December 2021
MICRONUTRIENT
DEFICIENCIES IN
THE PALESTINIAN
TERRITORIES:
Identifying the Bottlenecks of
Anemia Prevention and Control
and Assessing the Feasibility of
an Oil Fortification Program
© 2021 International Bank for Reconstruction and Development / The World Bank
1818 H Street NW
Washington DC 20433
Telephone: 202-473-1000
Internet: www.worldbank.org
This work is a product of the staff of The World Bank with external contributions.
The findings, interpretations, and conclusions expressed in this work do not necessarily
reflect the views of The World Bank, its Board of Executive Directors, or the governments
they represent.
The World Bank does not guarantee the accuracy, completeness, or currency of
the data included in this work and does not assume responsibility for any errors,
omissions, or discrepancies in the information, or liability with respect to the use of
or failure to use the information, methods, processes, or conclusions set forth. The
boundaries, colors, denominations, and other information shown on any map in this
work do not imply any judgment on the part of The World Bank concerning the
legal status of any territory or the endorsement or acceptance of such boundaries.
Nothing herein shall constitute or be construed or considered to be a limitation
upon or waiver of the privileges and immunities of The World Bank, all of which
are specifically reserved.
Rights and Permissions
The material in this work is subject to copyright. Because The World Bank
encourages dissemination of its knowledge, this work may be reproduced, in
whole or in part, for noncommercial purposes as long as full attribution to this
work is given.
Any queries on rights and licenses, including subsidiary rights, should be addressed
to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington,
DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org.
Report design
Spaeth Hill
December 2021
MICRONUTRIENT
DEFICIENCIES IN
THE PALESTINIAN
TERRITORIES:
Identifying the Bottlenecks of
Anemia Prevention and Control
and Assessing the Feasibility of
an Oil Fortification Program
Takahiro Hasumi
Health Specialist, Health, Nutrition and
Population Global Practice, the World Bank.
Hiya Mahmassani
Nutrition Specialist, Health, Nutrition and
Population Global Practice, the World Bank.
Disclaimer: Financial support for this work was provided by the government of Japan
through the Japan Trust Fund for Scaling Up Nutrition.
4
CONTENTS
Background.. ......................................................................................... 5
Objectives............................................................................................. 7
Methodology........................................................................................ 8
Assessment to identify bottlenecks of existing anemia
prevention and control programs.................................................................... 8
Assessment of the feasibility of edible oil fortification
with vitamins A, D, and E................................................................................... 8
Findings.. ................................................................................................ 9
Assessment to identify bottlenecks of existing anemia
prevention and control programs....................................................................9
Targeting........................................................................................................................... 11
Service delivery and supply........................................................................................ 11
Demand............................................................................................................................ 12
Assessment of the feasibility of edible oil fortification with
vitamins A, D, and E. . ........................................................................................ 12
Consumption................................................................................................................... 13
Repacking industry....................................................................................................... 13
Monitoring for quality control/assurance.............................................................. 13
Fortification level calculation..................................................................................... 13
Cost...................................................................................................................................14
Implementation and stakeholders............................................................................14
Recommendations and Way forward.. ......................................... 16
Annexes............................................................................................... 18
References.. ......................................................................................... 18
Micronutrient Deficiencies in the Palestinian Territories 5
BACKGROUND
In the Palestinian territories (PT), decades of conflict, economic stagnation, and
restricted movement of people and goods, coupled with high unemployment and
poverty rates, continue to affect social, health, and nutrition indicators. For decades,
several assessments have indicated a poor nutritional status of the population in the
West Bank (WB) and Gaza Strip (GS). Specifically, a high prevalence of micronutrient
deficiencies still exists among pregnant and postnatal women and children of ages 6–23
months despite multiple initiatives to address them. Micronutrient deficiencies are one
form of undernutrition that occur because of insufficient intake or sufficient intake
coupled with inadequate absorption due to infection, disease, or inflammation.1
Anemia is a public health problem and can negatively affect human capital devel-
opment in the PT. Anemia is defined as a condition in which hemoglobin concentration
and/or the number of red blood cells is lower than normal and insufficient to meet
physiological needs. Anemia is associated with poor birth outcomes when it occurs in
pregnant women (e.g. higher risk of maternal and perinatal mortality, low birthweight,
premature delivery), with impaired cognitive and motor development outcomes in chil-
dren, and fatigue and low work productivity in adults.2 Given that anemia is associated
with increased morbidity and mortality in women and children, its high prevalence in the
Palestinian population is likely to have significant consequences for human health as well
as social and economic development. In the GS, anemia is a severe public health problem
where more than half of pregnant women and children 6-23 months of age were found to
be anemic.3,4 In the WB, anemia is a moderate public health problem where more than a
quarter of pregnant women and children 6-23 months of age were found to be anemic.5
High proportions of the Palestinian population are deficient in vitamins A, D, and E.
