.,........-.. {.,3;------------------ CI' f.THRIPOSHAPRODUCT AND PROGRAMbyIrwin HornsteinforU.S. Agency forInternationalDevelopmentWashington, D.C.January 1986THRIPOSHAPRODUCT AND PROGRAMPreparedbyIrwin HornsteinforThe Office of NutritionU.S. Agency forInternationalDevelopmentWashington, D.C.January 1986Thismonographwas producedbytheFoodTechnologyBranch, Officeof InternationalCooperationandDevelopment, U.S. Department of Agriculture, withsupport providedbytheOHiee of Nutrition, U.S. Agency for InternationalDevelopment.PREFACEThisisthethirdina seriesof descriptionsof innovativeorunusual nutritionprogramsundertakeninThirdWorldcountriec; whichincludeafood technologycomponent. Theyhavebeenpreparedinthehopethat othersmayfindtheinformationuseful intheirownworkin development.TheTllriposhaprogramcombinesanumber of elementsthat giveittJarticularinterest.It representsasuccessful conversionof afeedingprogramfromfull relianceonimportedcommoditiestoaprogramwhereasubstantial shareof thefoodusedislocallygrownandprocessed. It illustratestheuseot nameandpackagingtocreateastrongpositiveimagefor asupplementaryfood. It provides ademonstrationof thecapabilityof take-homefeedingto achievenutritional impactwhencombinedwithother nutritionandhealthservices. Andit includesintroductionof the supplement throughcommercial channelsas acomplemJnt to the donation element.Thispiecewaswrittfi>:1byIrwinHornstein, VisitingProfessor, ColorL)do State University(at timeof withassistancefromRobert Weil, FoodTechnologyBranch, Of-fice of International Cooperation andDevelopment, U.S. Department of AgricUlture.Martin J. FormanDirector,Office of NutritionAgency for International DevelopmentR ....INTRODUCTIONWalk down astreet in Colomboand ask anymanor womaniftheyhave hearc of CAREor theUnited States Agency for International Develop-ment (AID) and ~ o u will probably be met withablank stare. Ask if theyknowwhat Thriposhaisand the Ghances are excellent that a smile ofrecognition will follow. Thriposhais ahouseholdword tv virtually all Sri Lankans. Its name issynonymous withgoodnutritionandits valueas afood for children is well understood. In Sinhala,Thriposhastands for threetypes of nourishmentandconveystheidea of a foodwiththree-foldnu-tritional value. The supplement provides energy,protein and vitamins and minerals. It consists of 40percent locally grown and processed comandsoyaand60percent of adonatedU.S. blendofcorn, soya, non-fat driedmilk, minerals andvita-mins. Thegoal isthat withinthenext six yearsThriposhawill becomeawhollyindigenousprod-uct.TheThriposha Programcombines feeding andhealths9rv:ces. It isajoint effort by Sri Lanka'sMinistry of HealthandCARE, a U.S. private volun-tary organization that promotes developmentin theThirdWorld. Support for ttlAprogramisalsopro-videdbyAID. Thecereal hasedfoodsupplement,Thriposha, is given at nocost to nutritionally atriskinfants, preschoolersandpregnantandlactat-ingwomen. It Is essentially a"take-home" pro-gramwiththeproduct distributed througha varietyof health centemin urban and rural areas. Thetake-home programcovers five out of every sixThriposha beneficiarieG. On-(>ite fee!'ling, primarilyon government-owned tea, rubber endcoconut es-tates, servestheremainder. Theprogram, whichreached onl:'! 75,000in1973, served632,000 in1983. ~ c h recij)ient receives 1500grams (3.3317S0-gram packets of Thriposha (Colorado StateUniversity)Ibs)of Thriposhapermonth- enoughfora daily50 gram serving that provides 10 grams of protein,about 200caloriesandafull dailycomplement ofminerals and vitaminc.Anevaluationby the Community Systems Foun-dationof theThriposhaProgramconcluded, "Theamount of nutritional improvement surpassesthatseeninanyother food supplementationprogramthat hasbeensubjectedtotherigorousstatisticaltests applied tothis data."The authors emphasizethat thepositivenutritional impl:ictoftheprogram"is duetotheentireprogram- immunizations,primary health care including deworming andmineraland vitamin supplementation, health educa-tion and Thriposha." The evaluators, however,foundit impossibletosort out theroleof Thripo-sha, independently of other factors. In their words,'Weemphasizethepackageof servicesbecausewe ct'lnnot isolate the contribution of Thriposhaalcne. However, we firmly believe thatThriposha the benefit observed would not befound."1This messageisclear - what makes the SriLankaProgramdistinctive andeffectiveisthe syn- combination of a nutritionally balanced foodsupplement, nutritioneducationandahealthpro-gramthat controlsandtreatsinfection. Thecom-blnecJ packageof food, healthandnutritionserv-ices is all-important.Inthehopethat theThriposhaprogramwill en-courageothers to explorethefeasibilityof intro-ducingsimilar programsin their owncountries, theproductionof ThriposhaandthesettinginwhichItis distributed are described here.BACKC1ROUNDSri Lanka, atear-shaped25,000square-mileis-land, 18milessoutheast of India, hasa populationof 15.9 million. Itstransportationsystemar.dcom-pact geographymakeall areasreadilyaccessibleto major populationcenters. Seventy-fivepercentofthepopulationlives inrural