Food Fortification Initiative | GiveWell

# Food Fortification Initiative

The Food Fortification Initiative (FFI) does not meet all of our criteria to be a GiveWell top-charity but is a program we believe is worthy of special recognition. Although we don't recommend these organizations as strongly as we do our top charities, they stand out from the vast majority of organizations we have considered.

More information: What is our evaluation process?

Published: September 2016

## Summary

What do they do? The Food Fortification Initiative (FFI, www.ffinetwork.org) works to reduce micronutrient deficiencies (especially folic acid and iron deficiencies) by doing advocacy and providing assistance to countries as they design and implement flour and rice fortification programs. (More)

Does it work? We believe that food fortification with certain micronutrients can be a highly effective intervention. However we do not have a strong sense of what FFI’s impact may be in the typical country to which it provides support; because FFI typically provides support alongside a number of other actors and its activities vary widely among countries, it is difficult to confidently assess the impact of its work. We reviewed case studies of FFI’s work in the Solomon Islands and Kosovo in order to try to better understand its track record. We do not yet have enough information to have a confident understanding of FFI’s impact in these cases. (More)

What do you get for your dollar? Our impression is that, when effective, micronutrient fortification programs may be in the range of cost-effectiveness of our other priority programs. However, we do not have enough information to make an informed guess as to the cost-effectiveness of FFI’s work to date. (More)

Is there room for more funds? FFI estimates that it could use about $460K in additional funding per year for new staff to support additional fortification activities and a further ~$1.6 million to support new fortification-related projects. More details on these activities are below. (More)

What are GiveWell’s next steps? FFI has successfully completed the first phase of our investigation process. We now plan to make a $100,000 grant to FFI (as part of our "top charity participation grants," funded by Good Ventures). We do not plan to do further work on FFI at this time because we are doubtful that additional investigation of the kind we've done so far will resolve our remaining questions, but we may consider returning to FFI if we do additional work in the micronutrient space in the future. ## What does FFI do? The Food Fortification Initiative (FFI) works to reduce micronutrient deficiencies (especially folic acid and iron deficiencies) by advocating for flour and rice fortification and providing assistance to countries as they design and implement fortification programs.1 FFI primarily works in Africa, Asia, and Eastern Europe.2 FFI told us that its activities vary widely from country to country, but that its main activities include:3 • Supporting advocacy to governments to pass mandatory fortification laws and to implement fortification. FFI told us that it supports advocacy by (a) holding workshops, (b) establishing national coalitions that include non-profits, government actors, and private industry representatives, and (c) providing technical assistance with drafting legislation.4 • Providing technical assistance for the implementation and monitoring of fortification. For example, FFI told us that it helps producers to properly implement fortification into their production lines, trains producers and governments on the best monitoring methods for tracking fortification, and assists countries with choosing the best micronutrient mixes for their populations’ needs.5 • Tracking and sharing global progress on fortification via its website. For example, it told us that its database aims to show: burden of micronutrient deficiencies, which countries have mandated fortification, and whether industries are successfully fortifying.6 See Food Fortification Initiative website, “Global Progress” for more details. FFI told us that its work in countries can range from cases in which it is the only non-governmental organization (NGO) actor providing a large amount of direct help to a fortification program (e.g., having a full-time staff member on the ground supporting all aspects of implementation) to cases in which it is one among many NGO actors supporting a single aspect of a complex fortification program (e.g., having its Nutrition Specialist provide input on which iron compound a country should be fortifying with).7 FFI told us that it most often works as one NGO actor among many supporting a particular aspect of a fortification program.8 More information on FFI’s work in particular countries is available in the following footnote,9 and in the following sources: We also explore two case studies of FFI’s work in particular countries below. ### Micronutrients and foods that FFI works with FFI told us that it primarily aims to support fortification of wheat flour, maize flour, and rice with iron and folic acid in order to reduce anemia and neural tube defects.10 In many cases, FFI also supports fortification with other micronutrients (e.g., other B vitamins, zinc, vitamin A, and vitamin D) based on a particular country’s needs.11 FFI aims to fortify cereal grains: either wheat flour, maize flour, or rice.12 FFI does not work with fortification of other foods, but refers countries to other experts when they want to fortify other foods (such as salt, oil, or milk).13 ### Staff As of May 2016, FFI had about 12 staff (though some staff work less than full-time):14 • Six central staff based in the U.S. and Canada, including: its Director, a Senior Nutrition Scientist, a Communications Coordinator, a Micronutrient Specialist, a Training and Technical Support Coordinator, and an Administrative Coordinator. • Two staff members in India: a Network Coordinator and Senior Advisor. • Two staff members in Asia: an Executive Officer and Technical Officer. • One Senior Advisor based in the Netherlands. • One Network Coordinator based in Africa. Generally, its central staff and advisors provide various kinds of support to actors across the globe while its network coordinators focus on supporting fortification programs in the regions in which they work.15 Sometimes (as in the Solomon Islands case discussed below), FFI hires someone to work on the ground in a particular country. ### Spending FFI told us that its yearly budget has been roughly$1.6 million to $2 million dollars from 2014-2016.16 FFI told us that it allocated its budget as follows:17 Expense category 2014 expenses % of total 2015 expenses % of total 2016 budgeted expenses % of total Africa (regional support)$625,200 38% $695,200 36%$710,200 42%
Asia (regional support) $258,254 16%$369,732 19% $366,390 22% India (regional support)$309,400 19% $338,493 18%$328,888 19%
Europe (regional support) $158,200 10%$158,200 8% $31,640 2% Technical Assistance$58,012 4% $117,550 6%$31,640 2%
Advocacy $58,640 4%$58,740 3% $50,830 3% Tracking Progress$61,620 4% $61,620 3%$52,010 3%
Global Secretariat $136,155 8%$136,155 7% $128,245 8% Total$1,665,481 100% $1,935,690 100%$1,699,843 100%