Vitamins A, D and E are fat-soluble vitamins and play key roles in multiple physiological
processes namely vision, bone health, and immune function.6,7 Vitamin A deficiency
can have severe effects on the eye and is associated with
a weakened immune system. Lack of sufficient vitamin A
“Given that anemia is
during early pregnancy may lead to birth defects and fetal
mortality. In infants and children, a deficiency in vitamin associated with increased
A can impair growth. Vitamin D is used by the body for morbidity and mortality
normal bone development and maintenance of normal in women and children,
blood levels of calcium and phosphate, which are in turn
its high prevalence in the
needed for good skeletal health. Vitamin D deficiency
Palestinian population is
is associated with multiple problems, notably rickets in
children and osteoporosis in adults. Vitamin E plays an likely to have significant
consequences for human
health as well as social and
economic development.”
Micronutrient Deficiencies in the Palestinian Territories 6
important role in the body’s antioxidant network
by protecting cells from free radical damage,
which is involved in many diseases including
heart disease and cancer. According to the
Palestinian Micronutrient Survey conducted
in 2013 (PMS 2013),8 which remains the most
reliable and comprehensive source of data on
micronutrient status to date, around 72 percent
of children (6–59 months old) and 47 to 58
percent of pregnant women (depending on the
trimester of pregnancy) suffer from low plasma
vitamin A. Fifty-four to 68 percent of children
(6–59 months old) and 99 percent of pregnant
Photo: Natalia Cieslik / World Bank women in their second and third trimesters
(18–43 years old) have low vitamin D status.
Around 65 percent of children (6–59 months old) and 16 to 42 percent of pregnant
women (depending on the trimester of pregnancy) have low vitamin E status.
Main factors leading to micronutrient deficiencies include widespread food insecurity,
driven by high levels of poverty; limited access to nutrient-dense foods; and reduction
in the variety of the Palestinian diet.9,10,11 Even before the COVID-19 outbreak and the
recent hostilities, nearly a third of the population (around 1.7 million people) were food
insecure, of which 80 percent are in the GS and 20 percent are in the WB.12 In 2021, an
estimated 2 million Palestinians were considered moderately or severely food insecure,
of which 1.4 million live in the GS and 0.6 million live in the WB.13,14 This data suggest that
iron deficiency anemia and other nutritional deficiencies are likely to contribute to a large
extent to the development of anemia. Studies of women and children living in the PT
find that poor dietary intake of iron and lack of a diverse diet are major risk factors for
anemia.15,16,17 Although the impact of the COVID-19 outbreak on food security and nutri-
tional status of the Palestinian population is not clear yet, it is expected that the continued
political instability, economic decline, and restricted access to markets will have additional
detrimental effects. The relative contribution of diseases (parasitic infection and inflamma-
tion)18 and genetic hemoglobin disorders to anemia in the PT is assumed to be low com-
pared to nutritional deficiencies19 but deserves further investigation.
Current initiatives to improve the micronutrient status of the Palestinian population
include universal fortification of flour, supplementation programs targeting high-risk
groups, and promotion of breastfeeding and intake of a micronutrient-rich diet. The
wheat flour fortification program was mandated by law and initiated by the Palestinian
19
o cases of malaria were reported by the MoH in the Annual Health Report 2020 (State of Palestine, 2021),
N
and few carriers of thalassemia were reported in the WB, of those tested in 2017 (State of Palestine, 2018).
It is assumed that helminth infections that cause blood loss, and thus iron deficiency, are also low, although
incidence is not reported by the MoH in 2020.
Micronutrient Deficiencies in the Palestinian Territories 7
authorities in 2006. The fortification program was designed to provide 80 percent of the
Estimated Average Requirement (EAR) for 10 micronutrients, including vitamins A and D,
iron, and folic acid. In addition, iron supplements are distributed to pregnant and postnatal
women and children 6–23 months old in primary health care clinics. The program also
incorporates the promotion of iron-rich foods, including fortified wheat flour, through
health services, schools, and mass media. The Maternal and Child National Nutrition
Protocol (MCNNP) provides guidance to service providers on the promotion of breast-
feeding, dietary counseling during pregnancy and lactation, and complementary feeding
of children 6–23 months old.
