On August 26th 2014, RACHA's Executive Director Theary Chan participated in a two day World Health Organization (WHO) consultation in New York City, in collaboration with Micro-nutrient Initiative and the Sackler Institute for Nutrition Science on the "Fortification of Condiments and Seasonings with Vitamins and Minerals in Public Health." Here, Ms. Chan shared RACHA's experience in developing iron-fortified fish sauce and soy sauce in Cambodia and the challenges it faced from piloting its efficacy study to its continuing countrywide scale up 

Anemia contributes to 20% of all maternal deaths in Cambodia. It disproportionately affects women of reproductive age and children under the age of five, which leads to poor pregnancy outcomes, impaired physical and cognitive development, increased risk of morbidity in children and reduced work productivity in adults. RACHA actively addresses iron deficiency as the major cause for anemia with the implementation of fortifying fish sauce and soy sauce with iron. Fish sauce and soy sauce are the most common ingredients in Cambodia cooking and the most accessible in rural communities of Cambodia. A baseline assessment conducted by RACHA in 2012 captured the community's gap in knowledge about iron fortified food. Therefore two key goals were developed to (1) develop the supply chain in order to increase community access to combat iron micro-nutrient deficiency and (2) develop an effective educational outreach campaign through social marketing on national television and local comedy for health performances to increase community awareness and demand to tackle this type of micro-nutrient deficiency. Results of the efficacy study and the market trial proved to be successful and have segued to its continuing nationwide scale up. 

In order to bring this innovation to national scale, RACHA is advocating on the national level by collaborating with National Subcommittee for Food Fortification (NCSFF) and the private sector for iron fortification. RACHA with International life Sciences Institute, Japan, Unicef have been providing technical expertise to help draft the National Standards for Iron Fortification of Fish and Soy Sauces, which it hopes to be incorporated into a sub-decree and signed into Cambodian National Law come early 2015. RACHA has already received the voluntary signatory support by over 40 sauce producers to voluntarily iron fortify their fish and soy sauces. 

One unintended barrier to sustainably fortify fish sauce is the lack of compliance of fish sauce producers to meet global standards (International Codex Alimentarius standard) levels of protein and sodium. Specifically, a portion of fish sauce have protein levels that are too low to qualify as fish sauce and too high in sodium to be safe for consumption. Therefore additional efforts need to be made to make sure these sauces comply with the global food safety standards in the Codex Alimentarius, through mandatory legislation. In addition, there is a strong need for strengthening the appropriate monitoring and evaluation mechanisms to ensure consistent enforcement of these food safety regulations. 

Another challenge to a successful scaling up is the high cost of fortificant, which industry partners have argued is a competitive disadvantage for them to produce without mandatory legislation. It is therefore vital to lower the cost of premix in order to make it locally accessible to sauce producers before legislation is passed to ensure the industry will have the capacity to absorb the additional cost of fortification. On 9-12 November 2014, Chan Theary presented again during the WHO symposium in Las Palmas de Gran Canaria, Spain the topic entitled: â€œConnecting Public-Private-Civil Society and Community to Address the Challenges in Increasing Access to Iron Fortified Fish and Soy Sauces among Rural Communities in Cambodia.” 

The abstract: High prevalence of Iron Deficiency Anemia among children and women is a major public health issue in Cambodia. Fortification of flavoring sauces is an effective strategy to deliver and increase the iron intake of populations. Fish and soy sauce are widely consumed by the entire population, and iron fortification has been widely introduced and is currently being further developed. 
With support from Global Alliance for Improved Nutrition (GAIN), the iron fortification project implemented by Reproductive and Child Health Alliance (RACHA) in collaboration with the National Subcommittee for Food Fortification (NSCFF) and Private Sector is now being scaled up nationwide with the aim of preventing Iron deficiencies. 
RACHA had successfully influenced the government to issue the proclamation for the official label/logo for iron fortified products, and the proclamation for the production and consumption of Iron fortified fish sauce and soy sauce (IFFS/SS). Now, the mandatory standard is being prepared for an approval. With the strong political commitment from the government, we expect the mandatory legislation will be ratified by the end of 2015.

Multi-sectoral collaboration is crucial to ensure institutional and social sustainability like joint advocacy for mandatory legislation and ensuring its enforcement, to strengthen community’s capacity to address important issues by weaving together the skills, resources, networks and knowledge of the government, business and voluntary sectors.