Thursday, 28 August 2014

Does fortifying food improve nutrition for the poorest people?

Globally, deficiencies in micronutrients are staggering in scale. According  to some estimates, between 40 and 60 percent of all children in developing countries suffer negative health consequences from not receiving enough iron, and a similar percentage don’t get enough Vitamin A.

One response to this problem has been more widely adopted than any other: food fortification, the process of adding micronutrients to basic foods such as wheat flour, salt or vegetable oil. According to the Food Fortification Initiative, 81 countries have passed legislation requiring at least one cereal food to be fortified.

While the rationale behind this approach is clear: fortification costs relatively little and has the potential to rapidly reach large numbers of people, case studies by IDS and partners have highlighted that fortification programmes need to do more to have an impact on the social groups that suffer the most from undernutrition – especially the rural poor. These programmes need to examine whether they are successfully covering the products and markets that reach the poorest people.

Why mandatory fortification as a nutrition strategy?

There is a clear logic underlying using legislation to make fortification mandatory: markets, if left on their own, don’t provide enough nutrient-dense foods. This is because consumers are often unwilling to pay for these foods compared to cheaper, unfortified alternatives, and there are numerous products that falsely claim to contain added nutrients or provide health benefits.

Mandatory fortification gets around these challenges by levelling the playing field, requiring all food producers to add micronutrients to their products. At the same time, they avoid the complexities of changing consumer behaviour by providing nutrients in products that people already eat.

The difficulty of regulating value chains at the ‘bottom of the pyramid’

  1. To be successful, a fortification programme needs to accomplish two things: Cover the products that poor people eat 
  2. Motivate ALL businesses making the product (and similar alternative products) to comply with the rules
Our research in Nigeria and Tanzania highlights why these conditions are difficult to achieve.

Even under the best of circumstances, motivating businesses to comply with fortification requires a well-functioning regulatory system. Experience from Nigeria shows how difficult it is to achieve this: even with support from government and donors, and commitments from large companies, only about 30 percent of products covered by the programme contained enough micronutrients.

Meanwhile, the value chains that reach poor people at the ‘bottom of the pyramid’ are difficult for policymakers to regulate. For example, in Tanzania, there are tens of thousands of small businesses processing maize flour, many of which do not appear in government records. A USAID-funded programme (pdf) has strived to motivate these small businesses to fortify since 2011. Yet, as of early 2014, none of them had started fortification – most were unable to meet the requirements for registration with the government.

Such experiences suggest that programmes need to provide support for small enterprises over longer periods, while also improving the ability of regulating institutions to cover these markets.

Fortification programmes need strategies to work with informal businesses

Food fortification programmes and partnerships should develop strategies to ensure they reach the poor, and recognise that success with larger companies doesn’t necessarily lead to better nutrition for the poorest people. If they are to improve nutrition for the poorest, programmes need strategies for working with small and informal businesses. They also need to grow and protect households’ ability to access these foods through social protection.

We still have a lot to learn about what combination of approaches works. Our policy briefing on fortification in Tanzania recommends that policy actors and donors should pursue the following actions:
  • Invest in robust regulatory systems that cover both large and small food businesses and are effective at the local level.
  • Create incentives for small enterprises to complete business registration – even if they are not currently fortifying. This will make them easier to identify, support and monitor.
  • Fund research on how poor households source food, and strengthen national surveillance systems. Nutrition stakeholders need much more accurate data on which groups are reached by which fortified products.
  • Government and donors should fund other programmes that do reach the poorest households, including social safety nets, food distribution and support for the poorest farming households.

About the Authors

Ewan Robinson is Research Officer at Institute of Development Studies, currently helping to run the 'Strengthening Agri-food Value Chains for Nutrition research project' , assessing policy options for enhancing food markets and increasing access to healthy food.

Martha Nyagaya is Food Security and Nutrition Advisor at Irish Aid.


Nelson N said...

What about the dangers of putting extra substances into food? Have they been researched? Are small firms in poor countries (and other countries) able and willing to put extra substances into food safely? The article does not deal with this issue.

Ewan said...

Dear Nelson,
Thanks for your question. You are correct: we didn't focus on the technical side of food fortification. This isn't our expertise. There is quite a lot of work by food scientists on the safety and effectiveness of different kinds of fortificants under different conditions, as well as what dosage should be used. (example link below)
You are right to point out that even when an additive is technically safe, this doesn't mean small firms will have the incentives and be able to use it in a safe way. That definitely needs follow up in any fortification programme.

Trax Ghana said...

The FAO's State of Food and Agriculture 2013 found that Ghana had the most severe level of vitamin A deficiencies in West Africa. Trax Ghana (a local NGO) is working together with the International Potato Center (CIP) in an attempt to combat this. It has introduced 151 of its farmers in the Upper East Region to an improved variety of the Orange-Fleshed Sweet Potato, bred by the national branch of CIP. This variety has a higher beta-carotene content than the traditional variety. Please take a look at this article for more information:

Ewan said...

TraxGhana and Hungerexplained - Thank you both for your comments. Trax - Your initiative on orange-fleshed sweet potato sounds interesting. How widely were sweet potatoes eaten in Upper East in the past? Are they available in local markets? If so, are you tring to work with the traders to convince them to sell the orange varieties?

Hungerexplained, you are right to point out that there are very different options for improving nutrient intake. So why do international donors and national governments seem to focus on large-scale fortification? Yes, private companies have an interest, especially if fortification programmes help them push out their competitors in the informal sector. But the donors are also looking for programmes that reach large scale quickly and that are easy to measure. We need to question whether being measurable actually means they are more effective in the long term.

On your comparison between the US and Tanzania - I’m not a nutritionist, but I’m not sure how helpful this is. Personally, I wonder if it’s desirable for people to get all of their nutrients from supplements. But the scale of micronutrient deficiencies in children in rural areas of Tanzania can't be compared with recent history in the US: in some places, 50-70% of children are chronically malnourished. Can local farming produce a sufficiently nutritious range of foods throughout the year? (and ensure it reaches the people who need it)? I think we need to examine this in specific places, climates and socio-economic conditions. But our hunch is that getting enough production would require fundamental transformations in local agricultural systems. please do read more in our report on policies to promote nutritious food in Tanzania:

Thanks again for your comments!

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