Trials and tribulations of local RUTF producer in Haiti

By Steve Taviner

Steve is Development Director of Meds & Food for Kids (MFK) based in St Louis, USA. Before taking on this role, he spent the last 15 months overseeing MFK operations in Haiti, including coordinating the earthquake response. He holds a Masters in Social Work.

Thanks go to Thomas Stehl, Coordinator of Operations, and Patricia Wolff, Founder and Executive Director of MFK, who both provided valuable input for this article. We collectively extend our gratitude to all of the partners, donors, volunteers and staff who share and support our vision, and most importantly to the citizens of Haiti, whose courage and spirit help turn adversity into opportunity.

This article presents Meds & Food for Kids, an independent local producer of therapeutic and supplementary foods in Haiti, and its pursuit of accreditation as a manufacturer of Ready to Use Therapeutic Food and acceptance in international supply chains. This story serves as a backdrop to a wider conversation on the viability of the national production model for Ready to Use Foods, and the obstacles and opportunities that are present for specialised manufacturing in developing world contexts.

Meds & Food for Kids (MFK) is a social benefit enterprise that is dedicated to preventing and treating malnutrition in Haiti's vulnerable populations, especially its children. It was founded in 2003 by Dr. Patricia B. Wolff, an American paediatrician based in St. Louis, Missouri, after many years of working in Haiti and witnessing the plight of its children.

In 2001 and 2002, Dr. Wolff travelled to Africa to visit Dr. Mark Manary, a fellow St. Louis resident and colleague at Washington University School of Medicine, and his Ready to Use Therapeutic Food (RUTF) project in Malawi. Witnessing first hand the benefits of not only using RUTF to treat acute childhood malnutrition, but also of the intention of producing it in the country of use, Dr. Wolff took this model to Haiti, introducing both the product and the idea of national production.

MFK is now both a U.S. not-for-profit organisation and a registered non-governmental organisation (NGO) with the Haitian Ministry of Planning. Its offices are based in St. Louis, Missouri, and its production facilities are located in Cap Haitian, in northern Haiti. MFK's RUTF (called "Medika Mamba" in Haitian Creole, meaning "Peanut Butter Medicine") is made in Haiti, employing Haitians, and, where possible, using Haitian raw materials. MFK is reimbursed for part of the production costs by humanitarian organisations, hospitals, health clinics and other groups that purchase and distribute the product. The remaining costs are supported by grants and donations. Since 2003, MFK has provided Medika Mamba to treat over 15,000 acutely malnourished children.

From the start, MFK has worked closely with the Ministry of Health and Population in Haiti to build commitment to RUTF programming as the preferred treatment for childhood malnutrition. In 2007, it received a two-year grant from the World Bank Development Marketplace to pilot RUTF treatment in Hôpital Universitaire Justinien, the country's second largest public hospital, as well as in rural clinics in northern Haiti, to train health workers in community management of malnutrition, provide an evidence base for RUTF in Haiti, and to build capacity in the public sector.

Jamie Rhoads, MFK Agricultural Development Specialist, and Jonas Coeurcius, Peanut Farmer, in Bar Lumbe, Haiti

In addition to RUTF, MFK also produces Mamba Konple (Haitian Creole for 'complete peanut butter'), a Ready to Use Supplementary Food (RUSF). This product was designed in consultation with a PhD candidate from Cornell University's Division of Nutritional Sciences, Rebecca Heidkamp, for the nutrition support programme at the GHESKIO Centres in Port-au- Prince, Haiti's leading HIV treatment and research centre. Mamba Konple is being used as part of a supplementation and education strategy to improve infant feeding practices among HIVexposed infants.

National production

MFK believes treating malnourished children with imported RUTF, however effective, will remain a palliative measure, as treatment per se does not address the root causes of the problem. Through national production, MFK hopes to contribute to development processes across multiple sectors - economic, social, health and agricultural - as well as supplying public health providers with the best treatment for malnutrition. Our organisation now works across four sectors:

• Producing and distributing safe, highquality nutritious foods and training Haitian employees to make this possible
• Improving the quality of peanuts produced by farmers, decreasing aflatoxin contamination and augmenting agricultural productivity of Haitian peanut farmers
• Working with and training Haiti's healthcare providers to implement therapeutic and supplementary feeding programs using MFK's products
• Developing new food products for vulnerable populations (HIV+, elderly etc.) and designing programs to deliver them.