Although the effectiveness of these initiatives in addressing “Despite efforts by the
micronutrient deficiencies is well-recognized globally, their MoH and partners to
impact in the PT seems to be limited, as the prevalence of
improve quality and
micronutrient deficiencies remains high. Pregnant women
and children up to six years old have free access to preven-
coverage of existing
tive and curative care at the MoH facilities. In addition, the interventions, anemia
micronutrient supplementation program, including iron and folic and micronutrient
acid supplementation program shows a high coverage (91.4 deficiencies are a
percent of pregnant women in 2016), and the fortification persistent challenge.”
of flour with iron and other micronutrients is mandated
by law. The flour fortification program is currently active, but
its impact on nutritional status is uncertain.20 Testing of fortified flour samples showed
inconsistent adherence to the recommended levels of micronutrients suggesting chal-
lenges in the implementation of the program. Despite efforts by the MoH and partners
to improve quality and coverage of existing interventions, anemia and micronutrient
deficiencies are a persistent challenge. There is a need to identify the underlying factors
hindering the improvement of micronutrient levels and to find practical and innovative
solutions well adapted to the local context.
OBJECTIVES
Two detailed assessments were conducted in the PT (1) to identify the bottlenecks of
anemia prevention and control programs and (2) to explore the feasibility of fortification
of edible oil with vitamins A, D, and E. This report aims to present policy makers in the
relevant ministries, donors, and partners with a summary of findings from these two
detailed assessments.
20
s part of the PMS 2013, iron was detected in 62 percent of the flour samples retrieved from the West Bank
A
and in 11 percent of those retrieved from Gaza.
Micronutrient Deficiencies in the Palestinian Territories 8
METHODOLOGY
Two detailed assessments were conducted (1) to identify the bottlenecks of anemia
prevention and control programs in the PT and (2) to examine the feasibility of an edible
oil fortification program. Due to the COVID-19 outbreak and conflicts, the assessments
largely relied on the use of readily available data for secondary analyses and remote
data collection through online/phone surveys, key informant interviews, and focus group
discussions. To the extent possible, the assessments collected data from key informants
(for example, health care service providers) and beneficiaries through field visits and
stakeholder interviews. The detailed methodology for each of the assessments are
available in annexes 1 and 2.
ASSESSMENT TO IDENTIFY BOTTLENECKS OF EXISTING
ANEMIA PREVENTION AND CONTROL PROGRAMS
The assessment focuses on the following areas and research questions:
1. Targeting—Are the programs targeting the right population?
2. Service delivery—Is the at-risk population receiving adequate and necessary
prevention? Are the control measures as planned?
3. Supply—Are the iron supplements at facilities and iron-fortified flour and food
products at retail shops available/distributed to beneficiaries?
4. Demand—Are there incentives and barriers to the implementation of preven-
tion and control interventions? How will barriers be managed with the existing
resources and programs?
Specifically, the targeting module was designed to identify the prevalence and severity
of anemia among high-risk groups by location and socioeconomic and physiological sta-
tuses. The service delivery module consisted of mapping and reviewing existing anemia
prevention and control (APC) programs. The supply module consisted of a review of the
supply chain of iron supplements, including stocks at the facilities and governorates, and
of the availability of fortified and nonfortified flour in retail shops. The demand module
aimed to identify reported or observed barriers to complying with the recommended
APC programs.
ASSESSMENT OF THE FEASIBILITY OF EDIBLE OIL
FORTIFICATION WITH VITAMINS A, D, AND E
Given that the current flour fortification program has not proven effective in increas-
ing micronutrient intake and reducing micronutrient deficiencies, the fortification of
a new food vehicle is necessary to complement it. Edible oil is a prime candidate for
Micronutrient Deficiencies in the Palestinian Territories 9
fortification with fat-soluble vitamins, given that it is widely and frequently consumed as
part of the Palestinian diet. Specifically, the MoH asked the World Bank to explore the
feasibility of fortifying edible oils with vitamins A, D, and E. With the exception of olive
oil, edible oils are not processed in the country, but are either imported in ready-to-sell
packages or in bulk from different countries and repackaged locally, which is an excellent
opportunity for fortification. Compared to flour, oils have very limited producers/import-
ers, and vitamins can be more easily detected in oils, which makes the monitoring of an
oil fortification program more manageable than a flour fortification program. To assess
the technical and financial feasibility of introducing an edible oil fortification program,
the assessment estimated habitual oil consumption and collected information on the
following areas:
1. Industry assessment—assessment of the supply chains for various edible oils,
identification of oil and premix supply chains, identification of the industry capacity
and fortification needs, and assessment of the level of industry commitment
2. Consumer assessment—analysis of consumer behavior, attitude, and practices
related to edible oils and fortification
3. Market assessment—identification of edible oils distribution systems
4. Stakeholder mapping—identification and consultation of all stakeholders potentially
involved in the production, regulation, monitoring, and implementation of the program
5. Fortification level calculation—calculation of the appropriate fortification levels and
types of fortificants
6. Cost estimations—data collection on the cost of fortificants and costs related to the
program implementation and monitoring
FINDINGS
The PT are likely to suffer from negative consequences of micronutrient deficiencies
unless more investments are made for prevention and control. Micronutrient deficien-
cies remain a public health concern, particularly for at-risk population groups in the PT.