areas. Theper capi-taannual incomeisabout US:)320, althoughtheincome in rural areBS, urban slums and on thegovernment-runestates is lessthanhalf that fig-L:re. Theprimarytarget groupsfor supplementaryfeedingprogramsare themalnourishedamong thecountry's 2.25 million preschool children and250,000pregnant and lactating women.Malnutritionisaseriousproblem. In1976a nu-tritional statussurveyof preschool childrenbasedonmeasurementsof heightandweight foundthat35percent of preschoolersweretoo small for theirage(stunted), and 6.6 percent were appreciablyunderweight for their height (wasted). The samedataintermsof theGomeznutritionclassificationsystem indicated that 42 percent of allpreschoolerssufferedfrommoderate(GradeII) orsevere(Grade III) malnutrition.2Morerecent sur-veys confirmthe existence of malnutrition as acontinuing problem.Thenutritional statusofmanypregnantandlac-tating women is a!soprecarious. Their increased10rake,W.O. et al. Nutrition Programs in Sri LankaUsingU.S. Food Aid - AnEvaluation of PL480Title 1/ Programs. (Community Systems Founda-tion, Ann Arbor,Mich., 1982) pp. IV, 25.2Sri Lanka Ministry of Health, National NutritionSurvey, 1975/76 (Colombo).2requirement foradditional calories, protein and oth-ernutrientsduringpregnancyandlactationissel-dommet, andatleast one-fourthofthesewomenare classified:J::I anemic.Thisprofile- undernutritionandlow-income -is typical of most developing countries. The SriLankanhealthstatistics are, however, veryatypi-cal: Infant mortalityis, or. theaverage, 31 infantdeaths per 1000 live births. Average life expectancy at birth is 69 years.Thesedataarefar superiortofiguresforinfantmortality andlife expectancyincountries withsimi-lar percapita incomes. A WorldBank report foundthat Sri Lank::} hashalf againthelifeexpectancyand one fourth of the infant mortality than might beexpectedfora country witha similarper capita in-come.In great measure, tl-;:3 anomaly reflects thegovernment'sconcernwithfood, healthandnutri-tion. Sincetheearly1940s, Sri Lankahasstrivento make health services and foodavailable toallitspeople. The substantial drop in infant mortalityfrom145per1000in1945tothepresent 31 per1000 was achieved, in a large part, through ahealthsystemthat providedbettercoveragethaninmost developingcountriesandafood subsidy that providedamplerationsof ricetothepoor. However, in themoreremoterural villages,citys:um3andonthegovernmenttea, rubberandcoccmut estateswhere1.2millionpeopleliveandwork, infant mortality is higher, life expectancylower andfewer children attend school thande-pictedby the national average. ; .. .:II_...-:.::a. _To overcome existing shortcomings, both thefoodsubsidyschemesandthehealthsystemarebeing restructured. Increased emphasis is beinggiventohealthcaredeliveryat thelocal level andto increasedcommunityparticipationinhealthpro-grams.The food subsidy schemes in existence from1940 to 1977 provided free rice but proved aheavy bu.rden on the government, consuming up to14 percent of its revenues. In 1977, a new govern-ment came to power and replaced thefree ricedistributionprogramwitha lesscostlyfoodstampplan. Recipientsarelimitedtohouseholdswithin-comesof lessthan400,upees($20) per month.Thestampscanbeusedtopurchasebasicfoodstaples. About 7.5millionpeople, halfthepopula-tion, benefit fromthisprogram. However, thein-crease in the price of food has outpaced theperiodic increasesin thepurchasingpower of foodstamps. Asaresult, familiesthathadbeenreceiv-ing 80to90kilograms of riceper year receivedonlyabout 60kilograms in 1983. Dailycaloricin-takehas dropped substantiallyfor the poor. Forexample, on the tea estates it is estimated thattwo-thirds of the population nowconsume lessthan2000caloriesa day. Intheearly1970sonlythree percent wereinthis category. The overallef-fect hasbeentofurtherenhancetheneedfor aneffectivesupplementary food. Thriposhahelpsfillthat need.Program participants withThriposha packet (CARE- Steve Maines)THRIPOSHAThrlposhawasconceivedasa foodsupplemeilttomeet immediateneedsandattainfuturegoals.The concept was: Timely. It helped ease thenutritional problemscreated bythegovernment's belt tightening pro-grams of the early 1970s."Innovative. The use of low-cost extrusiontechnology reduced processing costs and pro-duceda centrally-processedproductwith excellentacceptability. Dynamic. From its inception, the programsought tocombat malnutritionby(a) providing afood which would be more effective than mosttake-homefoods becauseit would have amoredistinctiveimageas anutritional supplement; (b)progressivelyincreasingthelocally-producedcom-ponent of Thriposha until a whollyindigenous nutri-3tional food, not dE'oendent onforeignfooddona-tionsor imports, wouldbecomeareality; and(c)ultimately selling Thriposha through commercialoutlets, aswell, toreachthosenot qualifyingforthe feedingprogram or not reached by it.The approachesused to attain these goals havecreateda product that enjoys widespread consum-er acceptance. Everyeffort wasmadetodissoci-ateThriposhafromthestigmaof beinga"poorman's" food. Thriposhawasintroducedasawellpackaged, attractiveproduct