taking part and focused members the means to equip the secretariat. Government has 15 passed laws but is losing money (in taxes) because without a legal framework. It took one year." In the of it. It was not easy." end four ministries--of Health, Industry, Com- merce, and Economy and Finance for the prime minister--signed an agreement into force. The next Institutional Framework: The Ground Rules stage was to have a presidential order issued, fol- lowed by new legal frameworks, for salt iodization, A second element of fortification in Côte d'Ivoire for example. The Ministry of Economy and Finance was to build the capacity of control institutions: signed the decision for tax exemption of inputs used labs, offices of the directorate of quality promotion for fortifying. The Customs director also signed and standardization, and the various ministries. and enforced the implementation orders barring The Ministry of Commerce had to control illegal imports of unfortified oil and flour. oil, fight fraud, enforce compliance with fortifica- tion rules, and monitor the market for food safety Other agencies were involved too: the National issues. The Ministry of Commerce and the Min- Public Health Laboratory sampled in the field to istry of Industry were two distinct institutions in verify compliance with parameters and the MOI Côte d'Ivoire. The Ministry of Industry monitored Office of Promotion of Quality and Standardiza- factories. At the time, explained HKI Abidjan's tion performed inspections. "Each one comes and Bosso, "there was no legislation regulating factory expresses their work conditions and concerns about quality, but under the fortification system, firms operations," Gagne noted. "All are under the ANF had to agree to accept Ministry of Industry check- permanent secretariat and forward the results to ers. Minimum consensus was reached on the level HKI as implementor. HKI is in charge of executing of fortification although the industry's wish was to on those concerns. HKI gets funded for this." do production and raw material checks only. The Ministry of Industry wanted to check everything in every plant, but industry refused because it was Outcome already producing at ISO 2000 and Côte d'Ivoire fortification standards." New entrants had to be at The project started in 2005, though with an existing that standard too before they could start fortifica- 55% coverage rate for Ivoirians, thanks to Uni- tion. "This is an example of consensus: loss and lever's preexisting oil fortification. At the time the gain to both sides. Industry agreed to MOI inspec- country's civil unrest was ebbing, but the country tions every three months but now they are every remained effectively split in two between north two months. MoI samples the premixed fortificant and south. Despite years of upheaval, four different and the final product. Industry conceded to MOI ministers signed the document decreeing manda- inspections. MOI agreed to the process. We have tory oil fortification. not seen any implementation problems." Production data from 2007 indicated that Unilever Finally, the Ministry of Economy and Finance had had capacity to produce 100,000 metric tons of to be involved to manage some grant money and palm oil, and Cosmivoire could produce 80,000 the tax exemption process. Getting all these pieces tons of palm oil. United Oil Company (UOC) was together Bosso said, was "the hardest part. GAIN's set up in 2006 and began fortification in 2007, with position was that there would be no more funding a theoretical capacity of 40,000 tons. Trituraf, a 16 small producer of cottonseed oil, closed due to lack catalyst. With too many people involved, conflicts of raw material in the face of prices for cottonseed of interest abounded: industry saw the budget for that were exceeded by the cost of production inputs. the project and hence knew what to bid; or there Trituraf was attempting to reopen in early 2009. was poor clarity around ANF's role, as oversight or implementer. One third of Côte d'Ivoire production was exported. Cosmivoire exported to Benin and Togo, Unilever exported to Mali, Burkina Faso, and Niger. Major Country Vignettes: agribusiness player Olam was a shareholder of Cos- Mali and Burkina Faso mivoire, and bought unrefined oil for local process- ing. From early 2007 unrefined oil prices rose 40%, Mali increased finished prices in 2008. context To educate Ivoirians about the benefits of food for- tification, the caravan had put on shows throughout The seventh largest country in Africa and among Côte d'Ivoire to reach audiences as diverse as army the poorest in the world, Mali was a landlocked leaders and local chiefs, among others. Reaching the nation, bordered by Algeria on the north, Niger most remote areas was essential according to N'Dri, on the east, Burkina Faso and the Côte d'Ivoire on because "not easily reached people are the most the south, Guinea on the south-west, and Senegal important to reach. Such an effort involved a team: and Mauritania on the west. Its size was just over HKI, a communications agency, the national nutri- 1,240,000 km² with an estimated population of tional program, and the ANF office." The outreach almost 12 million people. Mali's borders on the also involved public puppet shows, public criers, or north reached deep into the middle of the Sahara "griots," as well as short speeches from prefects, the Desert, while the country's southern region, where ANF, nutrition program staff, artists, and humorists. the majority of inhabitants lived, featured the Niger These GAIN-funded efforts