Despite various efforts by the MoH and other partners, current interventions need to
be further strengthened in service delivery, supply availability and management, and
demand creation. In addition, the MoH should consider establishing a new intervention
targeting the entire population to improve micronutrient intake.
ASSESSMENT TO IDENTIFY BOTTLENECKS OF EXISTING
ANEMIA PREVENTION AND CONTROL PROGRAMS
Children under five years old, adolescents, women of reproductive age (15–49
years), and pregnant women are the most vulnerable to anemia in the PT . This is
similar to other countries and mainly due to increased iron needs related to growth, fetal
Micronutrient Deficiencies in the Palestinian Territories 10
development, and losses of blood during childbirth or menstruation. Tables 1 presents the
prevalence of anemia among high-risk groups in the PT and the corresponding World
Health Organization (WHO) classification to determine the public health significance of
anemia at the population level. Among the at-risk population groups, pregnant women
and children 6–23 months old are the most vulnerable. By region, the prevalence of
anemia is higher in the GS than in the WB across all subpopulation groups. The
prevalence has remained static during the last decade in the PT (see figure 1).
Table 1: Prevalence of anemia in the Palestinian territories
PREVALENCE DATA SOURCE PUBLIC HEALTH
POPULATION GROUP REGION OF ANEMIA (YEAR) PROBLEM
GS 57% HAR (2020)3 Severe
Pregnant women
WB 27% HAR (2019)5 Moderate
GS 55% NNSS (2018)4 Severe
Children 6–23 months*
WB 39% HAR (2019) Moderate
GS 21% PMS (2013)8 Moderate
Children 2–5 years
WB 15% PMS (2013) Mild
GS 35% PMS (2013) Moderate
Postnatal women
WB 25% HAR (2018) Moderate
GS 12% PMS (2013) Mild
Adolescents 15–18 years (Male)
WB 9% PMS (2013) Mild
GS 22% PMS (2013) Moderate
Adolescents 15–18 years (Female)
WB 19% PMS (2013) Mild
*
The prevalence reported for this age group by the Health Annual Report (HAR) and National Nutrition Surveillance System (NNSS)
corresponds to anemia testing at 12 months of age.
Figure 1: The prevalence of anemia at the national level from 2012 to 2018
60%
54%
51% 52% 51% 51%
47% 48%
50%
40%
32% 32%
30% 31% 29%
27% 28%
30%
20%
10%
2012 2013 2014 2015 2016 2017 2018
Children 12 months Pregnant women
Source: NNSS
Micronutrient Deficiencies in the Palestinian Territories 11
Certain characteristics among the at-risk groups are associated with lower hemoglo-
bin levels or a higher prevalence of anemia in the PT. In particular, based on bivariate
and multivariate analyses using the Palestinian Micronutrient Survey 2013 (PMS 2013)
data, those with the following characteristics are more likely to be anemic: iron defi-
cient, residing in the GS, deficient in vitamin A and folic acid (for pregnant and postnatal
women and adolescents), having an infection (fever or diarrhea; for postnatal women
and children), not taking iron folic acid (IFA) tablets regularly (for pregnant and postnatal
women), not taking IFA tablets during or after pregnancy (for postnatal women), lacking
awareness about the fortified four (for postnatal women), having lower consumption of
iron-rich food (for pregnant women, adolescents, and children), being in the second or
third trimester of pregnancy, being a child 6–11 months old, and being a female adoles-
cent (15–18 years old). This highlights how demand-side constraints are significant in the
PT. For details of the analysis results, refer to annex 1.
Targeting
Anemia prevention and control (APC) programs target the most vulnerable groups in
the PT. The programs consist of two main interventions: a food fortification program and
an iron supplementation program. The fortification program aims to increase the intake
of iron and other micronutrients for the entire population by adding 10 micronutrients to
wheat flour. The MoH and United Nations Relief and Works Agency for Palestine Refu-
gees in the Near East (UNRWA) distribute iron supplements to pregnant and postnatal
women and children 6–23 months old. This aligns with the supplementation program
inclusion criteria by the WHO and has been designed to respond to the high prevalence
of anemia in the PT. In addition, health care workers are trained to provide nutritional
guidance and promotion of breastfeeding and complementary feeding as per the
Maternal and Child National Nutrition Protocol (MCNNP).
Service delivery and supply
The MoH orders iron and folic acid (IFA) supplements based on the push-based
approach. The push-based procurement approach of IFA tablets could be a constraint
in a context where demand does not materialize. Information about the frequency of
stockouts of iron supplements was not available as MoH facilities do not report such
information to the central level. However, according to health care providers interviewed
at central, governorate, and facility levels, the occurrence of stockouts of iron
supplements is rare.