withanauraandim-agebefittingafooddesignedtoimprovenutritionand health.Low-cost extruders enabled the program togrowtoitspresent dimensions. Theapplicationoflow-cost extrusion (LEC) technology to the produc-tionof blendedfoodsIndevelopingcountrieswaspioneered by Paul Crowley. Scarcely a decade agohe recommendedthat AIDexplore the utility of thistechnology for the preparation of centrally-proc-essed, nutritious, low-cost blended foods indeveloping countries. AIDacted on thisrecommen-dation. Implementationwasplacedin thehandsoftheNutritionand Agribusiness Group in theU.S.Department of Agriculture(USDA), headedbyMr.Crowley. TheKoehringCo., manufacturersof theBrGdyCropCooker - one of several low-cost ex-truders developed in the U.S. for on-farmproc-essing (cooking) of soya beans - loaned AIDthrADextruders. Theirfor quick-cookingmix-tures of cereais, :>oya, legUi nes and/or oilseedswas demonstrated under field conditions indeveloping countrip.s.Colorado State University served as the re-searchanddevelopment backstopfor theproject.JudsonHarper, nowColoradoState's vicepresi-dentforresearch, heade,j theproject andsupportwasprovidedcooperativelybytheDepartment ofAgricultural andChemical EngineeringandbytheDepartment of FoodScience andNutrition.To thosewho hadbeenassociated withthe pro-gramsinceitsinceptionandhadseenit start asaBrady anchored to a small concrete slab at ademonstrationsite, thefirst viewoftheThriposhaplant at Ja-Elamust havebeenal1excitingandin-spiringexperience. Thismodern, well-planned, im-maculat0facility, housedinabuildingcoveringanareaaslarge as a football field, is notonly a forceincombattingmalnutritionbutalsoa tributetothepeopleandinstitutions that brought the concepttofruition.Ja-Ela plant - main processing building withwarehouseto left (RonTribelhom)4Jacque Lauriac, director, and Justin Jackson,as-sistant director,of theCAREprograminSri Lankawere key CAREfigures who, In conjunctionwiththeLankanGovernment, madeThriposhaareality. InMarch1972, CAREsubmittedtotheSri LankanGovernment aproposal todevelopanindigenouslyproduced, cereal-basedweaningfoodto be usee: :n the government's maternal/childhealthcare programs.The initial plancalladfor thereplacement a small portionof theU.S.donatedfoods byloc,truders, cleaningand dehulling equipment, pack-aging equipment, an office and aquality controllaboratory. The plant is man&ged byCeylon To- r"'IiIllIW_-"____III_ .. .. .. .. ZFigure1. Flow Diagram for Making ThriposhaCleaning and DehulllngRawCom+___De_s.,.to_n_er__1+ExtruderRawSoybeans--SeourerlAspiratorandMillingProportionerHammer Mill+HullsProcessingbaccoLtd., thesuccessful bidderona contract tcperform this function.As afirst step, rawcornand soyarecleanedanddestoned, andsoyisdehulled. Thesedryin-gredientsare thenmeteredIntheproper combina-tionintothetwoextruders. Eachextruderhasanauger that rotatesat acontrolledspeedinasta-tionarycylindrical barrel. Asshowninthedrawingbelow, astheauger rotates, theuncookedcerealmixture is forced through the barrel. The augerworks the material mechanically and also gen-eratesheat throughfriction, cookingthe mixture atatemperature of 160C. Thecooked pr"duct isdischarged through an orifice. The rapid dropbetween thehigh internal pres;1ure and the outsideatmosphere causes some of the superheatedmoistureinthemixto flashoff andtheproducttoexpand to forma cooked flake.CoolerAction of extruder screwHammer MillPackagingVitamins 1 B_le.,.nd_e_r IJSifterMinerals- --IIn asinglestep apre-cooked product is pro-duced. Itsstarchandproteinconstituentsare bro-ken down into readily digestible components.Chemical factors present in soybeans and otheroilseeds andpfJIses which interfere with the body'sability to use their protein are deactivated. Furthrmore, the product's storage life is extended bydestructionof microorganismsfromtheheat gen-eratedby the rotating auger..\fter theproduct isextruded, it is cooledandground, andvitamins, mineralsandmilksolids areadded. It is thenpackaged. A flowchart for theThriposhaproductionprocess Is showninFigure1.Blending and PackagingInfestationInsect Destroyer+PackagingGauge+Instant ComSoy Milk

NonFatDry Milk

7 " '1 , I .' ~ j tmillion. Of t ~ amount 85percent representedthecostsof thefoodmaterials(includingthecost ofU.S. donatedfood). Fortheseexpenditures, morethan 12.5millionpacketsof Thriposhawerepro-duced. The cost of a two-week ration - one750-grampacket - wasU.S.