Dear Reader,

Following up on our successful India Learning Visit from last month, we wanted to provide additional context on rice fortification in Sri Lanka and its impact on schoolchildren.

In 2021, a study was conducted in Gujarat, India that looked at the effects of fortified rice on schoolchildren aged 6-12. The results were encouraging: a 10% reduction in anemia prevalence and an improvement in average cognitive scores by 11.3 points. Evidence, in other words, that when children get enough micro-nutrients, such as iron and vitamin B12, it will lead to better learning outcomes. Studies similar to this provided justification for India's investment in and reliance on fortified rice.

India’s national rice fortification program started as a pilot program in 2019. At the time, India lacked the domestic production capacity, so it set a goal of procuring 520 Lakh Metric Tons annually. Since then, capacity has scaled impressively. More than 2/3 of the country’s operational rice mills can fortify rice, while testing infrastructure can now meet domestic needs. With this track record, India has established itself as a model to emulate, which is why we, along with Global Health Strategies, facilitated the India Learning Visit hosted by PATH.

Sri Lanka’s own journey with fortified rice began a decade ago, but it wasn’t until February 2024 that a program was launched to distribute fortified rice to schoolchildren, through the National School Meal Programme, to combat anemia. Program partners included the Ministry of Agriculture and Plantation Industries, the Ministry of Education, the WFP, the National Food Promotion Board, and the Gates Foundation.

Anemia remains a debilitating public health challenge in Sri Lanka. According to the WHO, 29% of the population has it to some degree. Curiously, despite the fact that people generally eat an iron-rich diet, tea consumption and a lack of foods rich in vitamin C hinders non-heme (plant-based) iron absorption.

Children are at a disproportionately high risk of anemia - up to 22% in some regions. What we know about anemia is that it has a negative impact on cognitive development and learning outcomes. As such, anemia’s negative long-term impact on a country’s human capital is concerning.

We also know that Sri Lanka is in the top-10 worldwide for per capita rice consumption, with nearly half of the total calorie intake coming from the staple. Rice, therefore, remains the logical target for tackling the country’s nutrition issues, especially among children. It’s why in 2018 the WHO recommended that it is essential that rice be fortified with iron in countries which have it as a staple food.

For those unfamiliar, rice fortification typically happens through a process of extrusion in which micro-nutrients, such as folic acid, non-heme iron, and vitamin B12, are mixed with rice flour, formed into kernels, and then blended with regular rice. Alternative methods include coating and dusting rice grains.

One of the nutritional challenges with rice fortification in a population that doesn’t consume enough vitamin C is ensuring that the iron in the fortified rice is actually absorbed. Eating foods rich in vitamin C with the rice and avoiding tea after lunch help, but in some cases absorption enhancers are needed.

But perhaps the biggest challenge is logistical. In short, setting up production and distribution capacity that can put fortified rice in every school. It takes collaboration and investment at all levels, from international donors and national governments to the producers and individual schools.

Rice fortification is one of the important investments a government can make in its country’s future. For Sri Lanka, the bottleneck continues to be a lack of capacity and technology to fortify rice at scale. A core part of our work with the nutrition program, in concert with PATH, is facilitating technology transfer from India and a rapid scale-up of fortification capacity. To date, we have identified a local production partner and completed the installation of machinery for domestic fortification.

The Gates Foundation, with its goal to ensure that all women and children have the nutrition they need to live a healthy and productive life, provides support. It has recently given nutrition program grants to India’s Global Health Strategies, CBCI Society for Medical Education, and Post Graduate Institute of Medical Education and Research, Chandigarh.

The next major milestone is to begin distribution of locally produced fortified rice. This gets us one step closer to fulfilling the government’s pledge that all school meals will include domestic fortified rice from 2026 onward.

Sincerely,

Emaali Gunasekera
CEO

Nutrition Program Stakeholder Meeting

Representatives from the Presidential Secretariat, Prime Minister's Office, Ministry of Health, National Food Promotion Board, Ministry of Agriculture, SLSI, ITI, University of Wayamba, PATH, World Food Programme, and others were invited to address some of the programmatic issues facing the domestic rice fortification program. We discussed the lack of governmental leadership, the previous model of coordination and management from the Presidential Secretariat, and the potential of returning to a similar model set up under a governance structure established by the government, either under the Presidential Secretariat or the PMO.

The primary outcome of the meeting was that officials from the Presidential Secretariat agreed to arrange an all-hands meeting to discuss the matter with the Secretary to the President.

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