Current IFA supplementation program does not meet the needs according to the
national guidelines . In 2019, the MoH estimated iron supplementation needs that cov-
ered only 77 percent of those who should receive iron supplementation based on the
MCNNP (based on number of pregnant women receiving antenatal care [ANC] services).
The amount of iron folic acid (IFA) tablets distributed by the MoH to its clinics is sub-
stantially lower (61 percent) than the amount needed to meet the iron supplementation
Micronutrient Deficiencies in the Palestinian Territories 12
needs. The gap in identifying adequate amount of iron supplements is due to how the
needs are calculated. The MoH orders iron supplements for pregnant women based
on previous orders, not based on actual needs of the number of participating pregnant
women and their recommended intake of IFA. The past order is not the accurate indica-
tor, as beneficiaries may not have complied with their iron supplementation schedule and
quantity due to the late start of ANC, insufficient nutritional counseling (both frequency
and quality), and inadequate follow-up and monitoring of the compliance with the iron
supplementation by the target population.
IFA tablets may not be dispensed as recommended . Interviewed health care provid-
ers did express concerns that the technical guidance is not comprehensive enough for
anemia prevention, which suggests that health care providers may not be proactively
providing tablets, according to the protocol, to beneficiaries who do not request them.
Quality of care is a probable bottleneck . The monitoring process of iron supplemen-
tation activities registers the volume of supplements dispensed but does not collect
data on patient compliance with the supplementation schedule. Interviewed health care
providers considered that their patients’ compliance with iron supplementation was
satisfactory, however, no information is available on the level of compliance.
The food fortification program is not contributing to the increase in iron intake as
expected. Only 3 to 5 percent of the flour sampled for spot checks was confirmed to be
compliant with the national standards. The monitoring and enforcement capacity within
the Palestinian authorities is limited due to insufficient budget and human resources.
Demand
There are no significant cultural barriers impeding available interventions, but both
beneficiaries and service providers reported gaps in the quality of care. In the PT, the
target population does not seem to have beliefs or cultural practices that could prevent
them from engaging in APC activities. However, some beneficiaries reported their
dissatisfaction with the interventions due to the lack of information sharing about possi-
ble side effects of iron supplementation and their management and poor communication
between beneficiaries and health care providers. On the other hand, some health care
providers reported the lack of adequate training on nutritional counseling and effective
patient-provider communication.
ASSESSMENT OF THE FEASIBILITY OF EDIBLE OIL
FORTIFICATION WITH VITAMINS A, D, AND E
An edible oil fortification is a technically and financially feasible option in the PT to
improve intake of vitamins A, D, and E . Summaries of the assessment results are pro-
vided below, and details are available in annex 2.
Micronutrient Deficiencies in the Palestinian Territories 13
Consumption
Based on available literature and data on the import, production, and export of edible
oils, it is estimated that in the PT, 25-40 grams of edible oil (excluding olive oil) are
consumed per person per day. Most common edible oils are sunflower oil, corn oil, olive
oil, soybean oil, and palm oil. Except for olive oil, these oils are all imported mainly from
Egypt, Ukraine, Turkey, and Malaysia. Sunflower and corn oils are widely used in house-
holds, whereas palm oil is common in the food industry (restaurants).
Repacking industry
Two repackaging plants are present in the WB, but none exists in the GS. Therefore,
a combination of local fortification at repackaging plants and importation of already
fortified oils should be considered. Fortification plants would need to invest around
US$12,000 (per plant) for fortification and postprocessing—that is, for equipping a tank,
piping, dosing pump, agitation/mixer, and so forth.
Monitoring for quality control/assurance
Different monitoring strategies need to be established between the WB and GS,
given that the GS needs to fully rely on importing fortified oils. While edible oil
repackaging plants can be equipped for fortification in the WB, fortified oil must be
imported into the GS. This leads to different control strategies at different levels (i.e.,
border, production site, warehouse, market, and household levels) in two regions. If for-
tified oils are imported, a thorough inspection of imported oils with approved technical
specifications needs to be conducted at customs/border level. In WB, if the edible oil is
fortified at repacking plants, two forms of monitoring are required: internal and external
monitoring. Internal monitoring is performed by the plant itself to ensure compliance with
the required fortification levels. External monitoring must be conducted by the appro-
priate authority to endorse compliance with fortification guidelines. To do so, accredited
laboratories will need to be identified and supported with regular external quality con-
trols for the measurement of vitamins in oil, availability of chemicals, and other necessary
supplies and consumables. Monitoring at warehouse and market levels will need to be
done on a regular basis. Additional capacity building is necessary for customs to enforce
import regulations at the border with thorough monitoring and inspection.
