Implementing large-scale food fortification in Ghana: lessons learned.

Food fortification began in Ghana in 1996 when legislation was passed to enforce the iodization of salt. This paper describes the development of the Ghanaian fortification program and identifies lessons learned in implementing fortification initiatives (universal salt iodization, fortification of vegetable oil and wheat flour) from 1996 to date. This paper identifies achievements, challenges, and lessons learned in implementing large scale food fortification in Ghana. Primary data was collected through interviews with key members of the National Food Fortification Alliance (NFFA), implementation staff of the Food Fortification Project, and staff of GAIN. Secondary data was collected through desk review of documentation from the project offices of the National Food Fortification Project and the National Secretariat for the Implementation of the National Salt Iodization in Ghana. Reduction of the prevalence of goiter has been observed, and coverage of households with adequately iodized salt increased between 1996 and 2006. Two models were designed to increase production of adequately iodized salt: one to procure and distribute potassium iodate (KIO3) locally, and the second, the salt bank cooperative (SBC) model, specifically designed for small-scale artisanal salt farmers. This resulted in the establishment of a centralized potassium iodate procurement and distribution system, tailored to local needs and ensuring competitive and stable prices. The SBC model allowed for nearly 157 MT of adequately iodized salt to be produced in 2011 in a region where adequately iodized salt was initially not available. For vegetable oil fortification, implementing quantitative analysis methods for accurate control of added fortificant proved challenging but was overcome with the use of a rapid test device, confirming that 95% of vegetable oil is adequately fortified in Ghana. However, appropriate compliance with national standards on wheat flour continues to pose challenges due to adverse sensory effects, which have led producers to reduce the dosage of premix in wheat flour. Challenges to access to premix experienced by small producers can be overcome with a central procurement model in which the distributor leverages the overall volume by tendering for a consolidated order. The SBC model has the potential to be expanded and to considerably increase the coverage of the population consuming iodized salt in Ghana. Successful implementation of the cost-effective iCheck CHROMA rapid test device should be replicated in other countries where quality control of fortified vegetable oil is a challenge, and extended to additional food vehicles, such as wheat flour and salt. Only a reduced impact on iron deficiency in Ghana can be expected, given the low level of fortificant added to the wheat flour. An integrated approach, with complementary programs including additional iron-fortified food vehicles, should be explored to maximize health impact.