### How FFI chooses where to work

FFI told us that it has analyzed the fortification situation in many countries in Africa, Asia, and Eastern Europe to determine where to focus its work.18 FFI told us that all else being equal, it largely prioritizes working in countries where:

• It is feasible to have a large impact through fortification. Two key factors that affect feasibility are: 1) whether the relevant population consumes sufficient quantities of cereal grains,19 and 2) whether the milling industry in the country is sufficiently centralized.20
• There is strong support across the government for micronutrient fortification.21
• There is a large burden of micronutrient deficiency.22

FFI has shared some of its strategy documents with us but we have not yet carefully reviewed them. See, e.g., 2016 Strategy Review presentation.

FFI told us that the type of support it provides to a particular country generally depends on the country’s needs, how much funding FFI has available to support the country, and which other actors are already working there.23

## Does it work?

To evaluate FFI’s impact, we focused on the following questions:

• Does micronutrient fortification improve health? Broadly, we believe that micronutrient fortification may be a highly effective intervention, with possible effects on cognition, child mortality, anemia, and other outcomes. Our research into the main micronutrients that FFI promotes for fortification (folic acid and iron) as well as other micronutrients (zinc, other B vitamins, and vitamin D) is ongoing. We have completed an intervention report on vitamin A supplementation but have not yet investigated vitamin A fortification.
• Has FFI demonstrably improved micronutrient fortification in particular countries? We reviewed case studies of FFI’s work in the Solomon Islands and Kosovo in order to better understand its track record. We do not yet have enough information to have a confident understanding of FFI’s impact in these cases.

Details follow.

### Has FFI demonstrably improved micronutrient fortification in particular countries?

To estimate the impact of FFI’s activities, we focused on trying to understand the impact of particular cases of FFI’s past work. In our experience, it is challenging to verify impact in such cases, so we began by asking FFI to identify its “success stories” where it seemed most likely to be able to prove its impact.