Current production facility

Production of local RUTF

From humble beginnings in 2003, using local market produce and a church school room, MFK has moved production site five times. Its current facility is in a converted rental house, retrofitted to meet international food safety standards. In 2009, MFK produced over 75 metric tons (MT) of Medika Mamba, sufficient to treat over 7,000 acutely malnourished children. MFK has trained and employs over 30 Haitians in Cap Haitian, from where it distributes Medika Mamba to public and private clinics throughout Haiti, through either direct sales to organisations such as World Vision, or by donations to missions, clinics and orphanages, supported through grants and individual donations. The facility, the quality control processes and the product all conform to international food safety specifications, passing a food safety audit by Supply Chain Management Systems led by a Food and Drug Administration (FDA)-trained auditor. The product has a shelf life of 15 months and is packaged in 0.5 kg and 1 kg re-sealable sachets that caregivers use to give the recommended daily dose to each child.

MFK would prefer to purchase all its raw materials in-country, to direct capital to local markets where it is most needed, and to encourage investment in the agricultural sector. However, current technical requirements for RUTF ingredients and the low level of industrial production in Haiti mean that for now, MFK restricts its sourcing to working with local peanut farmers, with training to boost production and avoid aflatoxin contamination. Thanks to funding from the USAID Peanut Collaborative Research Support Programme, MFK has connected Haitian farmers with leading scientists from the University of Georgia, Oklahoma State and Cornell University. With the help of these scientists, MFK have worked with over 500 Haitian farmers and agronomists on interventions designed to produce greater yields and better quality. This involves partnering to test different cultivars, seeds, tillage methods, row spacing and weed control, irrigation, harvesting and improved post-harvest drying and storage methods.

The importance of accreditation

The joint statement issued in 2007 by UNICEF, WFP, WHO, the United Nations Standing Committee on Nutrition (UNSCN), and supported by many other agencies, including Médecins Sans Frontières (MSF), marked a major policy milestone for the treatment of severe acute malnutrition. It recommended a community-based approach for children without medical complications by treatment with RUTF, provided nutritional specifications for these foods, and required that the product comply with the Recommended International Code of Hygienic Practice for Foods for Infants and Children of the Codex Alimentarius¹. The statement did not detail how these standards could be applied to RUTF production, or what body would be responsible for monitoring and regulating this production.

In response, the two main purchasers of RUTF, UNICEF and MSF, took on the responsibility of validating and accrediting suppliers according to their own purchasing needs, following Codex Alimentairus, ISO 22000², and HACCP³ procedures. As a consequence, other agencies by default now defer to these auditing decisions when choosing suppliers. It is of course essential that suppliers of RUTF conform to the highest standards of quality and food safety, given the nature and purpose of the product, but currently manufacturers that do not supply UNICEF or MSF are de facto excluded from supplying other agencies, due to the lack of accreditation.

In Haiti, this means that an independent manufacturer such as MFK is excluded from contracts issued by UNICEF and USAID's President's Emergency Plan for AIDS Relief (PEPFAR) - who distribute the product to such implementing partners as Action Contre la Faim, Concern, Save the Children, among others - and which accounted for over twothirds of the market in 2009 in Haiti, and are expected to account for over 90% in 2010.

Certification and long-term contracts are vital for MFK's future, as it is a prerequisite to:

• Supplying NGOs and health care providers currently serviced by UNICEF and other agencies through imported RUTF
• Obtaining supply contracts from other large-scale health care providers in Haiti . Building and ensuring our production capacity and supply chain management systems
• Enabling and validating MFK's agricultural development programmes that support and develop capacity and quality of peanut farming in Haiti
• Supporting and making credible MFK's plans to raise funds for a new, dedicated production facility to open in 2011.

MFK's pursuit of accreditation

MSF

Following the publication of therapeutic food manufacturing standards in October 2007, in 2008 MFK approached the quality control division of MSF to request a food safety audit of MFK's manufacturing process. MSF agreed to visit MFK's facility in December 2008. MSF issued an Audit Report at the beginning of January 2009, which MFK addressed the same month with a Corrective Action Plan for all noted deficiencies. In March 2009, MSF informed MFK that for internal reasons, all pending certifications had been put on hold. Therefore, no result for MFK's audit would be issued.