were to be completed by and Senegal rivers. Agriculture and fishing were key August 2009. economic and social pillars, although the country also had gold, uranium, and salt resources. In terms of process, some saw tensions. "The private sector was unhappy with the ANF because it took a long time to arrive at decisions," explained a re- process searcher familiar with the situation. "There was too much discussion. Non-primary role people inter- A key challenge in Mali was getting the consumer vened in areas they didn't know anything about. For organizations onboard. The power of consumer or- example the person in charge of communications ganizations varied across countries but in Mali they prepared a promotion campaign for fortified oil, but were strong and tended to be hostile to imported the Ministry of Health intervened about fashioning products and highly protective of the consumers. the message. They'd get bad advice, have to report The goal here was to head off the misperception back to the group; it took up time and accomplished that fortified products were somehow suspect and nothing." More generally this researcher believed should be avoided. Beyond that the power of a that ANFs might be a roadblock as much as a consumer organization could be harnessed to serve 17 as strong advocates for the cause of fortification in the region in Mali. HUICOMA was the country's and more generally to promote a particular product biggest industry, but it is now barely functioning." among consumers. On the positive side, the fact that HUICOMA; the largest oil producer in the country produced cooking oil in Mali and fortified Burkina Faso it with the blessing of the government meant that the issue was not entirely novel. In addition, since context the oil was locally produced, Mali's anti-import sen- timent could not be channeled against this cause. Like Mali, Burkina Faso was landlocked, surround- ed by Mali to the north, Niger to the east, Benin to the south east, Togo and Ghana to the south, and outcome Côte d'Ivoire to the south west. Its 13 million people lived in 274,000 km². Burkina Faso was the leading Overall the edible oil industry had seen major ups cotton producer in Africa. World Bank subsidies and downs in part because of massive price fluctua- and recommendations had encouraged Burkina tions in the movement in other commodities. For Faso's focus on the crop at the expense of peanut example, Mali's major oil producer, a parastatal in oil production. (Palm plantations for palm oil the process of being privatized, came under pres- were sited only along coastal Africa.) Domestically sure when a crash in cotton prices led to a drop produced oil met only about 40% of Burkina Faso's in production, reduced the supply of raw materi- demand, reflecting a sharp decline in cottonseed als and raised demand for imports of palm- and availability. Access to cottonseed depended on the peanut-based cooking oil. The demise of the state local cottonseed associations. There were 250,000 monopoly also meant that output was now divided tons of cotton seed available for the year, of which among several producers. In early 2009 Unilever in 80,000 tons were reserved for SN-Citec (Citec), the Côte d'Ivoire was exporting oil to Mali. There had country's major oil producer, and 85,000 tons for also been institutional tensions. Observers reported smaller, less efficient firms. Much of the country's that the head of the oil company was original skepti- cotton was exported for clothing. cal about the effort, and the fact that the effort was driven by the Ministry of Health, a relatively low Established in 1941, Citec in 1995 had invested priority ministry, did not help drive policy. CFA 12 billion in new U.S. production technology to increase capacity and modernize. The process According to AIFO president Bintou Diallo, Mali was unusually efficient, permitting Citec to generate had been a major cottonseed producer, with capac- 95% of the power that it consumed for production ity three times that of neighboring Burkina Faso. from otherwise unused cottonseed husks, and to However, due to cheap Asian palm oil imports and produce protein-rich pelletized animal feed with the unavailability of domestic cottonseed, Mali in husks and cake created as a byproduct of the oil 2008 did not produce even 10,000 tons. "They are production process. Citec was the first plant in flooded with Asian oil. They moved to sunflower oil, West Africa to install the process. At the time of the brought in peanut oil, but it was hard to produce case Citec processed about 120,000 tons of cotton up to capacity for several years in a row. We didn't seed per year, yielding 20,000 tons of oil. While this expect this situation. Fortified oil was first launched made Citec Burkina Faso's leading oil producer, it 18 was still small by regional standards, where plants consumer was CFA 5 cents, or one US cent per liter yielded 40,000-45,000 tons of oil per year. Burkina's of oil, an amount that observers and participants in production of all fats (butter and oil) was 70,000- the process expected consumers could easily bear. 75,000 tons per year, of which vegetable oil com- About 70%-80% of the market would have access to prised 40,000-45,000 tons. Number two company fortified oil by 2010. While Citec president Bintou Josira produced some 7,000 tons of oil annually. Diallo noted that social marketing by the MOH in Small scale artisanal producers contributed limited the media had been effective in boosting consumer quantities as well. The remaining oil on the market