$0.35. This includedthe cost of:6Medical ResearchInstitute, Sri LankaMinistryofHealth in Low-cost Extrusion Cookers, SecondInternational Workshop Proceedings eds. David E.Wilson and R.E. Tribelhorn (Agricultural andChemical Engineering, ColoradoStateUniversity,Fort Collins, Colo., 1979), p 211; Medical Re-search Institute, "Table of Average Intake", inLow-Cost ExtrusionCookers, International Work-shop (1976), op.cit. p.110.Thus, packagingaddeJ7.1 percent tothe com-modity cost and processing added another 10.2percent. Aspercentagesofthetotal cost, packag-ing accounted for 6percent and processing 8.6percent.Packaging and processing taken togetherrepresented acost of U.S. $1 .22per beneficiaryper year or one-third of one cent per day. Thisone-thirdofapennyperdayassuredareadilydi-gestible food, insect free and microbiologicallysafe. Furthermore, thissmall cost enabledsavingsto be made in the amount of fuelnormally requiredfor the prolongedcookingof cornand soyaandsavingsintime for the homemaker.The50-gram (2-ounce)daily rationof dry Thripo-shamakesupintotheequivalent of onethird- toonehalf-poundof preparedfood. Thesupplementprovidesahighlevel of protein, about 40percentof therecommendeddietaryallowancefor aane-ta three-year-old child. And it provides approxi-mately 15 percent of the calorie requirement,corresponding to roughly half of the estimated defi-cit of alow-incomerural preschool child. Essentialvitamins and minerals are also included.6Commentingontheconvenienceaspect of theproduct, Dr. DeMelstates, "Thriposha hasled thewayinourcountryfor thewomenwhofindit soU.S. $0.30U.S. $0.02U.S. $0.03raw materialspackagingprocessingThe investment cost to build this plant in1977-79wasabout U.S. $850,000. Approximatelyone-third of thisinvestment represented thecostof tlquipment, another thirdthecost of construc-tionandthefinal third the cost of land, rail sidings,installationandmiscellaneousitemssuchasfurni-ture and canteen equipment.Muchlarger costsarethe recurringones for therawcommoditiestobeprocessedand, toamuchlesserextent, theoperationoftheplant itself. Forexample, In 1981, recurring costs came to $4.3Twin Bradys inoperation at tha Ja-Ela plant -overhead surgetanks provide corn and soy forextrusion (RonTribelhom)The product Is a70/30 mixture of maizeandfull-fat soya. This mixisblendedwith12percentnon-fat dry milk and a 2 percent premix of vitaminsand minerals. It isthen combined in the ratioof40/60withdonated InstantCornSoy Milk to makeThriposha. The final product contains maize, 59percent; full-fat soya, 27percent; non-fat drymilk,12 percent;and vitaminsand minerals.8difficult toput one, two andthres to-gether tomakeaweaningfood. It'sall thereandall processed, and I thinkthat is one of the biggestthingsinits favor. It isconsideredbotha conveni-ence and a nutritious food.7,- .\!750-gram packets in master bags (30 packets perbag) for delivery to health centers (CARE - SriLanka)TheJa-Elaplant now extrudesabout 4.6millionkilograms of indigenously grown corn and soy.Thisrepresents40 percent of the, total 11.5 millionkilograms of Thriposha which is consumed bysome650,000recipients. Asaresult, theplant'stwoBradys are now operatingat full capacity, 900kilogramsper hour, 22hours per day.TheBradyshaveprovedeminentlywell suitedtoproducingatthis level of output. Their simplefrictionprocessresults in amachine that is relatively simple tocperate andmaintain. In addition, whereproduc-tionrequirementsremainbalowonetonperhour,theBradyscan turnout products at thesameunitcostasmuchlarger and more expensive extrudersthat useamorecomplex moistening and dryingprocess. But an expansion of plant capacity is.neededtoincreasethenumber of recipientsandsupport commercial marketing, while continuingthe shift inthe ratioof indigenous to importedma-terials.Accordingly, as a next step, a proposal wasdevelopedthat wouldincreasetheextrusionproc-essingoutput fromthepresent 900kilogramsperhour to2500kilogramsper hour. AnengineeringteamfundedbyAIDandprovidedthroughUSDAdesignedan expandedprocessinglinetomeettheincreasedrequirement. Costsofequipment, instal-lation, engineeringservicesandelectrical connec-tions were estimated at slightly under U.S.$500,000. Theproposal recommendeduseof aneight-inch Anderson International extruder whichhasthecapacityof approximatelyfiveBradys. In-crease of production beyond the present pointwouldmakealargemachineoperatingat full ca-pacity moreeconomical than the useof severalsmaller Bradys. Thegeneral questionof plant ex-pansionwas one cf thetopics discussed at a 1985workshop in Colomboattendedbyrepresentativesof the SriLankanGovernment, AIDand CARE andat subsequent meetingsof these parties. Afinaldecisionregardingexpansionhas not,however, asyet been made by the gov6mment.DISTRIBUTION AND IMPACTThefurnishingof anutritious, attractivelypack-aged, processed product has been a majorachievement of the Thriposha program. But the fullimpact of theThriposha approach resulted fromthen joining this product to other nutrition andhealthservices. Theseservicesare made available7De Mel, B. "Question and Answer Se:.sion"Low-Cost ExtrusionCookers, Second Internation-al Workshop Proceedings,op. cit., p. 201.9throughclinicsandrural healthcenters. Theyarethe first line of an extensive network which in-cludeshospitalsaswell ashealthposts. The sys-temisstaffed bymedical officers, medical practJ-tioners, nurses, family health andmidwives. Healthcareisreadilyaccessible. It hasbeenestimatedthat theaveragedistanc.e afamilyhastotravel toreachagovemment healthfacilityisonly threeandtl1at in1980, 83 percent ofpregnant womenand60jmrcentofchildrenbornthat year visited a health post at least':.:ince.,... ...,..,'U11 _""". iJlIlJ,l.. .. . . . ~ - ..r ...,.o;,....... w ~ ~ . . _ _Thepublicsystemisalsocomplementedbyanextensivenetwork