In collaboration with FFI, we chose to investigate its work in the Solomon Islands and Kosovo. We investigated the Solomon Islands because FFI was the primary NGO actor there, so it seemed like it might be easier to verify impact than in a case where many NGOs and other actors are involved. We investigated Kosovo because FFI does not usually work on the ground as the primary technical assistant on all fortification activities like it did in the Solomon Islands; we therefore thought Kosovo might be more representative of FFI’s typical work while still being identified as a particularly strong success by FFI.

We relied on FFI for the information in these cases. We did not seek to vet them with independent sources.

#### Solomon Islands case study

Background

FFI told us that it was asked by the Australian government’s Department of Foreign Affairs and Trade to assist the Solomon Islands with its fortification program.24 We have not tried to investigate what would have happened if FFI had decided not to assist the Solomon Islands (e.g., whether another NGO might have been able to provide support).

FFI told us that the Solomon Islands passed legislation mandating that all imported and domestically-produced flour be fortified with iron and folic acid in 2010, but that no progress had been made on actual implementation of this law at the time that FFI began working with the Solomon Islands in June 2014.25

FFI told us that its main activities in the Solomon Islands included establishing a national fortification committee that regularly meets about fortification-related issues, training producers on how to fortify flour properly, and supporting the government in drafting legislation for rice fortification and in setting up monitoring systems.26

