Improving how we communicate about food fortification

The most common response in discussions was a skepticism about the success of implementation - mostly framed around how challenging it is to get companies to change in places where regulatory systems are limited in their inspection and enforcement. LSFF has a very clear theory of action, but success requires large companies complying with fortification regulations (perhaps when their competitors are not). Some people highlighted the low compliance rates that persist many years after mandatory legislation and asked, "Why haven't we solved this yet?"

The investment roadmap diagram was well-received - mapping out the large-scale food fortification system and key levers of change. But in our conversations, investors often wanted more examples of transformative investments designed to change the system - digital innovations, rapid testing, innovative advocacy campaigns. Even where we do include these examples, they often don't include basic business cases outlining what will change and why it makes a difference.

Because many in the LSFF community hold that the economics for fortification don't work for smaller companies, the work often focuses on large producers. Fortifying a supply chain where production is spread across many smaller, more informal, mills presents additional costs and challenges for both millers and the government. Investors, however, wanted to understand more. They asked how well the supply from large mills reached into some markets, whether there were proven models to engage SMEs, and what the evidence was on the cost differences.

At the very heart of food fortification as a public health intervention is the ability to change the nutrient intake of an entire population without asking families to change their eating habits. To achieve this, governments need to figure out fortification plans across different staple food supply chains, in commonly eaten processed foods, and across packaged and bulk markets. One Tanzanian government official said: "Historically, small- and large-scale fortification were treated as mutually exclusive approaches. We are now in a position where both can coexist and be advanced in parallel. This is particularly relevant in contexts where industry and political dynamics are conducive to small-scale fortification in some sectors, while large-scale fortification remains more appropriate in others."

In several conversations, people noted that the measurability of fortificants might enable intersting outcome-based financing opportunities. Nutrition-related outcomes-based finance mechanisms are often constrained by the prohibitively high cost of testing for changes in disease incidence or micronutrient deficiency in a person, and the difficulty in linking those changes back to programmatic actions. But testing for fortificants in market products or at production sites is less expensive and might be linked to a range of financial mechanisms.

The way the LSFF community presents costs (and cost-effectiveness) sometimes needed some explaining. For example, when we cite the per MT cost to fortify, we're presenting the change in COGS that a company faces when they start to fortify. But we're not asking investors to pay that cost (which would be a subsidy to companies). There was confusion as to why we produced these numbers and then redirected the investor to the 'real' investment opportunities (advocacy, premix compliance, rapid testing innovations, digital systems to improve inspection services, etc). 

The investor materials for this project talk about cost-effectiveness and financial sustainability (because it's a privately delivered public good). But the messages about how quickly food fortification can change lives, reducing micronutrient deficiencies, really caught investors' attention. Within a year you could, for instance, stop neural tube defects. Every advancement you make in getting the system to work better has remarkably fast impacts in the population.

Investment cases in LSFF require pulling together government data, population health data and company data. Each of these has separate challenges. For example, because LSFF cuts across multiple ministries, government budgets of what is spent on LSFF. Even within food safety, for instance, it's unlikely there is a specific 'food fortification' sub-budget. Also, data from government plans and progress against plans is political by nature. Population data for food fortification needs to be derived from general nutrition surveys occuring only periodically or inferred from research projects. Again, the impacts specifically of food fortification have to be modeled within the larger set of nutrition deficiencies, changing diets, etc. Company data, of course, is sensitive and often confidential. Surveys of end-product compliance are a way to understand and track backward. Several organizations work with companies to gain insights into their premix purchasing, their costs and their compliance, but it is challenging.