of privatecarewhichincludes10,000 Ayurvedlc Indigenous health practitioners.Thepublicsystemisthemajorprovider of Thri-posha andhealthservices. Mothers are advised tobringtheir preschoolerstothegovernment healthposts atleastoncea month. A well attended ruralcenter mayaccommodate250childrenand50to75mothers per month. Theobject istoprovidethemother with health, nutritionandfamilyplan-ninginformationandtofurnishhea',thcarefor thechild. If immunization is called for, the child re-ceivestheappropriatevaccine. Theimmunizationprogram, avital element of thecountry's healthprogram, protects against diptheria, tetanus,whooping coughand tuberculosis.Asanaccompaniment totheseserv!cesThripo-sha is also provided. Mothers aregiven aone-monthsupplyof Thriposhafor eachchildconsist-Ing of two 750-gram packets. The resultis that therecipient receivesacombinedhealthandnutritionpackage which is considered the key to theprogram'ssuccess. TheThriposhaisintendedforpreschool children identified as malnourishedthrough periodicweighings andfor pregnant andlactatingwomenshowingclinical signsof anemiaorhavingdifficultyinbreast feeding. Th;sscreen-ing of recipients seeks to target Thriposha tothosemostinneed. It isa veryimportant elementof theprogram. Screeningisinplaceinmanyofthe program's centers. At the same time, therealsoremainagoodnumberof centerswherethis....Mothers and children at/ending health clinic (CARE- Steve Maines)10elemont hasnotyet beenimplemented. Implemerl-tationin these centers has aCl.ordlnglybeenrecog-nizedasanimportant further program objective.Intheevaluation of theprogram's Impact onnu-tritional status, madebytheCommunitySystemsFoundation, children were considered malnour-ishedif their weight was lessthem70percent oftheU.S. National Academyof Sciencesstandard.Thenutritional statusofchildrenwhowereintheprogramfor varying amounts of time was com-pared. Comparisonsweremadebetweenchildrenof similar age because variationin nutritional statusmay occurasa functionofage. This isduetothefact that needychildrentypicallyexperiencemax-imumnutritional risk in theperiod after weaningwiththerisklaterdecreasing. Bycomparingchil-drenof similar agEl, theevaluatorssoughttoavoidconfusing possible improvement in nutritionalstatusoccurringwithagewithimprovement asaresult of participationin the program.Theevaluation was basedonrecords of 1799childrenat42sitesinvariouspartsofthe countryand included bothrural andurban populations. Theevaluatorsfoundthat therateof malnutritionwaslowest among thosechildren withgreatest expo-suretotheprogram. For example, 44percent ofnew entrieseged1 to 2yearswere malnourished.In contrast, only29 percent of childrenof similarage who had been participating in the programwere malnourished, a difference of 33 percent.Health workers give out 750-gram packets ofThriposha to pregnant and lactatingwomen (CARE- Sri Lanka)1----'I,ISimilarly, inthecaseof childrenaged2 to 3and 3to 5 years theprevalenceof malnutritionamonglonger-termparticipantswaslesothannew entriesby 28 percent and 31 percent respectively. Theevaluatorsalsocompared therateof malnutritionamong similarly agedchildrenwhowere allalreadyparticipating in the program but for differentlengthsof time. Herealso, substantial differenceswerefoundin theprevalence of malnutrition, whichprogressively decreasedasparticipation in the pro-gramincreased.The evaluators noted that the data, althoughtaken fromafairly large number (.)f clinic sites,werenot basedonarandomsamplesincethes;were clinics whichhad adequateweight records.Theybelieve these clinics may,therefore, bebetterrun, althoughtheystatetheyhavenoevidenceofthis. Asaresult, theycautionagainst generalizingtoall elementsof theprogram. But what theydoconclude is that substantial impact is beingachieved in an operational setting even If state-mentsregardingthislevel ofimpactcannotneces-sarily bemadefor thetotal program. It might beaddedthat duetomeasurement factors, includingabsencefromthesampleof fullyrecoveredgradu-atedchildren, theevaluatorsbelievetheirfindingsactually understatethe true degreeof impact atthe clinics studied.Inreportingtheir results, the evaluatorswent ontostatethat it wasthepackageof servicesthatwascritical sincethestudywasnot designedtoisolatethe independent contributionof eachele-ment. Contributing factorswouldhave includedthefood, whichwasprobablysharedwithother familymemberstosomedegree, andtheother services,theutilizationof which was believed itself to bepartly induced by Thriposha'sincentiveeffect onclinic atte'1dance. In addition, improved mother'scaremayalsohavebeencalledforthbyexposuretothecombinedpackage. Of central importance,however, whateverthemechanismactuallyopera-tive, the evaluators concludedthat theobservedbeneficial impactwouldnothaveoccurredwithoutThriposha.Although take-home feeding is considered bymany themost effectivemeans of reachingpre-school children, there are few documented in-11stances of Its nutritional impact. Thisisdue Inpartto tho fact that it is considered very difficult tomeasure nutritionalimpact In a fieldsettingwithoutacarofullycontrolled