Local and centralised therapeutic food production

Smaller scale production of RUTF in Malawi

Summary of editorial¹

An editorial in 'Maternal Health and Nutrition' explores some of the issues around local versus centralised control of food production for treatment of severe acute malnutrition. The discussion draws parallels with debates that raged over 20 years ago about home (local) production of oral rehydration salts (ORS) versus the supply of pre-produced (centralised) ORS packages.

The editorial starts with the premise that with community-based management of acute malnutrition (CMAM) scaling up nationally and internationally, the demand for Ready to use Therapeutic Food (RUTF) is rising and the challenges for local production are changing. While small-scale RUTF production can easily supply local feeding programmes, considerable changes are necessary to provide for a country's or a region's needs. Factors such as quality control become increasingly important. Not only must the final product be quality monitored, but also some international manufacturing standards must be provided for, e.g. being able to trace each batch of raw ingredient to the original supplier. Such standards are, of course, expensive and require a level of capital and logistics that are not always straight forward in the countries where severe acute malnutrition (SAM) is prevalent. Thus, while delivery is decentralising over time, there is increasing pressure to centralise and control production.

The editorial raises a number of questions:

• RUTF production in local factories will not have the same specificity/formulation concerns as home ORS, although other quality concerns may remain. What level of quality control would be appropriate and acceptable?
• RUTF production would be in the hands of individual organisations or companies. What would the nature of these be? And how closely would they link to, and benefit local communities?
• Local RUTF producers might still be under pressure both to compete with each other and with large-scale central producers. What would the optimal size of a local production unit be and how would that be determined? In practice, how could a more regulated market reward not just price but other factors, such as sourcing local ingredients and supporting local farmers?
• If local producers experimented with new local recipes, what level of evidence should be demanded to show they are clinically effective? Is RUTF a food (having to adhere to food standard regulations) or a medicine (having to adhere to much tighter and more complex clinical regulations)?

Smaller scale production of RUTF in Malawi

A search of the literature found no published study comparing in detail the costs and benefits of smaller-scale local versus larger scale foreign production. Certainly, no study available has attempted to value the broader social impact of local versus international production. The editors also ask what lessons can be learnt from the ORS experience. According to the 2003 Lancet Child Survival series, population coverage of ORS therapy was only 20%, yet universal coverage could have prevented 1,477,000 child deaths per year (15% of the total of child deaths). Clearly, the centralised mode of ORS production and distribution did not achieve the necessary coverage -perhaps there may have been a different outcome with greater emphasis on local home-made ORS.

It is asserted that if the argument for RUTF production were to be made on economic merits alone, even in the absence of 'hard evidence', it is probable that local production would be the preferred option. Centralised production affords economies of scale that place downward pressure on prices. However, if production takes place mostly in high-income countries, much of that benefit risks being eroded by transporting the finished product to low and middle income countries and the higher cost of production inputs (land, labour, capital and entrepreneurship). Furthermore, a simple 'price based' argument neglects the broader economic benefits of producing some quantity in low income countries, i.e. increased employment levels bring a greater opportunity to gain skills and earn a cash wage.

The editorial concludes that public health strategies are not, and should not be, based on economic principles alone, even principles with a possible developmental bias. Quality standards and the need for a ready and substantial supply of RUTF at short notice are just two reasons why this debate cannot be entirely polarised. Current realities must be recognised. The optimal solution is likely to lie in a balance that evolves with time, with the nexus of production shifting gradually south. This will require both support and vision by the international community, local governments and participating organisations in SAM-affected countries.

¹Skordis-Worrall. J and Kerac. M (2009). Localised or centralised control of food production for treating severe acute malnutrition: echoes of a past child survival revolution? Maternal and Child Health (2009), vol 5, pp 195-198