Market dysfunction is a feature of current food systems, leading to widespread malnutrition. This includes moderate and severe vitamin and mineral deficiencies which hold entire communities back – children don’t develop fully, parents can’t work productively, and too much money is spent on the treatment of nutrition-related health problems. Many hundreds of millions are suffering from this hidden hunger. It must be addressed if we are going to achieve SDG 2.
The good news is that because food is almost entirely delivered by markets, there is a tool readily available: food fortification or the addition of essential vitamins and minerals to commonly consumed foods such as wheat flour, maize flour, edible oils and salt. Fortification reaches entire populations using existing supply chains and does this by re-engineering food systems through a public health lens while keeping private sector interests in mind. In fact, food fortification is the best example we have of a working partnership between business and government in the food sector over this past decade. Thousands of companies in Africa and Asia — most of which are local and national — are adding micronutrients to their branded staple and condiment products. Today, there are over 140 countries implementing salt iodization, 50 implementing large-scale fortification of edible oils with vitamin A and over 80 fortify their grains with iron and folic acid.
Photo 1: Fortified oil produced in India with technical support from the Global Alliance for Improved Nutrition (GAIN)
The evidence shows that national fortification programmes are most successful when they are mandatory, driven by partnerships and trust between the public and private sector actors, and delivered with a final public health objective in mind. Private sector actors including the food processing industry, equipment manufacturers, suppliers of vitamins and minerals/multi-micronutrient premixes, private food laboratories, and retail organizations all play an important role in the fortification value chain (Figure 1).
Figure 1: The Fortification Value Chain
Because the private sector is undertaking the actual fortification processes – incurring most of the costs and taking the fortified product to market — its motivation and interests require a special focus. This focus includes the need to see a level playing field, profitability as markets expand, enhanced brand value through improving nutritional content, and the need to understand the positive outcomes of fortified for the consumer base in low income communities. These two apparent competing interests of the public health interests of the government on the one side, and business profits on the other, must be navigated successfully at all times of a fortification programme if fortification is to have its intended benefit. The SUN Business Network and National Food Fortification Alliances are two important platforms which are helping to create the enabling environment for business and government to address their interests appropriately and deliver fortification programs.
Photo 2: The fortification of edible oil with vitamin A by industry
While fortification has gone to scale, it has not yet delivered the impact it has promised in Africa and Asia. One major reason is that the quality and compliance of fortified foods need urgently improved. On staple food fortification programmes in 25 low- and middle-income countries (LMIC), results of external quality assurance and quality control activities indicate external pass rates from 18% to 97%, with an averages between 45-50%. This figure serves only as an inference but indicates a systemic problem with compliance. In addition, many of these non-compliant foods are labelled as compliant thus misleading consumers on vitamin and mineral content. There will be limited health impact of fortification programs when foods are not adequately fortified.
Both business and government need to fix this issue as a matter of priority throughout many countries in Africa and Asia. This can be done by improving legislation, regulations and enforcement regimes to ensure clear and consistent enforcement mechanisms are in place. Regulation on paper will not improve fortification compliance without real incentives as well as strong consequences which drive non- and under-fortified foods out of markets. Second, the potential of civil society or ‘third parties’ is largely untapped in monitoring fortification programmes — civil society can be a powerful watchdog, improving consumer awareness of the health benefits of fortified products and naming brands which are not compliant. Third, national business leaders need to speak out and take more leadership on this issue in countries where the quality of delivery of fortified foods is compromised.
In 2012, it was estimated that 35,500 birth defects were prevented due to flour fortification. However, that was only 13% of birth defects which could have been prevented if flour fortification was scaled up and delivered in a compliant way. Similarly, compliant flour fortification with iron could reduce iron deficiency anaemia by at least 2.4% in LMIC. The case for improved salt iodization is even more compelling. Primarily due to the private sector’s involvement in delivering iodized salt in 140 countries, there are now only 25 countries identified as having insufficient iodine intakes — this is down from 54 in 2003. We are now in an unprecedented position: on the verge of being able to eliminate iodine deficiency at a population level, in a sustainable way. According to WHO, eliminating iodine deficiency would rank alongside some of the world’s biggest public health achievements like eradicating smallpox. But we will need sustained commitment in partnership between the government and industry to get there. The successes and challenges outlined here in relation to businesses, partnerships and nutrition make a compelling case for increased attention to delivering high quality food fortification programmes. Business has already been engaged in this off-the-shelf solution and can help governments by actively engaging country by country to scale up and improve the delivery of food fortification.
Photo 3: A boy in India running past supplies of iodized salt
The Global Alliance for Improved Nutrition (GAIN) is a global, Swiss-based foundation that mobilises public-private partnerships and provides financial and technical support to deliver nutritious foods to those people most at risk of malnutrition. For more information on our programs, visit www.gainhealth.org and follow us on Facebook and Twitter
The SUN Business Network – on of the four networks of the Scaling Up Nutrition Movement – mobilises businesses to take action on reducing malnutrition at a global, regional and national level. For more information about our work, visit http://sunbusinessnetwork.org/ and follow us on Twitter
#FutureFortified is a movement to improve #nutrition and help eliminate hidden hunger on a global scale, led by GAIN with significant inputs from partners, government and the private sector. Follow #FutureFortified on Facebook and Twitter for the latest updates.
This blog is part of the December 2016 series on Inclusive Business models delivering nutrition, in partnership with DFID and GAIN. Don’t miss the webinar series in January 2017 on Marketing nutrition to the BOP.