experiment designedinad-vance. In addition, t'lCJ problemisfurther compli-catedinthecaseof!c?ke-homefeedingwheretheactual feedingdoes nottakeplace in asupervisedsituation. ButintheThriposhacase, clinicsprovid-ingtake-homefoodwere foundcapableofachiev-ing substantial impact under field conditions. Ademonstration was provided that the ttlke-homeapproach can be made to work, given the rightcombinationof inputs.On-Site ProgramInadditiontothetake-homeprogram, about 15percent of the recipip:':ts are provided Thriposhathrough day-care r;enters serving Sri Lanka'sgovernment tea,rubber and coconut estates.Mothers bring their children to a day-care center,or Creche, beforegoingtowork. Crecheattend-ants are responsible for caring for the children,preparing their food and acting as preschoolteachers. Thsyreceive six weeksof formal trainingprovided through an ongoing UNICEF program.Backing up the attendants are a family healthworker(midwife)anda FamilyWE;llfareSupervisor.TheFamilyWelfareSupervisor servesas theliai-sonbetweentheestate's250to500familiesandthe healthsystem. Hearranges medical appoint-ments, meetings, etc. ARegional Estate MedicalOfficer, appointedbytheFamilyHealthBureauintheMinistryof Health, coordinatesthe activitiesofthehealthteamson20to30estates. Inaddition,he conducts a monthly clinic at eachestate. At theclinics, childrenare examined,weighed, immunizedand dewormed. Mothers receive family planning,h l ~ h andnutritioneducation. All estatesin whichclinicsareconductedrecaivefreeThriposha. TheThriposha reaches the children through theCreches and is fed to the childrenonsite.The estate superintendent holds the key to asuccessful program. Hisinterest inthewelfareoftheestateworkers and their childrendeterminesthe resources that will be aliocatAd to the program.Thus,thehealthcare facilitiesandthe number andqualityof theCrechesonthe estatereflect this in-terest.-Children at a Creche on atea estate being giventheir mid-morning meal (CARE - Sri Lanka)Dr. !l.S. Perera, Medical OfficerfortheSri Lan-kaStatePlantationCorporationBoardII, woodeOffice,Talawakelle, assessedtheimpfl(.:t ofon-site feeding of Thriposha in an integratedhealth/nutritionThriposhaProgramon40estatesin the Kalutara region. Infants andpreschoolers en-rolledintheprograminJanuary1982receivedadaily50-gramrationof Thriposhafedon-siteforayear. Hecomparedtheirnutritional statusprior toenteringtheprogramandafter ayear Inthepro-gram.The percentago drop insecond andthird de-gree malnutrition was about 55 percent for bothin-fants and preschoolers with a concomitant in-creaseinthe percentage of normal children andthosemildlymalnourished, I.e., first degreemalnu-trition.Another, much smaller but interesting, on-sitesystem in which volunteerism is emphasizedservesasavehiclefordistributionof Thriposhainthe Mahaweli region. A resident project manager isresponsible for community development in about20,000 homes. At the next lower level a blockmanager is responsible for 4,000 homes. At thebase of thesystem is a volunteer who provides ru-dimentaryhealthcareandsupplementaryfoodto20homes.One of the functions of thisvolunteer isto provide Thriposhatochildren under five. volunteer preparesThriposhaintheformof por-ridge. In the early morning hours prior to setting'Offfor work, women bring their children to thevolunteer's homewherethe children receiveandeat the food.COMMERCIAL DISTRIBUTIONThriposha has been used primarily in feedingprograms. In addition, however, a:start hasbeenmadeinc.iistributing it through commercial chan-nels. Approx!mately 100,000 one-pound packetsare now soldin nine districts each month.Use of commercial outlets was envisioned asearly as 1972when CAREsubmittedits originalproposal for a newproduct forSri Lanka'sfeedingprogram. Thriposha, sold for a lowprice, couldhelpchildrennot sufficientlymalnourishedtoquali-fy for freedistribution but whoseeconomiclevelput themin jeopardy of becoming malnourished.Theuseof commercial outletscouldplayamajorpreventiverole. It couldalsoprovideameansofservingchildrenwhoweremalnourishedbut werenot reached by the feeding program.12Normally, a major obstacletotheintroductionofacommercial proces:::edfoodisthelackof pUblicawareness. Without extensiveadvertisingaprod-uct may never achieve the ima.ge required formassacceptance. Eventhen, newproductsoftenfail becausethey do not meet perceived needs.Butinthecase of Thriposhath'c3situationwasdif-ferent. The feeding programhad already estab-lished Thriposha's image. As a result, when, In1977, Thriposhawastriedout inconsumer trials,there was ready acceptancl3. AstUdybyCARE,Lever Brothers and Texas A&MUniversityfoundthat 92 percent of those surveyed had alreadyheardof Thriposhaandthat 67percent hadusedThriposha at some time;. The survey concludedthat the concept of Thriposha as a "nutritiousproduct" that Is "goodfor children" was"under-stood,believed and accepted. "BTh'sstrategyof creatingaspecial packageandname for a take-home food had paid off. Ob-serversbelievethat it wastheawarenesscreatedby the feeding program which induced