Factors contributing to indifference to the private sector under the scaling up nutrition framework

Failure to acknowledge the effort of the private sector is presumably due to the challenge of clearly defining who to engage from this sector and the following plausible factors: the paranoia stance of some stakeholders regarding the enforcement of the International Code of Marketing of Breast milk Substitutes and the fear that including the private sector will automatically jeopardise progress in promoting exclusive breast feeding; the wide range of opinions on the plethora of actions that could potentially be undertaken by the private sector in SUN interventions with unintended negative consequences; extreme anti private sector sentiments linked to negative perceptions of the business culture and practices of some food manufacturers; the perception of some stakeholders that the private sector independently has the panacea to resolving all the challenges of under nutrition at scale.

The scepticism and caution in engaging the private sector is however a denial of their potentially positive contribution to improve nutrition service delivery at scale.

Engaging public private partnership on scaling up nutrition in Africa: why and who?

The high number of people suffering from hunger and under-nutrition in Africa continues to undermine the health and socio-economic development of the region. Sub-Saharan Africa is home to 14% of the world's population with micronutrient deficiencies⁽ Reference Begin and Greig ^{3 )}. Even though the region represents only 12% of the world's population, it bears 26% of the global burden of disease^{( 4 )}. It is estimated that >42% of preschool-age children in West Africa alone are vitamin A deficient⁽ Reference Aguayo and Baker ^{5 )}. Recent evidence shows that subclinical vitamin A deficiency is associated with an increased risk of severe illness and even death from such common childhood illnesses as diarrhoea and respiratory infections⁽ Reference Faber and Spinnler Benade ^{6 )}. In most countries in Africa, over 50% of women of reproductive age and preschool children suffer from varying degrees of iron deficiency anaemia with negative consequences on mortality, cognitive development, learning ability and work capacity⁽ Reference McLean, Cogswell and Egli ^{7 )}. There has been limited progress in reducing the prevalence of under-nutrition and the actual number of underweight children has in fact increased during the past decade⁽ Reference Brown, McLachlan and Cardoso ^{8 )}. Early stunting and micronutrient deficiencies have been proven to result in permanent negative intellectual and development outcomes and it is now known that stunting is also linked to later onset of diabetes and CVD⁽ Reference Fuster and Kelly ^{9 ,} Reference Delisle ^{10 )}. Countries in the region are challenged by economic constraints, seasonal harvests, low production output, poor food consumption patterns and lack of infrastructure, resulting in limited access to micronutrient-rich foods, especially those of animal origin⁽ Reference Sablah, Klopp and Steinberg ^{11 )}.

The Lancet series on maternal and child under-nutrition (2008) stated that ‘Of the available interventions, counseling about breastfeeding and fortification or supplementation with vitamin A has the greatest potential to reduce the burden of child morbidity and mortality’⁽ Reference Black, Allen and Bhutta ^{12 )}. The Copenhagen Consensus Centre deliberations of 2008 ranked micronutrient fortification of staple foods through PPP collaboration, among the top development priorities⁽ Reference Horton, Alderman and Rivera ^{13 )}. In the context of addressing nutrition related challenges in Africa, the private sector leads in the production and supply of complementary food, micronutrient premix or supplements, food safety products and therapeutic food. The public sector sets the rules to oversee the operation of the private sector.

The rules of engagement between the public and private sector and their inter-relationships must however be well defined (Table 1).

Table 1. Broad classification of public–private sector engagement in nutrition

NGO, non-governmental organisation.

Table adapted from PSP One – Private sector partnerships for better health^{( 14 )}.

Food fortification is expanding in Africa with HKI acting as a neutral broker and creating the platform for open dialogue to ensure commitment and engagement by both the public and the private sector. The public sector builds the enabling environment for the private sector to thrive on the food fortification initiatives. The government leadership role goes beyond policy directions, regulatory enforcement and provision of services, to include monitoring and measuring progress. The role of civil society is crucial in advocating and sustaining mutual accountability of the stake-holders engaged in PPP.

Experience in engaging public–private partnerships to scale up vitamin and mineral fortification of staple foods in West Africa

Food fortification with essential vitamins and minerals usually complements other nutrition interventions. Multiple complementary nutrition strategies require a comprehensive mapping of coverage to ensure maximum reach. Certain food staples and condiments are commonly available to those most at risk of developing micronutrient deficiencies. Preliminary consumption surveys have confirmed that vegetable oil, salt, sugar, bouillon cubes and cereal flour, reach over 80% of national households in West Africa. During the decade between 2000 and 2010, HKI catalysed PPP towards food fortification by leading and supporting the development of the empirical evidence base for coverage of potential staple food vehicles in selected countries⁽ Reference Hess, Brown and Sablah ^{15 )}. A series of evaluations were carried out to assess the private sector industrial capacity to fortify the targeted food vehicles. Wheat flour is fortified with iron, folic acid, zinc, vitamin B₁₂ and other B-group vitamins. Vegetable oil is fortified with vitamin A. Mandatory fortification of selected food vehicles are estimated to provide between 30 and 50% of the estimated recommended daily allowance of this micronutrient for adults⁽ Reference Sablah, Klopp and Steinberg ^{11 )}.

