Pakistan has a serious malnutrition problem, and it’s getting worse. Incidence of anemia is now at 62% in children and 51% in women, stunting affects 44% of children and 32% of children are underweight.
But while Pakistan faces a particularly high malnutrition burden, this isn’t a problem that only affects one country. The question of whether food fortification is a successful and cost-effective approach to the global challenge of malnutrition is now generally considered to be beyond question. What’s less clear is exactly what a best practice fortification program looks like. In particular, what part mandatory regulation plays compared to voluntary fortification by local producers.
The case of Punjab
The Punajb province is Pakistan’s cultural centre and home to over half of its people. Working closely with the Punjab Food Authority and the Pakistan Flour Mills Association, in 2014 the Global Alliance for Improved Nutrition helped to secure new mandatory fortification standards to ensure the addition of iron and folic acid to all Aatta flour in Punjab.
Not set to be enforced until September 2015, as of last month over 200 Punjab flour millers had already committed to voluntarily fortifying according to the new standards. The early adopters of course have much to gain from leading the pack, including goodwill from local authorities, freedom to initially impose their own prices and increased market share come September when the new standards – together with centrally regulated prices – will be enforced.
But the millers’ move to adopt early is influenced by the availability of subsidized premix. It also raises important questions about the nature and effectiveness of mandatory vs voluntary fortification. For instance, can you ever have true voluntary adoption without either the threat of mandatory regulation or the lure of subsidisation?
Supply and demand
The answer to that question lies in simple economics: supply and demand. True voluntary fortification only makes business sense where demand exists to sustain the costs of producing the new fortified products. Unfortunately, this kind of customer demand is usually only seen in more mature markets where products are branded and purchasing habits more closely shaped by factors such as nutrition.
Encouraging this kind of demand in less mature markets can be done, but it requires massive investment in communications in order to spread awareness of the benefits of fortified food and so foster demand.
Such an approach has been trialled by GAIN and the Program for Appropriate Technology in Health in Brazil, where an extensive social marketing campaign was used to create awareness about fortified rice. One private rice company made the investment to produce a fortified rice brand, and another grocery store chain launched a private label. According to sales reports, over two million consumers tried the new products in the space of just eight months. On the other hand, while 2 million consumers is an impressive reach, it is a far away cry from reaching the whole population of Brazil, which is the typical goal of a fortification program.
As Rebecca Spohrer from GAIN points out, encouraging voluntary fortification is an approach which is still reliant on significant donor funding in order to pay for the crucial communications element. “One of the fantastic things about food fortification is its incredible cost-benefit ratio – something which high communications budgets start to eat into” says Spohrer. Further, as many staple foods are sold in loose and unbranded form, it is difficult to incorporate fortification logos on a product without a package.
Different approaches for different markets
“In many countries we’re dealing with consumers who buy most of their food loose from open markets” says Spohrer; meaning consumers can struggle to identify fortified products if they are not buying packaged food products regularly. “As these countries move into middle income status and people become more brand conscious the opportunities for voluntary fortification may expand” says Spohrer.
From these examples and others it seems that when it comes to cost effectiveness and immediate public health impact, direct subsidisation and mandatory standards may well deliver better results in less mature markets. But mandatory standards are not the whole story. There still needs to be a supportive system.
GAIN works closely with local producers to help them prepare for incoming fortification regulation. When mandatory standards are enforced with fines this can lead to protracted lawsuits. But while these local lawsuits are always a risk, even with carefully planned and apparently successful local engagement, it seems clear that mandatory standards will continue to have an important role to play in less developed markets for some years to come.
Spohrer explains that when it comes to fortification the same two points are always raised by local producers: the problem of demand and the need for a level playing field between producers.
So if you can’t create demand, you have to level the playing field.
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