RESUMO
Objectives: Rural smallholder farming communities are inadequately reached by national food fortification initiatives. World Vision projects in Malawi, Senegal and Tanzania explored the implementation and sustainability potential for community level fortification to increase households' access to micronutrients. Methods: Fortification projects were initiated within an integrated nutrition and health program. Micronutrient premix was added to staple grains during milling at medium scale mills (Malawi), village hammermills (Malawi, Tanzania) or at home after milling (Senegal, Tanzania). In Senegal two community bakeries for fortified bread were established. Partial cost-recovery systems were implemented in all projects but sustainability plans in Malawi and Senegal relied on a transition to independent business models to fund ongoing premix and quality control costs, with community oversight. Results: The projects introduced a novel method of increasing micronutrient intake which was widely accepted by local communities. More than 20,000 households accessed fortified grains. Common challenges included accessibility of premix supply and quality control services, and costrecovery. Operating in rural areas increased premix supply costs and limited quality control monitoring by national standards agencies. Sustainability of activities without external funding was limited. Transition to cost-recovery was overcome in Malawi through extensive community sensitization but resulted in a shift to food-to-food fortification in Tanzania. In Senegal, community committees sustained premix procurement through fortified bread sales. Conclusions: Community level fortification was well accepted and has potential to improve micronutrient intake of rural households unreached by commercially fortified products. Further formative work is needed to identify contextually feasible systems for premix supply, quality control and cost recovery.