Africa grapples with a profound challenge – over 40 percent of its children face chronic malnutrition. Many of these children suffer from stunted growth, impaired cognitive development, and weakened immune systems, according to the United Nations. Stunting is the single greatest predictor of death in children under five, contributing to 3.1 million deaths annually. In Rwanda, at least 33 percent of children aged 6 to 59 months have stunted growth.
Additionally, existing complementary food to support pregnant women, new mothers, and children’s health often lacks sufficient nutrition or is unaffordable. The unavailability of quality nutritious food results in a self-perpetuating cycle of undernutrition. Poorly nourished girls grow up to be undernourished pregnant women, who are at greater risk for poor birth outcomes.
Addressing chronic malnutrition
To address chronic malnutrition among children in Rwanda, CHAI facilitated the launch of Africa Improved Foods (AIF). AIF, a local joint venture between CHAI, the Rwanda government, and private investors, including Royal Dutch State Mines (DSM), International Finance Corporation (IFC), and FMO (the Netherlands Development Bank), produces nutrient-dense fortified blended foods (FBF) for mothers and children. It began FBF production in late 2016.
Since its launch, AIF has become a regional leader in FBF production. Its products are primarily delivered through relief programs such as the World Food Programme (WFP) and the GoR. It is the first producer in Africa capable of producing FBF that meets WFP’s quality requirements. AIF’s impact extends beyond relief efforts. AIF products are available directly to consumers through retail markets in the region.
The Fortified Blended Food Products
Working alongside other AIF partners, CHAI played a pivotal role in developing a suite of nutrient-dense FBF products named “Shisha Kibondo.” These products are designed for young children and pregnant/lactating women (PLW). They are produced locally, incorporating local agricultural products, and aligning with regional and local eating habits.
“Shisha Kibondo has helped us a lot because it contains nutrients that support other foods. We give it to children, and it helps them to grow up well. In that porridge, there are all those other nutrients we did not have the capacity to find, and they get all those vitamins the child did not get from other foods” Beneficiary of FBF beneficiary, living in Nyarugenge District, Rwanda.
The formulation for children is based on WFP’s Cereal Plus, containing maize, soybeans, soybean oil, sugar, skim milk powder, and a micronutrient blend. In contrast, the PLW formulation aims to address pregnant and lactating women’s increased macro- and micronutrient requirements.
Government initiatives to reduce chronic malnutrition
The Shisha Kibondo brand consists of two types of FBF, Ubedehe 1 and 2, which are both fully subsidized by the government at the cost of production.
The products are distributed to households through the public health supply chain (health centers). Ubudehe 1 products are for children aged 6 to 23 months and PLW in the lowest tier. This tier also includes very poor and vulnerable citizens who are unable to feed themselves without assistance. The products are also distributed in select districts to households in the second tier “Ubudehe 2.” This category includes citizens who can afford some form of rented or basic accommodation, but who are not gainfully employed and can only afford to eat once or twice a day. Individuals on this tier are also part of the national social support scheme. FBF products are provided monthly, alongside counseling on product preparation and use, as well as infant and young child feeding.
Working collaboratively to drive the uptake of fortified foods
Funded by the U.K. Foreign, Commonwealth, and Development Office (FCDO), FMO, Sight and Life, and Royal DSM, CHAI worked alongside the GoR to develop the distribution, promotion, and monitoring systems to ensure that FBF products reached vulnerable households across Rwanda. We educated households on product use and the importance of continued breastfeeding. The GoR managed the program, and CHAI supported program implementation. We helped design a more efficient and effective supply chain for FBF. We also guided communications activities to drive improvements in product coverage and uptake. In addition to operational support, CHAI, in collaboration with the GoR and technical advisors from the London School of Hygiene and Tropical Medicine (LSHTM), led an evaluation of the impact of FBF distribution on reducing malnutrition. The evaluation captured changes in stunting among 18–23-month-old children before and after introducing FBF. The study’s secondary objectives included understanding the micronutrient status among children in the Ubudehe 1 tier.
Unveiling Key Findings
By the end of 2021, over 85 percent of children in the poorest households had consumed the FBF product. Despite challenges posed by the COVID-19 pandemic, children had consistently consumed the product. Nearly 60 percent of children aged 18-23 months from these households reported consuming the FBF product in the last week. Further, 55 percent of these children reported having consumed the product in the last 24 hours. This positive uptake can be attributed to the program’s continued product education and promotion.
“Honestly, there are so many benefits. If a mother receives it during pregnancy, it is to support the mother so that she will give birth to a healthy child, and then they support her during lactation to ensure that a child will get necessary nutrients from the breastmilk and finally support a child for better growth. Therefore, I think that it is very important in the prevention of malnutrition and improving the growth of a child.” Beneficiary of FBF, living in Gatsibo District, Rwanda
Nutritional Impact on chronic malnutrition
The nutritional status of children aged 18-23 months in Ubudehe 1 substantially improved from 2017 to 2021. Stunting prevalence decreased from 47 percent at baseline (2017) to 35 percent at endline (2021), reflecting a 27 percent change. Concurrently, the percentage of anemic and iron-deficient children in Ubudehe 1 decreased from 35 to 9 percent and from 34 to 24 percent, respectively.
Statistical analysis revealed a 42 percent reduction in the odds of being stunted among children in Ubudehe 1 from 2017 to 2021, even after adjusting for various factors. Secondary analyses focused on micronutrient status indicated an 82 percent reduction in the odds of being anemic. Moreover, it indicated a 50 percent reduction in the odds of being iron deficient during the same period.
Discussion of Findings
These results, both globally and locally, are exceptional. The significant reduction in stunting, especially among children in the poorest households defies conventional expectations. Although recent data show a 10-percentage point reduction in stunting among children aged 18-23 months from 2015 to 2019, the reduction observed in the Ubudehe 1 population is notably higher.
Several factors contribute to this exceptional outcome. The program used a targeted approach to reach the most vulnerable children and PLW; the beneficiaries sustained consumption even through the pandemic, and broader improvements in socio-demographic factors all played pivotal roles in increasing consumption. Finally, since the evaluation period was prolonged, more children were fully exposed to the FBF product throughout the first 1,000 days of life.
Limitations and Considerations
While the evaluation provides compelling insights, it comes with limitations. The absence of a control group deemed ethically inappropriate to withhold FBF from certain households, limits establishing a direct causal link. Additionally, the evaluation did not systematically monitor participants’ interactions with other nutritional or livelihood interventions, potentially impacting the outcomes.
Conclusions
Despite challenges, the consistent consumption of FBF over the years and the statistically significant declines in chronic malnutrition and improvements in micronutrient status paint a promising picture for childhood nutrition in Rwanda. The program’s impact surpasses the initial target, achieving a 27 percent relative reduction in stunting among children living in the poorest households.
Stunting remains a significant public health challenge. However, the results of this evaluation offer a concrete solution to drive rapid and substantial reductions. These findings underscore the success of a comprehensive approach and highlight the positive impact of the Rwandan Government’s commitment to holistic solutions promoting healthy child growth and development. The journey of fortified blended foods in Rwanda stands as a testament to transformative change and the potential for global solutions to local challenges. Link to the full manuscript.