Fortification level calculation
In order to decide on the fortification levels, the MoH is presented with three possible
scenarios to choose from. The optimal fortification formula for edible oils would be 12
mg of vitamin A, 300 µ g of vitamin D, and 300 mg of vitamin E per kilogram of oil. This is
based on a conservative fortification level and calculated based on an estimated intake
of 25 grams of edible oils per person and EAR coverage of 50 percent. The proposed
vitamin E content optimizes the ratio of vitamin E to polyunsaturated fatty acids,
which protects the oil from damages and prevents deficiencies. To decide adequate
Micronutrient Deficiencies in the Palestinian Territories 14
fortification level, the MoH needs to decide how the edible oil fortification program can
be managed with an existing wheat flour fortification program. The co-existence of two
fortification programs that cover the same nutrients might not be ideal, due to the pos-
sible toxicity caused by an overconsumption of vitamins. Table 2 presents three different
options for fortification level calculation.
Cost
Additional cost in fortified oil would be minimal in the final produce price. The cost
of the premix (vitamins A, D, and E) only adds about US$0.014 to a kilogram of fortified
oil. If the MoH decides to change the vehicle for vitamin A and D fortification from flour
to oil, the MoH would save about 47 percent of the premix cost. The same amounts of
vitamins can be delivered with a saving of approximately US$0.2 million a year by only
changing the vehicle from flour to oil. On the other hand, fortifying the two food vehi-
cles with the same vitamins would result in an additional cost of approximately US$ 0.5
million per year
Implementation and stakeholders
Implementation of an edible oil fortification program will require a legal process led
by the MoH. Representatives of the main stakeholders (the MoH, Ministry of National
Economy [MoNE], Palestinian Standards Institution [PSI], Palestinian Food Industries
Association, Food Union) will need to form a committee for the edible oil fortification
program. To legalize the edible oil fortification program, the MoH will need to discuss a
draft law and its technical application with the PSI. The MoH would need to form a tech-
nical regulations committee to establish national regulations in edible oil fortification with
relevant stakeholders. The national regulations would need to be raised with the Parlia-
ment to become law, with an implementation decree by the MoH. During the implemen-
tation phase, the MoH will need to closely work with relevant stakeholders, such as the
MoNE, for training and importation processes. In addition, the MoH would need to work
with different ministries and partners involved in sample testing (Ministry of Agriculture
for chemical residues), food distribution (UNRWA and World Food Programme [WFP]),
and health promotion (United Nations Children’s Fund [UNICEF] and WHO).
Micronutrient Deficiencies in the Palestinian Territories 15
Table 2: Options for vitamin fortification in two vehicles (flour and oil)
PREMIX COST
OPTION DESCRIPTION (US$/year/total population) ADVANTAGES CHALLENGES
• The solubility of vitamins A and D remains
Vitamins A and D will
• Increased amount of vitamin E in the food supply A low, which would hinder bioavailability upon
remain in the flour
negligible increase in the price of oil after fortification. consumption.
1 fortification program, 1,464,563
• Provision of an antioxidant property to the oil by the add- • Risks of failures during the implementation of
and only vitamin E will
ed vitamin E and prevention of its oxidation and rancidity. the new program (obstacles in monitoring, lack
be added to edible oils.
of commitment from industries, etc.).
• Higher solubility of vitamins A, D, and E in oil than flour.
Vitamins A and D will Higher amount of vitamin E in food supply.
be excluded from • Provision of an antioxidant property to the oil by the add-
• Risks of failures during the implementation of
the flour fortification ed vitamin E, and prevention of its oxidation and rancidity.
2 program, and vitamins
1,277,500 the new program (obstacles in monitoring, lack
• Added vitamin E also prevents degradation of other
of commitment from industries, etc.).
A, D, and E will be vitamins present in the oil.
added to edible oils. • The cost of the premix for flour fortification will decrease
by 47 percent.
• Addition of vitamins A and D to flour and oil
will require monitoring of fortification of two
• Higher solubility of vitamins A, D, and E in oil than flour.
Vitamins A and D will food vehicles.
Higher amounts of vitamin A, D, and E in food supply.
remain part of the flour • Risks of failures during the implementation of
• Provision of an antioxidant property to the oil by the
fortification program, the new program (obstacles in monitoring, lack
3 and vitamins A, D, and
1,756,563 added vitamin E, and prevention of its oxidation and
of commitment from industries, etc.).
rancidity.
E will be added to • Significant increase in the cost of the
edible oils. • Added vitamin E also prevents degradation of other
fortification.
vitamins present in the oil.