UNICEF

MFK contacted UNICEF, the remaining Consortium member with audit capabilities, to review the MSF proceedings. In April 2009, UNICEF declined to audit MFK, but suggested that an auditor from Supply Chain Management Systems (SCMS), the new contract holder in Haiti for USAID PEPFAR funds, could be approached about auditing MFK's Cap Haitian factory to determine compliance with the previous audit's findings and to certify MFK for food safety.

SCMS

In May 2009, USAID Washington and Haiti informed MFK that SCMS would inspect MFK's production facilities in August 2009. The final audit report was issued in December, and after nearly two years of pursuit of accreditation, MFK was placed on the list of SCMS validated suppliers for RUTF. On January 4th, 2010, MFK was asked to submit a bid by January 6th, 2010, on a Request for Proposal from SCMS for 50,000 kg of RUTF for the period February to August 2010. After requesting and receiving an extension of a few days to reply, MFK submitted a bid on January 8th. MFK learned the following month that this tender has been supplied by imported RUTF for two reasons: packaging and price.

Rhetoric and reality

Part of local RUTF production process

UNICEF and MSF have both issued statements underlining their support for diversifying production of RUTF, and for implanting suppliers in the countries of treatment. This not only simplifies supply chains, but also, in line with MFK's mission, introduces desperately needed development investments. However, as the above narrative demonstrates, small, independent and certified RUTF producers such as MFK appear to be excluded from the most important national and international markets due to organisational preferences for manufacturers producing in the developed world at industrial scale. While MFK supports these producers in their endeavours to supply large quantities of RUTF at competitive pricing for worldwide demand, it also contends that part of the budgets of agencies like UNICEF and USAID could be targeted to purchasing RUTF in developing countries, instead of channelling resources back to the developed world, thus perpetuating the cycle of 'rescue' instead of 'development'.

MFK introduced RUTF to Haiti in 2003, when RUTF was just emerging as an international commodity. In its first few years of operations, MFK supplied all of the RUTF used in Haiti. Following the joint statement in 2007 and the adoption of RUTF by major relief organisations, a new paradigm took root. This reflected a preferential option for RUTF distributed free of charge by UNICEF to eligible partners, from either developed world producers or from the newly emerging UNICEF-certified local production bases in the developing world. The emphasis on developed world production was an appropriate response for quick scale up and increased coverage. However, without parallel support, encouragement and a transparent policy for national production this approach will ultimately be instrumental in inhibiting local solutions. The surplus benefits created by national production will fail to accrue to those in most desperate need, including workers, farmers and health specialists in the developing world.

Clearly, growing and developing the market for locally-made RUTF in Haiti depends on two factors - supply and demand. It is MFK's responsibility to ensure that its production standards and capacity fulfil the expectations of both national and international organisations. We also believe that it is the responsibility of the large organisations that control demand to adopt a holistic strategy in organising supply chains of RUTF, that includes both international and local producers, in the interests of diversification and local development.

Many requirements presented to MFK by UNICEF and USAID have been met:

• Approval and endorsement of Ministry of Health and Population
• Acceptance of RUTF and Medika Mamba in the national protocol governing malnutrition
• International food safety certification
• Becoming a validated supplier for SCMS But in 2010, important barriers remain: packaging, acceptance of accreditation, and price.

Packaging

The international customer community is accustomed to Plumpy'nut®, packaged in 92g individual dose sachets. MFK's current packaging (500g sachets) is appropriate for our current level of technology, and has been readily accepted for over three years of use throughout Haiti. However, it is clear that in order to be competitive for new bids, MFK must retool its packaging machinery, starting in its current facility. However, this technology is complex and expensive, and when MFK purchases such equipment, trains Haitians in its repair and maintenance (possible but costly), does MFK have any assurance that there will not be yet another barrier to purchasing nationally produced Haitian RUTF?

Accreditation

Our products are made in a facility that has been certified to conform to international food safety standards. SCMS recognises our quality assurance processes, but prefers not to purchase due to questions of packaging and price. UNICEF has not offered to recognise formally the SCMS certification, so is unlikely to consider contracts with MFK anytime soon. And the third main purchaser of RUTF in Haiti, the Clinton Foundation, relies upon UNICEF certification decisions to guide its purchasing, resulting in product being imported.