LeverBrothers, alargeprivatecorporation, todecidetotake on Thriposha as a potentially viable product.In1980, followingthe positive results of the con-sumer acceptancetrials, LeverBrothersinitiatedatest market operationInfour salesareas- Kan-dy, Mutale, GalleandMatara. Thriposha, throughLever's extensive r':ltail network, now took itsplace - alongside soap, toothpaste and otherhousehold items - in 2,000 outletsincluding manysmall shops inremote rural areas.Initiallytheproduct wassupportedat thepointof sale withposters and leaflets but no convention-al advertising. AnanalysiscarriedoutinMay 1981showed that the averagemonthly purchasewasabout 1,000casesor 48,000poundsper month.LeverBrothers continuedto distribute the product,and sales remained at a similar level during1982-83.InAugust 1983, distributionwaswidenedtoin-clude two additional coastal areas, Ambalangadaand Tangalle. At the same time changes weremade inthe method of distribution.Prior to August 1983, Lever Brothers did notadd a charge for its role in distributingthe product.But inAugust It wasdecidedtoplacetheopera-tiononamorecommercial basis. Asmall chargewasaddedfor the cost of warehousing, transport,salesandadministration. This charge, about 4 per-cent, wasaddedtothemark-upof thewholesalerand retailer of about 20 percent.In November 1983, areviewof theThriposhacommercial lJrogrambyJohnNichols, TexasA&Mmarketing specialist, concluded that Thriposha wasamarketingsuccess, andthat sales wereincreas-ing despite the lack of a promotion effort.BCorea, R., "Commercial THRIPOSHAConsumerAcceptance Test - Analysis of Principal Find-ings" in Low-Cost Extrusion Cookers, SecondInternational Workshop Proceedings, op. cit. p.193,200.13Introducedin1980at 5.5rupeesperpound, in-creasedcosts required Increasestoapriceof 9rupees per pound, or about 451:, in 1984.Nevertheless, Thriposharemainsmuchlesscostlythanother weaningfoodsthat sellfromtwoto tentimesits pricefor acomparableamount of prod-uct. Arecent CAREanalysisindicatedthat the9rupeepricewouldbeintherangetocover costplus return on investment in a commercial setting.9A surveyconducted in1984 indicatedthatcom-mercial Thriposha was consumed in significantquantityandthat thosereceivingThriposhainclud-ed lower illcomegroups.10Thesurveywas con-ductedprior tothepriceincreaseof 9rupeessothat further experiencewill berequiredtoconfirmthese results, although an earlier one-rupee in-crease did not affect sales levels. The surveyfoundthat t:32 percent of thepersonsinterviewedpurchased Thriposha once a month and on theaveragebroughtthreeone-poundpackets. Eighty-twopercent of thechildren, aged 0to2years,werereportedtoconsumeThripCishaonanaver-ageof at least oncea day. Averageconsumptionper feedingwas20 to 23gramsdependingonthepreparationused. Seventy-two percentof children,aged3to5, consumedThriposhaonanaverageof at leas'( once per day. Average consumptionperfeedingwas27to29grams. All agegroupscon-sumed Thriposha, with greater consumption re-portedforchildrenandteenagersascomparedtoadults.While all income groups in the sample purchasedThriposha, asubstantial percentagehadquitelowincomes. In the rural areas, 40 percent of thehouseholdspurchasingThriposhahadano:3timat-ed monthly cash income of 750 rupees (about$37.50) or below, with 19percent having al1 in-comeof 500rupeesorbelow. Intheurbanareas20 percent hadanincome of 750rupees or below,and 8percent had an incomeof 500rupees or9The TI1riposhaProgram, BackgroundInformationto Facilitate Decision Making, prepared for theThriposha Program Implementation PlanningWorkshop, January29-Febru'.y13,1985,Annex(1-H).10Lanka Market ResearchBureau, Ltd., Thriposha,Study on the Imp/3ct of Advertising (1985).below. Theeligibilityrequirement for foodstampsis a family income of 400 rupees per month.It isalsoof interest thatsome of thosewho pur-chasedThriposhaalsoparticipated inthefeedingprogram. Thiswasthecasefor 38pArcentof therural sample and 15 percent of the urban.One-pound box of commercial Thriposha (ColoradoStateSomeobserversbelievethat commercial distri-bution 01Thriposhacouldrepresent anadditionalmeansofalleviatingSri Lanka'snutritionproblem.It might serve both as apreventivemeasureforchildrennot malnourished enough toqualify for thefeeding programand also help increase generalawareness of theimportanceof providinganap-propriatefoodfor weaning. Thismight beaccom-plished at little or no bUdgetary cost to the !l0vern-ment. InJohnNichols' view, furtherexperi-ence at thehigher priceisneeded beforeit will beknownwhether this is possible. Nevertheless, hebelievesthereisafairlygoodchancethatThripo-shacouldbesoldat apricenot substantiallydif-ferent fromthepresentone that wouldbothcover14