• A daily vitamin intake reaching 95 percent of the
upper limit (of vitamin A) in some (rare) cases.
Micronutrient Deficiencies in the Palestinian Territories 16
RECOMMENDATIONS
AND WAY FORWARD
The assessment results highlight the burden of persistent micronutrient deficiencies
and actions that can be taken to improve the coverage and quality of interventions in
the PT. In particular, the coverage and quality of existing interventions can be improved
by revising iron supplements stock management, strengthening quality of care in nutri-
tion counseling, raising awareness about the importance of adequate micronutrient
intake and about the existing APC and fortification programs to increase demand, and
strengthening monitoring and evaluation systems for service delivery and fortification
enforcement (refer to annex 3 for details).
While the report identifies challenges and opportunities based on readily available
data, collection of more recent data on biomarkers and dietary intake is necessary.
The report relies on the most comprehensive datasets, such as PMS 2013, but up-to-
date nutrition data is critical to assess the burden and design more context-specific inter-
ventions. For example, to design the edible oil fortification program, more recent data on
vitamins A, D, and E deficiencies and dietary intake among the Palestinian households are
critical to determine an adequate fortification level (i.e., amounts of vitamins to be added
into edible oils).
To improve the quality and coverage of APC interventions, the existing service
delivery system needs to be strengthened. First, IFA supplementation needs should
be calculated for each specific target group by using the number of registered users and
the schedule established in the MCNNP. To increase the IFA supplementation delivery,
MoH facilities can take an integrated approach by providing IFA tablets to children
who visit the facilities for other services, such as routine immunization and deliver IFA
tablets during home visits. IFA tablets stocks at central warehouses and MoH facilities
should be reported to relevant departments at the MoH to accurately monitor IFA tablet
dispensary and orders. Capacity building for the health care providers at MoH facilities
should be sought through pre-service and in-service training and supportive supervision.
Capacity building should include how to provide counseling regarding iron supplemen-
tation (during antennal, postnatal, and childcare). In addition, tailored communication
campaigns can raise awareness among women, mothers and children on the importance
of IFA supplementation through mass and social media or through influential personnel in
the community.
Edible oil fortification is a potential additional platform for improving micronutrient
deficiencies. From both technical and programmatic perspectives, an edible oil forti-
fication program, if implemented, has high chances of success as oil is a more suitable
vehicle for fortification with fat-soluble vitamins and the monitoring processes are simpler
Micronutrient Deficiencies in the Palestinian Territories 17
than those for flour fortification. Vitamins A and D are more soluble in oil and can be
measured more adequately in oil than flour. Edible oil is mainly imported or processed
in two repacking plants in the WB, which makes the monitoring more manageable than
that of the many small mills that process flour. To establish a new and feasible edible oil
fortification program, the MoH and relevant authorities should first decide the quantity
of vitamins to add in edible oils. This should be based on what option best addresses
the population needs, taking all health and economic variables into consideration. If
the edible oil fortification is implemented, both local and source fortification should
be considered to complement each other to fully support the program objective. The
enforcement of local fortification removes the technical barrier to trade, and this step is
mandatory for the PT to be able to import fortified food commodities.
Opportunities for strengthening the demand and uptake of micronutrient supple-
ments and fortified products exist within ongoing World Bank projects. The MoH
implements activities to improve caregivers’ parenting skills in promoting healthy devel-
opment of children under the Improving Early Childhood Development in the West
Bank and Gaza program, financed by the World Bank. The project aims to develop and
pilot a parenting intervention for families and is currently in the implementation phase.
The parenting intervention will consist of interactive information sessions for pregnant
women and caregivers of children 0–36 months old, which can be leveraged to counsel
beneficiaries about available APC services and the importance of compliance with rec-
ommended practices for positive health benefits . In addition, Social Protection Enhance-
ment Project and Emergency Social Protection COVID-19 Response Project targets poor
households with cash transfer programs. The target beneficiaries are likely to be food
insecure and at risk of micronutrient deficiencies. The findings can help design appropri-
ate resource materials for the households to improve diverse micronutrients intake, along
with available APC services.
At the request of the MoH, the World Bank will continue to provide additional tech-
nical and financial support in materializing recommendations from the assessment
results. Particularly, the MoH would like to develop a comprehensive road map for the
edible oil fortification program. This requires having a technical expert(s) working with
the MoH side by side for the program design, including costed implementation and a
monitoring and evaluation plan. In addition, the MoH needs technical and financial sup-
port in strengthening laboratory capacities; conducting spot checks of samples; estab-
lishing/revising technical regulations; building capacity for monitors at points of entry,
repacking plants, and retail shops in markets; and equipping the repacking plants for local
fortification of edible oils with premix.