Price

MFK has historically charged around $5 per kg, to remain competitive against the price of imported RUTF. However, the fully-burdened cost per kg of Medika Mamba is considerably higher. This is due to limited production capacity, the high cost of doing business in Haiti, MFK's direct support of health programmes, and our additional work on agricultural development programmes necessary to abate aflatoxin if MFK is to buy peanuts locally. MFK desires to lower prices to be near cost-parity, but this requires scale, something unobtainable in the current context.

The future

MFK recognises the necessity of a larger and more efficient factory, and in 2009 it launched a capital campaign for this purpose. On completion, this factory will enable MFK to increase annual production capacity to 800 MT, install machinery to package in individual doses to meet international client expectations, comply with all international food safety prerequisites, and make enough Medika Mamba and other products to treat over 80,000 children a year.

In order to realise these ambitions, MFK has had to rethink its strategy. Independence and small scale - restricting ourselves to one country - while useful to introduce and pilot a model, may not be the most effective attributes with which to engage international purchasing networks. MFK has entered into conversations with the global leader in production, Nutriset, with the intention of joining the PlumpyField network, which now counts 11 members in such countries as Niger, Ethiopia and India. The benefits of joining an established production and distribution network are clear: Nutriset will provide support for quality control and technical assistance, and MFK will also benefit from their research and development experience and extended product line as production increases and diversifies in the future. MFK will also be benefit from more formal links to Edesia, a Nutriset affiliated supplier and not-for-profit foundation in the US, in helping to expand local production capacity and product range. Finally, with PlumpyField's experience in supplying larger markets, the partnership should provide a more stable and long-term future for local production in Haiti, in essence the core mission of MFK.

MFK's plans for a new factory will enable economies of scale, which combined with future long-term contracts, will help make its operations financially sustainable in Haiti by 2015. Yet MFK will need to continue to be able to participate in bids, sell MFK products while this transition happens, and raise the necessary funds to cover capital and operational expenses once the new factory comes on line. All before it reaches financial selfsustainability.

We believe that this experience raises a broader set of critical questions for the international nutrition community about the role and involvement of the private sector, private and public sector partnerships, and how to utilise local market mechanisms to address some of the root causes of malnutrition in developing countries. In addition, it also highlights the need for a third-party body for certification, relieving the major purchasers from the role.

Following Steve Collins' Postscript in issue 38 of Field Exchange, we would add the desirability of creating transparency in purchasing policy and supply chain management in Ready to Use Foods (RUFs), so that all stakeholders can establish their needs and expectations to provide both a satisfactory business and development contract. We must remember the context in which these investments are being made. Haiti is consistently in the bottom quarter of the World Bank's 'Ease of Doing Business' rankings and Transparency International ranks Haiti in the bottom tenth of countries in its annual Corruption Perceptions Index. In order to help overcome the extreme uncertainty and risk of investing in countries like Haiti, major purchasing and development organisations must help to mitigate this uncertainty.

At their best, major purchasing organisations can facilitate the investment in, and increase the likelihood of success for, the national production of RUFs. We refuse to believe that anyone wants to see national production fail; the benefits to all parties are far too great. To prevent failure, however, we must create a more enabling environment for success.

MFK's experiences and difficulties in rooting national production in Haiti provide an example of the obstacles that must be overcome if national production is to be successful in other developing world countries. To achieve this, we call for:

• Major stake holders to state publicly their commitment to national RUF production as a central component to the global supply chain for RUFs.
• Leading organisations to convene a meeting that brings together multiple stake holders to identify the barriers to the successful implantation of RUFs in the world's poorest countries, and agree on appropriate action and policy to overcome these barriers.

The situation in Haiti post earthquake is both a reminder and an opportunity of how the international community can help to support interventions across multiple sectors that make sense both in the short and the long term, and how we can and should invest more aid dollars directly in the places that most need them.

For more information, contact Steve Taviner, email: staviner@mfkhaiti.org

¹The Codex Alimentarius is a collection of internationally recognized standards, codes of practice, guidelines and other recommendations relating to foods, food production and food safety. See http://www.codexalimentarius.net

²The ISO 22000 international standard specifies the requirements for a food safety management system, and is developed by the International Organisation for Standardisation dealing with food safety.

³HACCP stands for 'Hazard Analysis Critical Control Point'. It is an internationally recognised and recommended system of food safety management.