its cost and be within the reach of most low-income people.An important stephasrecentlybeentakento-wardthe goal of establishing commercial Thripo-sha on a fully self-sustaining basis. In October1985, thesource of rawmaterial forproductionofcommercial Thriposha was shifted completely to lo-cal foods.Whileexperienceisnotyet sufficient tomakeafinal determination, it wouldappear that commer-cial Thriposha has accomplished something thathas very seldombeen accomplished before. Fordespite a great many attempts, there has beenverylittlesuccess inprovidingafoodthat islow-cost, reaches youngchildrenandiscommerciallyviable. Thriposha, althoughalsoconsumedbyoth-er family members, appears to meet thesecriteria.11Observersciteseveral reasonsforthisachieve-ment.One,preViously noted, was the favorable im-ageof Thriposhacreatedbythefeedingprogram.Asecondis thelowprice, facilitatedby100li-costprocessingtechnologyandinexpensivepackaging.Athirdistheefficient distributionsystemof LeverBrothers. A fourthmaybe that Thriposha providesaconvenient pre-cookedbasefor makingatradi-tional snack, Aggala. The1984surveyfoundThri-posha was often prepared as Aggala and con-surnedinthisformbypre-school childrenaswellas other family members.11Another interestingapproachtouse of commer-cial outlets has been tried in Colombia usingfood coupons to partially support the priceofweaning andother special foods. Adescriptionof thisapproachappears in an earlier publicationinthisseries. Sanders, T.G. PAN - ADescrip-tion of the Colombian National Nutrition Program.(Office of Nutrition, USAID, Washington, D.C.1980)SOY PRODUC,.IONInadditiontoitscontributiontoSri lanka'snu-tritionprogram, thedevelopment of Thriposhahadanother, not fullyanticipatedbenefit. TheSri lan-kan Government was interestedin providing soyasa means of improving thecaloric andproteinin-takeofitspeople. In1973, itappliedto theUnitedNationsDevelopment Fundfor assistancefor thispurpose. But amajor obstacle to increasing soyproductionwaslackof a market for a foodnew to1J0tentiai consurrers. The Thriposha programhelped to provide this market, furnishing thestimulusforfarmerstoadoptthe cultural practicesneeded to incorporate soybean production intotheir farm!ngsystems. Italsoboughttime forpeo-ple to become accustomed to the use ofsoy! as afoodingredient.Other efforts werealsomadetostimulatedevel-opment of markets for soy. For example, CAREandUNICEFhelpedprovidesupportforthedevel-opment of the government's Soybean Food Re-searchCenterat Gannoruwa. Thepurposewastoincrease outlets for soy by developingnewsoy-basedproducts. Withtechnical assistanceprovid-edby the University of Illinois,the center wascom-pletedin 978. Itsworkhasincludedthedevelop-ment of asoy substitutefor coconut milk whichwas subsequently produced by the government.The first extensive use of the soya began in1976whenCAREpurchased26,000kilogramsoflocallygrownbeans for usein theproduction ofThriposha. As lateas 1980, Thriposha still con-sumed65percent of Sri lanka'sannual produc-tionof soybeans, whichwas1,000metrictonsascompared toamere25tons in1972. Inrecentyears, however, Sri lanka's soy production hasgreatlyexpanded withThriposha's useof soy in1983 representing less than 15 percent of a10,000 metric toncrop. Despite a setbackin1984,due to adverseweather conditions, soy productionisnow fullylaunched.Thanksinpart to Thriposha,soy cultivationhas become a viableagriculturalac-tivity in Sri lanka.SUCCESS FACTORS AND NEXT STEPSTheSrilanka experience hasbeensignificantInseveral ways. It has shown that:1. A feeding programcan be converted fromonerelyingexclusivelyonU.S. donatedcommodi-tiestoaprogramwhereasubstantial contributionismadeby locally grown andprocessed foods.2. Astrongpositiveimagecanbe crentedfor asupplement despite the fact that it is used in a pro-gram directed to the poor.3. A take-home feedingapproach canbeinstru-mental in achieving nutritional impact.4. Asupplementaryfoodcanalsobemarketedas alow-cost commercial product, permitting ex-panded access to the supplement.Observers citethefollowing factors as key tothese achievements:1. There was a high level of commitment bythose responsible for the program: The Government of Sri Lankashoulder8lJ alargepart of theprogram'ssubstantial recur-ring costs.15 Government personnel demonstrated anadaptability and willingness to experimentneeded to moveauseful concept toafullyfunctioning program. CAREsought tomakethebest possibleuseof Foodfor Pe',::ecommoditiesandhadthewisdomtoforeseetheneedfortheirreplace-ment by locally grown and processed foods. AIDalso provided importantsupport, includingboth technical assistance and financing. To-gether withCARE andthe Sri lankan Govern-ment, AIDhelped fundthe constructionof theJa-E!a plant.2. A :echnology wasidentified that in cost, easeof operationandoutput was compatible with Srilanka'scapabilitiesandneeds. TheSri lanka ex-periencedemonstratesth: t an"appropriatetech-nology" neednot beahomeorvillagelevel tech-nology to be successfully transferred to a develop-ingcountry. Productivitywasenhancedbyturningtheplant operationovertotheprivatesector.Ob- .serversattributetheefficiencyof theJa-Elaplantto its management by Cl3ylon Tobacco.3. An attractive name and package helpedmakethesupplement widely perceivedas "nutri-tious" and "goodfor children." This imagewasfurther strengthened by the nutrition educationprOVided.4. Thesynergisticcombinationof Thriposha, atake-homefoodwithadistinctiveimage, nutritioneducation, andhealthservicesledto thebeneficialnutriti'Jii