The assessment results will be widely distributed to all relevant stakeholders to help
inform their programs and interventions in the PT. Some donors have shown a strong
interest in using the assessment results, particularly on anemia, to inform their support in
strengthening maternal and child health service delivery in the PT.
Micronutrient Deficiencies in the Palestinian Territories 18
The assessment can help inform interventions to address micronutrient deficiencies
in similar contexts. Countries with socio-economic and cultural contexts similar to
those in the PT will benefit from the results and recommendations to better understand
determinants of high prevalence of anemia. In addition, the results from the edible oil
fortification feasibility study highlight an opportunity with a sustainable intervention at
the population level to reduce fat-soluble vitamin deficiencies in high-burden countries
(for example, countries in the Middle East and North Africa).
ANNEXES
1. Swiss Tropical Public Health Institute. 2021. Assessment Report: Bottlenecks in
Anemia Prevention and Control in the West Bank and Gaza Strip.
2. Conseil Sante. 2021. Final Report: Assessing the Feasibility of an Edible Oil
Fortification Program
3. Swiss Tropical Public Health Institute. 2021. Recommendations to Improve the
Implementation of Anemia Prevention and Control Interventions.
REFERENCES
1
R. L. Bailey, K. P. West, Jr., and R. E. Black, The Epidemiology of Global Micronutrient Deficiencies,
Annals of Nutrition and Metabolism 66, suppl. 2 (2015): 22–33. https:/ /doi.org/10.1159/000371618.
2
WHO (World Health Organization), Nutritional Anaemias: Tools for Effective Prevention and
Control (Geneva: WHO, 2017).
3
Ministry of Health, Health Annual Report, Palestine 2020, May 2021
4
National Nutrition Surveillance System 2018
5
Ministry of Health, Health Annual Report, Palestine 2019, June 2020
6
World Health Organization, & Food and Agriculture Organization of the United Nations (Eds.).
(2004). Vitamin and mineral requirements in human nutrition (2nd ed). World Health Organization ;
FAO.
7
Wardlaw’s Perspectives in Nutrition 10th Edition, by Carol Byrd-Bredbenner, Gaile Moe, Jacqueline
Berning, Danita Kelley.
8
Ministry of Health (Primary Health Care and Public Health Directorate, Nutrition Department),
UNICEF, State of Palestine, Palestinian Micronutrient Survey (PMS), 2013. March 2014.
9
A2Z: The USAID Micronutrient and Child Blindness Project, Determining the Dietary Pattern and
Biochemical Markers Among Women and Children in Hebron and Gaza City. n.d., 90. https:/ /www.
spring-nutrition.org/sites/default/files/a2z_materials/508-dietary_survey.pdf.
10
S. Radi, “Nutrient Intakes and Adequacy Among Preschool Children Under Blockade in Gaza
City, Palestine,” Eastern Mediterranean Health Journal 27, no. 5 (2021): 467–473. https://doi.
org/10.26719/2021.27.5.467.
Micronutrient Deficiencies in the Palestinian Territories 19
11
The Nutrition Working Group, Occupied Palestinian Territory, Report of the Multi-Sectorial Nutrition
Assessment Conducted in the Vulnerable Areas of the Gaza Strip, Occupied Palestinian Territory,
from October 15 to 31. (Save the Children, UNICEF, World Food Programme, 2018). Accessed
November 27, 2020, at https:/ /www.unicef.org/sop/media/1091/file.
12
Food Security Cluster and Palestinian Central Bureau of Statistics (PCBS), Socio-Economic Food
Security Survey 2018. (Palestine Economic Policy Research Insitute, 2018).
13
Food and Agricultural Organization of the United Nations, FAO in the 2021 Humanitarian Appeals
| Palestine. (Rome: FAO, 2021).
14
UN OCHA (UN Office for the Coordination of Humanitarian Affairs), Occupied Palestinian Territory
(oPt) Humanitarian Needs Overview 2021 (December 2020). (OCHA, 2020).
15
Halileh S, Gordon NH. Determinants of anemia in pre-school children in the occupied Palestinian
Territory. Journal of Tropical Pediatrics 2005; 52(1): 12-18.
16
Jalambo MO, Hamad A, Abed Y. Anemia and risk factors among female secondary students in
Gaza Strip. Journal of Public Health 2013; 21:271-278.
17
El Kishawi RR, Soo KL, et al. Anemia among children aged 2-5 years in Gaza Strip-Palestinian: a
cross-sectional study. BMC Public Health 2015; 15:319.
18
Hamarsheh, O., & Amro, A. (2020). Epidemiology of Parasitic Infections in the West Bank and
Gaza Strip, Palestine. The American journal of tropical medicine and hygiene, 102(2), 313–317.
https://doi.org/10.4269/ajtmh.19-0545