About 200 schoolchildren settled in a phalanx with disposable plates and spoons on a green carpet at the primary school in Vatika village near Jaipur, the capital of Rajasthan. Giant vats arrived a little later with savoury ‘kichri’ (rice and lentil porridge), which was served to the kids. It was through this event that the state launched its food fortification drive.
The high prevalence of anaemia and malnutrition in Rajasthan – 79 per cent of children between 6 to 35 months are malnourished, while 53.8 per cent ever married and 61 per cent pregnant women suffer from anaemia (as per the National Family Health Survey-3, 2005-2006) – has been an issue of concern. It was in his speech, during the presentation of the state budget in 2010-11, that Rajasthan Chief Minister Ashok Gehlot first talked about his government’s intention to move in this direction. Fortification was introduced, as a pilot project in 11 districts in February 2010. Two years later, in February 2012, Rajasthan became the first state in India to introduce fortified food items in the open market.
Explains J.C. Mohanty, Principal Secretary of Rajasthan’s Food, Civil Supplies & Consumer Affairs Department, “The government has entered into a tripartite agreement with Unicef and the Indian Institute of Health Management Research (IIHMR) to do this. The arrangement is for the technical upgrade of flour mills (we want to have the best mills in the state), quality control, as well as large-scale information, education and communication (IEC) activities. We also want to have an impact evaluation of the intervention through the public distribution system (PDS).”
According to Mohanty, in January 2012, 78,589 metric tonne of wheat was ground into fortified flour in 65 mills across Rajasthan and 7.46 million 10-kilo bags of flour were distributed through fair price shops.
Although he is optimistic about the outcome of this exercise, Mohanty points out that it was a challenging intervention given existing infrastructure. “When we first launched it, we had our share of hesitations. Flour is a perishable food item and we were apprehensive over whether we could make it available in fair price shops before its use-by date expires, and whether people would accept it,” he says.
The Rajasthan State Food and Civil Supplies Corporation (RCSC) was created in December 2010 to outsource the washing, cleaning, grinding and fortification of the wheat to roller mills, and quality control was outsourced to eight National Accreditation Board for Testing and Calibration (NABTC) laboratories. According to Mohanty, the RCSC has a monthly turnover of Rs 500 million, “The cost of wheat is Rs 6.40 (US$1=Rs 49) per kilo for families above the poverty line (APL), and we are providing them fortified flour in a 10 kg bag for Rs 81. This means, that for less than two rupees a kilo, we are adding micronutrients to the staple.” There are 10.79 million APL card holders and 18,27,152 BPL families under the PDS in the state.
Associated with this intervention is the Jaipur-based IIHMR. “Our brief is to demonstrate the feasibility of providing fortified food through the existing system and then gather evidence to show how it impacts anaemia levels,” says Dr S.D. Gupta, IIHMR director. IIHMR, he adds, is a research institute, and that is what makes this project unique. “It’s for the first time that a research body has been roped into such a project. We have to also build capacity, train mill owners and their staff and provide them with equipment for fortification and quality assurance. We have given them micro feeders used for mixing the premix into the ground flour, and an entoleter to spin flour at very high speeds to rid it of any impurities,” he elaborates.
According to Dr Dhirendra Kumar, Project Director of IIHMR’s Project Management Unit, fortified flour will be widely available in grocery shops and food superstores in a couple of months. “Over the next year, 200,000 metric tonne of fortified flour will be supplied in the open market and the target is to cover 50 per cent of Rajasthan’s population in five years,” he reveals.
The question often asked is whether fortification is required when supplementary nutrition programmes are already running in the country for many decades. In response Dr Gupta points out that prophylactic oral iron supplementation only maintains the available haemoglobin level, but doesn’t increase it. “Pregnant women are most susceptible to iron deficiency anaemia. In fact, most of them enter into a pregnancy
with high levels of anaemia. Also, going by existing evidence, the iron and folic acid tablets supplied through the anganwadi network are often not taken – only 60-70 per cent women are regular with the pills. In such a context, a food-based, cost-effective approach could be one way forward.”
Food fortification as a strategy to counter nutritional deficiencies has already notched notable success. The universal iodisation of common salt is regarded a successful public health programme, which has gone a long way in addressing iodine deficiency disorders.
The whole idea behind fortifying food commodities like salt and, as in Rajasthan’s case, wheat and oil, is that these foods are universally consumed by all population groups and are therefore the best vehicles for a broad-based intervention.
Fortification has its critics. Ashok Khandelwal, who has been associated with the Rozi Roti Adhikar Abhiyaan, or Right to Food campaign, in the state, believes fortification will only work when there is already sufficient intake of cereals and pulses. “The question of malnourishment is not a question of lack of micronutrients; it’s related to starvation, a complete lack of adequate food,” observes Khandelwal, who is an advisor to the Supreme Court Commissioners in the Right to Food case.
Professor V.S. Vyas, member of the economic advisory council to the Prime Minister and deputy chairperson of the Rajasthan Planning Board, however, is of the view that fortification is a useful initiative “not only because it enhances nutrition levels but will also check pilferage of foodgrain by fair price shop owners”. Fortification can help check pilferage because unlike PDS wheat, which is often pilfered and diverted to the open market, flour can’t either be diverted (because there’s no demand) or pilfered because it can’t be hoarded (it will perish) to be sold later.
What will be the impact of this ambitious programme? For that we will have to wait a little longer. After a period of one-and-a-half years, the IIHMR is to develop a research model in two village blocks in Pratapgarh district that will compare consumers and non-consumers of fortified food items to see whether the intervention has actually improved haemoglobin levels, reduced low birth weight prevalence, and brought down the disturbingly high number of maternal and newborn deaths in Rajasthan.