In West Africa, initial multi-sectoral PPP and national alliances were started in Cote d'Ivoire, Ghana, Guinea, Mali and Nigeria. Concurrently high level regional advocacy campaigns were targeted at private sector industry associations and regional political institutions. The partnership approach aligns with the principles of the Paris Declaration and the Accra Agenda for Action on development. This partnership model is illustrated in Fig. 1.

Fig. 1. (Colour online) Public–private partnership to fortify vegetable oil with vitamin A in West Africa⁽ Reference Sablah, Klopp and Steinberg ^{16 )}. AIFO-UEMOA, Professional Association of Cooking Oil Industries of the West African Economic and Monetary Union; BASF, Badische Anilin und Soda-Fabrik; DSM, Dutch State; HKI, Helen Keller International; MI, Micronutrient Initiative; CSO, Civil Society Organization; NGO, Non-governmental organization; WAHO, West African Health Organization; ECOWAS, Economic Community of West African States; QA/QC, quality assurance/quality control; M&E, monitoring and evaluation; USAID, US Agency for International Development; GAIN, Global Alliance for Improved Nutrition; MSDF, Michael and Susan Dell Foundation; UEMOA, West African Monetary Union; UNICEF, United Nation Children Fund; WFP, World Food Program; FAO, Food and Agriculture Organization.

The partners outlined in Fig. 1 were able to accelerate the mobilisation of regional political will, leading to the 2006 and 2008 Assembly of Health Ministers resolution for mandatory fortification of vegetable oil and wheat flour in all fifteen countries of the Economic Community of West African States (ECOWAS). The food industry associations passed a resolution to commit all their members to fortify their products as a condition for affiliation. The momentum resulted in scaling up of two regional initiatives on vitamin A fortification of vegetable oil ‘Faire Tache d'Huile en Afrique de l'Ouest’ (literally meaning, making fortified vegetable oil slick in West Africa) and ‘Fortify West Africa’ which enlarged the initiative to cover wheat flour fortification with micronutrients. Significant financial contributions were provided by United State Agency for International Development, Michael and Susan Dell Foundation, Bill and Melinda Gate Foundation through Global Alliance for Improved Nutrition. In 2007 the Clinton Global Initiative declared this initiative as a model PPP in Africa. Additional funding support from the Department for International Development, Global Alliance for Improved Nutrition, United State Agency for International Development and Michael and Susan Dell Foundation resulted in expanding food fortification programs to Cameroon, Mauritania, Mozambique and Tanzania. Partnership engagement was scaled up to nineteen countries across Africa. Over 70% of the total population in eleven countries with mandatory wheat flour fortification and ten countries with mandatory vegetable oil fortification are now covered with fortified food in West Africa. Over fifty million people daily consume vitamin A fortified vegetable oil and wheat flour in West African Monetary Union (UEMOA) of which 8·25 million are children under the age of 5 years.

PPP at both the regional and national level was facilitated through: reinforcement of human resource capacities; the establishment of formalised platforms for open dialogue; initial financial investment to catalyse support for the necessary government policy and regulatory framework for mandatory fortification; creation of a favourable environment and support to industries to acquire inputs (equipment, micronutrient premix and training); technology transfer including quality control, standards and operational system redesign; coordination of stakeholders and sharing of best practices; monitoring and evaluation of key programme indicators for result on impact.

Opportunities to harness lessons learned from food fortification in order to sustain public–private partnership commitment to scaling up nutrition in Africa

Mandatory legislation by the public sector on food fortification obliges the private industries to commit to sustainable food fortification. The private sector must not be an afterthought in the drive to scale-up nutrition. Private institutions have equal rights in establishing the required environment and regulatory framework for quality service delivery. The private sector provides direct and equitable nutrition products to all segments of the population. The public sector must encourage the private sector, recognise its contribution to SUN and establish a system of accountability. This entails appropriate legislation for the private sector to apply ethical nutrition principles which include food fortification with micronutrients.

In each context, there should be an analysis of the role and capacity of the private sector. Depending on the environment, enlightened consumers will look for value. However, the vulnerable consumer will require extra protection of their right to optimal nutrition. Effective PPP must consequently be grounded on the principles of transparency, equity, shared mutual objectives, benefits and accountability. Continuous dialogue is central to the dynamics of PPP and should be facilitated by neutral brokers in the partnership. Mediators of PPP such as HKI stimulate the SUN effort in Africa. New models and innovative approaches are necessary to scale-up nutrition interventions through PPP.

In West Africa HKI with the support of other stakeholders has successfully advanced food fortification to scale by harnessing the power of PPP. There is the need to sustainably engage all parties equally and equitably and to do this effectively the following principles are critical: effective coordination and management of partnerships; continuous advocacy especially in the light of the rapid turnover of political appointments; regular dialogue with transparent communication on the shared vision, best practices and applaud of successful contributions; respect for diversity, integrity and activation of leadership; continuous engagement by all stakeholders in the partnership; striving for excellence through formalised agreements and memoranda of understanding on the defined roles and responsibilities of all stakeholders; ensuring accountability by all parties within the partnership.

The synergy of PPP is warranted to surmount the challenge of malnutrition. Empowering PPP does not only imply partners must engage, but set the rules for engagement.