awareness, "since fortification has became manda- in Burkina Faso was palm oil imported from Côte tory, it is irrelevant in the end anyway." d'Ivoire and Malaysia. Unfortunately, in February 2009, Diallo had the sad task of announcing layoffs and planned to shut- process ter Citec for four months of 2009, far longer than the typical annual one-week shutdown for clean- Baker and other observers believed that having the ing and maintenance. Citec expected only 100,000 MOI leading fortification in Burkina Faso instead of tons of raw material in 2009. Citec hoped to secure the MOH was more effective because food fortifica- another 20,000 tons through a different association tion was primarily an industrial issue at the imple- of Burkina cotton producers. Failing to produce to mentation level. The results improved public health, capacity could cost Citec as much as CFA 300 mil- but the measures needed to get the program going lion (150,000) in lost discounts on raw materials. were closer to industry's needs and related to their Citec's operations manager explained, "Cottonseed challenges in the market and in regulatory issues. In needs to have a 21% oil content. If suppliers offer Burkina Faso the MOH had been a somewhat more us cottonseed with 20% less than that, we pay them difficult bureaucracy, Baker explained, very inter- less for it. There are moisture parameters too, and ested in getting funding for projects but unwilling additional discounts for substandard cottonseed. to commit the necessary resources to put them into Fiber content must be 11% and there are acidity action. In addition, Burkina's ANF was considered requirements as well. All of these factors affect less effective than others in the region. what we will pay for cottonseed. However, now that the quantity of cottonseed in the market is limited, Citec can no longer force discounts on suppliers for outcome lower quality cotton because we are lucky just to buy what we can. Regardless of cottonseed quality, Citec began selling fortified oil in May 2008. In early however, our refined oil must meet fixed standards." 2009, 100% of Citec's oil was fortified with vita- Insufficient cottonseed supply meant that Citec min A. The cost of fortification at Citec was as yet would face substantial oil imports in the Burkina unclear, because HKI had been financing Citec's for- marketplace. Though Diallo was quick to protest tificant purchases indirectly, and Citec would only the share of the West African market captured by begin taking full responsibility for its fortificant imports from Brazil and Southeast Asia, Citec's in- purchases in November 2009. The company added ability to meet demand offered no other choice. 60 IU of vitamin A per gram of cooking oil, and la- beled its oil as such. Total cost of fortification to the 19 Exhibit 1. UEMOA--West African Economic and Monetary Union 20 Exhibit 2. Estimated VAD incidence and child deaths, Sub-Saharan Africa, 2004 Sub-clinical VAD in children Annual number of child Country under 6 years of age (in %) deaths from VAD Angola 55 34,000 Benin 70 9,000 Botswana 30 500 Burkina Faso 46 20,000 Burundi 44 8,500 Cameroon 36 10,500 Central African Republic 68 5,000 Chad 45 12,500 Congo 32 1,500 Congo Democratic Republic 58 96,000 Eritrea 30 1,750 Ethiopia 30 51,000 Gabon 41 450 Gambia 64 1,000 Ghana 60 12,000 Guinea 40 8,000 Guinea-Bissau 31 1,750 Kenya 70 23,500 Lesotho 54 1,100 Liberia 38 5,000 Madagascar 42 13,000 Malawi 59 17,500 Mali 47 24,000 Mauritania 17 1,500 Mozambique 26 14,000 Namibia 59 500 Niger 41 26,000 Nigeria 25 82,000 Rwanda 39 9,500 Senegal 61 9,500 Sierra Leone 47 13,250 South Africa 33 6,000 Swaziland 38 600 Tanzania 37 -- Togo 35 3,250 Uganda 66 29,000 Zambia 66 19,000 Zimbabwe 28 4,900 Total Source: The Micronutrient Initiative, "Vitamin and Mineral Deficiency: National Damage Assessment and Protec- tion Audits, 2004," (LOCATION: Micronutrient Initiative and UNICEF, 2004), p, 2, 21 Exhibit 3. Estimated annual economic losses due to VAD and other vitamin and mineral deficiencies (percent of GDP) Country Percent of GDP loss US$ estimate in $000s (2004) South Africa 0.4 851.1 Nigeria 0.7 504.7 Kenya 0.8 124.8 Botswana 0.6 51.9 Mozambique 1.2 66.5 Zambia 1.3 70.1 Malawi 1.4 25.3 Guinea-Bissau 1.5 4.2 Source: Micronutrient Initiative, "Fortifying Africa's Future," (Johannesburg, South Africa: Miconutrient Initiative, 2006), p. 3. Exhibit 4. State of implementation in francophone West Africa Burkina Côte Guinea- Action Benin Faso d'Ivoire Bissau Mali Niger Senegal Togo Nutrition policy on food fortification Nutrition status assessment Food vehicle identified National alliance established Identification of site within industries Identification of equipment needs Establish standards Launch fortified foods Logo for branding fortified foods Social marketing/logo for branding Monitoring and evaluation Impact evaluation 22 Exhibit 5. State of oil fortification in West Africa non-UEMOA Sierra Cape Action Ghana Guinea Nigeria Gambia Liberia Leone Verde Nutrition policy on food fortification Nutrition status assessment Food vehicle identified National alliance established Identification of site within industries Identification of equipment needs Establish standards Launch fortified foods Logo for branding fortified foods Social marketing/logo for branding Note: No large-scale cooking oil manufacturing existed in Guinea. Normally, refined cooking oil was imported and repackaged for domestic sale there. Exhibit 6. Côte d'Ivoire's oil fortification social marketing and logo 23 Exhibit 6, continued. 24