Fortifying school meals: Rice fortification to address anaemia in Odisha

Shariqua Yunus Khan is a medical doctor and a public health practitioner currently managing the nutrition portfolio at the India office of the World Food Programme.

Background

Odisha, a state in eastern India with a population of 42 million, is one of the country’s most nutritionally vulnerable states, with high levels of malnutrition. Despite success in reducing childhood stunting (Odisha’s rate of stunting decline is at least three times that of other poor states such as Bihar), more than three in every ten children under the age of five are stunted (low height for age), while 18.3% children in the same age group are wasted (low weight for height). Moreover, anaemia in Odisha among children and pregnant women increased or remained static between the early 1990s and the mid- 2000s, at between 60-70%. According to a recent survey conducted in a few states, more than 80% of children aged between five and nine years old and 74.5% aged between ten and seventeen years in Odisha are anaemic.

Anaemia is a condition associated with maternal mortality, increased illness and mortality among children, and poor cognitive and physical development. These consequences negatively affect household and state/national level socioeconomic potential and development. Anaemia is caused by many factors, including disease and dietary intake; iron deficiency anaemia accounts for about 50% of all anaemia. According to the National Nutrition Monitoring Bureau (2011-2012), there is a gap of 50-70% between the recommended dietary allowances and actual intake across the school-age population for most micronutrients, including iron.

India’s midday meal scheme (MDMS) provides a free cooked meal for all children attending state primary and upper primary schools. Due to its wide coverage, the MDMS provides a good opportunity to address nutritional issues in this age group (the scheme is the largest school feeding programme in the world, delivering lunches to 120 million children in over 1,265,000 schools). The meal is designed to provide approximately 450 kilocalories and 12 grams of protein for primary schoolchildren, and 700 kilocalories and 20 grams of protein for children in upper primary school. The protein sources are pulses, soya bean granules and one egg per week (animal protein is not included as part of the meal). Other government programmes to address high levels of anaemia and malnutrition include: targeted public distribution system; integrated child development services; and the iron plus initiative, which involves the distribution of weekly iron-folic acid tablets to adolescents and women of reproductive age who are not pregnant or lactating. However, the World Food Programme (WFP), along with the Department of School and Mass Education (DS&ME) and the Government of Odisha (GoO), agreed to operationalise fortification of rice in the midday meal in Odisha in light of the scheme’s potential outreach.

Project approach, strategy and impact

WFP in India focuses on enhancing the systemic efficiency and nutritional effectiveness of the various food-based safety nets in support of the Government’s efforts. This is achieved by working on a pilot strategy to scale up through a four-phased approach:

1. Designing pilot projects in order to address known gaps in food and nutritional provisions, design or knowledge;

2. Implementation of these pilot projects and demonstration of results;

3. Assessment, evaluation, documentation and preparation of replicable, cost-effective models and

advocacy for scale-up/policy formulation as appropriate; and

4. Providing support for scale-up.

This approach guided the setting-up of a pilot project for fortification through the platform of the midday meals in

Gajapati district, Odisha. Gajapati has a population of 577,217, of whom 54% belong to the scheduled tribe communities, a group associated with extreme poverty. Rice was chosen as the vehicle of fortification since it is the preferred staple in Odisha and used in the midday meal in schools.

Piloting fortified rice

The pilot scheme was implemented between 2012-2015 and catered for 99,231 schoolchildren in the 6-14 year-old age group across 1,473 schools, with iron-fortified rice provided as part of the MDMS. The project focused attention on a number of factors to ensure adequate consumption of fortified rice in the schools, including: supply chain management; training of schoolteachers on causes, consequences and strategies to address anaemia and their role in the project; information, education and communication; quality assurance and control.

The project had an in-built system of monitoring, but an independent research organisation was also engaged to undertake evaluation of the project at end-line against established benchmarks. The project was also reviewed and assessed on a biannual basis by a technical advisory group consisting of policy makers from relevant departments at the national and state level, experts and WFP.

Results

Over 5,000 metric tons of rice were fortified, distributed and consumed by the schoolchildren without any perceived change in taste, odour or colour of the product. Furthermore, the project demonstrated a 20% reduction in the prevalence of anaemia in the given age group in Gajapati, bringing anaemia prevalence down from 65% to 45%. Of this 20% decrease in prevalence during the project time period (2012- 2015), 6% of the reduction was found to be attributable to the consumption of fortified rice in the midday meals. The evaluation could not determine the other interventions to which the remaining reduction could be attributed. Deworming and iron folic acid tablet consumption, other critical interventions in anaemia reduction, were investigated; however, as coverage was not universal for Gajapati, the extent to which these interventions contributed to the reduction in anaemia could not be estimated.

The allocation from the GoO under the MDM scheme per child at the end of the pilot project in 2015 was 4.04 rupees (US$0.06) for primary schoolchildren and 6.03 (US$0.09) for upper primary schoolchildren. The incremental cost on account of fortification was 24 paisa per beneficiary per day for primary schoolchildren and 36 paisa per beneficiary per day for upper primary schoolchildren in the pilot. The allocation per child has increased in the years following the project uniformly across the state, which is also expected to allow fortification to be continued and scaled up.

Way forward: What are the next steps for fortified rice in school meals?

The pilot project demonstrated its operational feasibility and technical effectiveness while facilitating necessary ‘know- how’ in the Government for the management of such a project. The DSME and the GoO are currently continuing the fortification programme in the district, with funds from the DSME budget. WFP is working with both partners to scale up fortification of the midday meals to other districts in the state in a phased manner. The project has also generated interest among other rice-consuming states, while at the national level the Government is considering including rice as a vehicle for fortification along with other commodities, such as wheat, oil and milk. Standards on rice fortification are soon to be released at a national level.

Fortified rice kernels (FRK)

Fortified rice kernels are manufactured by combining rice powder with iron and converting this powder into kernels using extrusion technology. These FRKs are then blended with regular rice in a ratio of 1:100 to give fortified rice.

Every 100 grams of fortified rice provided 10 mg of iron in the Gajapati pilot. The form of iron used was ferric pyrophosphate. The daily ration for rice is 100gm and 150gm for children aged between 6-10 years and 11-14 years respectively, which means that the fortified rice in the pilot scheme provided more than 50% of the recommended dietary allowance of iron.