According to the World Health Organization (WHO), an estimated 2 billion people worldwide suffer from micronutrient deficiency due to the insufficient consumption of key vitamins and minerals. In addition to poor health outcomes, such as stunting, anemia, child mortality and premature death, micronutrient deficiency weakens an individual’s ability to work, contributing to higher levels of poverty and reduced productivity for the economy as a whole. To combat these challenges, governments around the world promote food fortification.

Although the idea of nutrient supplementation originated as far back as 400 B.C., governments did not begin experimenting with widespread, population-level food fortification until the period between World War I and World War II. Today, cooking oils, flours, milk and salt are regularly fortified with essential vitamins and minerals — such as iron, iodine, calcium, zinc and Vitamins A, B and C — in much of the developed world.

After the better part of a century, the benefits of food fortification are no longer in doubt, and the technologies with which to accomplish it are widely known. In addition, much has been learned about the type of enabling environment needed to promote widespread access and adoption of fortified foods, particularly for the most vulnerable. Policy approaches often target a widely consumed staple food which must be fortified in a way that does not significantly increase the cost or change the characteristics of the final product, while also protecting against the risk of overconsumption. For example, food fortification in India was aided by a widespread shift to packaged foods and the near universal consumption of baked goods, which enabled the effective use of packaged refined flour.

At the domestic level, government policies aim to incentivize private sector adoption of fortification methods while ensuring a level playing field for food manufacturers. This can be achieved through mandatory fortification standards as well as incentives or subsidies to overcome the cost of manufacturing upgrades. The government must also invest in effective monitoring mechanisms to ensure compliance, protect consumer safety and collect data to guide future policymaking. To spur adoption, a multisectoral alliance between government, private sector and civil society is needed to raise public awareness of the benefits of fortified foods.

The adoption of a fortified food logo, such as the Enrichi logo used in West Africa, has been shown to be particularly effective in driving demand. It is also important to have a high-level coordinating body, such as the Cellule de Lutte contre la Malnutrition, a unit within the prime minister’s office in Senegal.

As domestic food fortification has become more commonplace, the incompatibility of fortification standards between countries has become a barrier to international trade. Even small differences in domestic fortification standards can create prohibitive barriers to market entry, thus limiting competition and economies of scale that reduce consumer prices. Barriers to cross-border trade also prevent the flow of fortified foods to countries that lack the capacity for domestic production and processing.

In response, policymakers and development partners have begun exploring regional solutions, including harmonized policies on food fortification to enable wider access to fortified foods. For example, recent work by the USAID Fortify West Africa project led to the adoption of a common regional standards for fortified wheat flour and vegetable oil that resulted in access to these products for 84 and 74 percent of the Economic Community of West African States population, respectively.

Regional approaches can promote the adoption of common standards (harmonization), or the signing of mutual recognition agreements whereby each country agrees to accept approval issued by certification bodies in the other country (mutual recognition). In 2019, the Feed the Future Enabling Environment for Food Security (EEFS) project discussed the distinctions, benefits, and limitations of harmonization versus mutual recognition with practical lessons from Southeast Asia.

Regardless of the regulatory cooperation mechanism employed, regional approaches to improving the enabling environment for food fortification present new challenges. For example, cultural differences in diet may preclude the selection of a single common staple as the vehicle for fortification. On the other hand, increasing regional flow of goods can also complicate the public health messaging and safety aspects of food fortification, for example if two countries fortify different staples with a particular vitamin which at high levels could be health-harming rather than beneficial.

The adoption of common regional standards or regulations can also have cost implications for businesses operating in the region. For instance, where agribusinesses have already paid for operational upgrades to comply with existing domestic regulations or standards. Additionally, there is a risk that the uniformity imposed by regional rules can inhibit experimentation and innovation that could lead to new and better fortification methods.

The experience of recent projects such as Fortify West Africa give insight into the enabling environment challenges that can engender or inhibit regional trade in fortified foods and can serve as a case study for future regional efforts. For example, in addition to harmonized standards, Fortify West Africa promoted regional quality assurance and quality control guidelines and built domestic capacity to implement them. Similarly, the United Nations Children's Fund-Global Alliance for Improved Nutrition (UNICEF-GAIN) Partnership Project, that promoted universal salt iodization, identified the need for common regional inspection manuals to ensure compliance in domestic manufacturing and imports. Effective regional action also requires a strong mechanism for regional coordination. For example, the UNICEF-GAIN Partnership Project has facilitated regional workshops for policymakers and food industry representatives in a number of regions to develop national action plans aligned with regional harmonization objectives.

Developing and executing an effective regional program requires a detailed understanding of the existing legal, institutional and socio-cultural factors that impact food fortification. The Fortification Rapid Assessment Tool is a commonly used method for evaluating micronutrient deficiencies and potential food fortification vehicles. Yet, evidence-based policymaking requires not only data on health outcomes and consumer habits, but also a comprehensive enabling environment review of national and regional policies for key fortified foods to determine the gaps and disparities between countries and the potential impact on cross-border trade. This analysis should include an evaluation of the potential benefits and challenges of different approaches, such as harmonization, equivalence or mutual recognition, as well as a clear delineation of the roles and responsibilities of various actors and key institutional constraints that may inhibit regional cooperation or domestic political will.

For more information on enabling environment analyses to support regional food fortification, please contact the EEFS project.

The Feed the Future Enabling Environment for Food Security (EEFS) project is a pre-competed Blanket Purchase Agreement (BPA) for USAID Missions and Operating Units to access evidence-based analysis of how the enabling environment influences agricultural market system performance, food security and nutritional outcomes. For further information on how USAID can access EEFS expertise, please contact the Chief of Party, Adam Keatts, at [email protected]. For additional information on qualitative diagnostic tools for the enabling environment, please visit the Agrilinks page to check out the various resources EEFS provides.