FFI told us that its main point of contact was a full-time contractor that it hired to work closely with the government in the Solomon Islands for about 10 months.27 Other FFI staff also provided a variety of support to the Solomon Islands.28 FFI estimates that the total cost of its work in the Solomon Islands will ultimately be about $350,000 and it told us that funding was necessary to the project because it enabled hiring on-the-ground support.29 As of May 2016, FFI told us that the main producer of flour in the Solomon Islands was fortifying properly.30 It told us that rice fortification was not yet occurring but that mandatory legislation was expected to be passed in the next few months and implementation would occur during a subsequent 6 month grace period.31 Micronutrient deficiencies and food consumption patterns FFI sent us a presentation that reports that in the Solomon Islands there are about 27 new neural tube defects per year (based on “March of Dimes estimates”) and that anemia rates are roughly 44-60% among women of child-bearing age, pregnant women, and children under 5 years old (based on “DHS 2006-07”).32 We have not attempted to vet these estimates or understand their underlying methodologies. In the same presentation, FFI reports about data on the availability of wheat flour and rice in the Solomon Islands, which it uses as a proxy for consumption.33 Its analyses report that there is sufficient expected consumption of wheat flour and rice to meet the World Health Organization’s fortification recommendations.34 We have not attempted to vet the estimates or sources underlying these claims and have not attempted to understand their methodologies. FFI told us that about 90% of wheat flour consumed in the Solomon Islands is made by the lone producer in the country (Delite Flour Mill), while the remaining 10% is imported.35 It told us that the reverse is true for rice: it said about 90% of rice consumed in the Solomon Islands is imported from a major Australian company and about 10% of rice is produced domestically.36 We do not have a strong understanding of the methodology underlying these estimates and have not attempted to vet them. Monitoring FFI told us that as of May 2016 it believed that flour was being properly fortified at the main flour producer in the Solomon Islands.37 FFI told us that its main reasons for believing this were that (a) FFI had provided training to the producers, and the producers seemed to set up the equipment and follow the necessary procedures after the training in 2015, (b) as of May 2016, meetings of the national committee for fortification were still occurring roughly every 6 weeks; the main producer (Delite) is represented in those meetings and has expressed continued commitment to fortifying, and (c) FFI has seen that Delite is regularly ordering the correct premix.38 We have not attempted to independently verify these claims. When FFI becomes less involved in the day-to-day activities in the Solomon Islands, it told us that it would expect the following monitoring procedures to be operating:39 • FFI would check with the micronutrient premix supplier (i.e., the company that provides the mix of folic acid, iron, and other nutrients added to flour) to verify that the flour producer (Delite) is purchasing the appropriate amount of premix.40 • Flour producers would be following an internal monitoring procedure.41 • FFI would support the government in setting up an external monitoring procedure in which the government would check at least once per year that the main flour producer is properly fortifying flour and conducting its internal monitoring. FFI told us that these would ideally be part of the government’s standard food safety checks.42 • FFI would support the government in setting up a monitoring procedure to check that imports of flour and rice are properly fortified.43 FFI sent us templates and procedure documents for internal monitoring systems, the government’s external monitoring system, and import monitoring.44 As of May 2016, we have seen two examples of producers’ internal monitoring. FFI sent us one example of a premix order and one example of a third party vitamin assay (i.e., a test in which the producer sends a sample of flour to an external party to determine whether the sample has the right level of nutrients).45 The internal monitoring document suggests that vitamin assays should be done once per quarter.46 We have seen the results from a flour sample that was taken from Delite in November 2015.47 We are unsure whether the results of the vitamin assay suggest that Delite’s flour sample had the right concentration of all nutrients and have not yet asked FFI for its interpretation of the results.48 We have not yet seen other results from producers’ internal monitoring. We have not yet seen examples of external monitoring or import monitoring. FFI told us that as of May 2016 it was not yet asking for verification that monitoring procedures were being implemented since the national committee for fortification was still meeting regularly.49 As of May 2016, FFI told us that rice fortification was still in the process of being mandated and implemented in the Solomon Islands,50 so we have not yet requested monitoring information from this work. Finally, regarding measuring the direct effect of fortification on population health in the Solomon Islands: • FFI told us that birth registry systems in the Solomon Islands are not comprehensive enough to enable an estimate of the effect of folic acid fortification on neural tube defects.51 • FFI told us that it may be possible to get an estimate of the impact of fortification on anemia using routine health surveys, but that data would not be available for at least a couple of years.52 Bottom line It seems plausible to us that FFI’s work has made it more likely that the Solomon Islands will properly implement flour and rice fortification. However, we have not yet tried to investigate what may have happened in FFI’s absence and we have not yet seen consistent reports from routine monitoring systems verifying proper fortification of both flour and rice over time (though we have seen one vitamin assay suggesting that the major flour mill may be fortifying properly). Note that FFI’s work in the Solomon Islands may not be representative of a large proportion of its past or future work because: • It is relatively rare that FFI supports all aspects of fortification on the ground like it did in the Solomon Islands; usually it works as one NGO among many in supporting a fortification program. • The Solomon Islands is a very small country (population of about 560,000)53 with an unusually simple industrial structure (one flour mill that serves 90% of residents and one rice importer that serves the vast majority of residents, according to FFI). #### Kosovo case study Background FFI told us that it has provided a variety of support to Kosovo’s fortification program since 2008.54 FFI said that it would be very challenging to quantify the total amount of resources it has devoted to Kosovo since it has allocated a small amount of many staff members’ time to Kosovo over the course of many years.55 FFI told us that UNICEF was a major partner in supporting Kosovo’s fortification effort.56 It told us that Kosovo passed legislation mandating fortification in September 2012 and that implementation of fortification was “launched” in February 2014.57 FFI told us that some of its biggest impacts on the Kosovo fortification program were:58 • FFI said that it influenced the Kosovo government to structure its legislation in a way that would make it easier to change technical standards around the specific nutrient levels and compounds that should be used in fortification if that were necessary.59 FFI told us that some countries (unlike Kosovo) require legislative action to change technical standards, which leads to long delays.60 FFI said that Kosovo has not yet needed to change its standards as of May 2016.61 • FFI told us that in 2012 it supported a graduate student to help Kosovo develop a monitoring system that would be easier for producers and the government to implement.62 FFI believes this is important because it said that if monitoring systems are too cumbersome then they may not be followed.63 FFI told us that it has not followed up with actors in Kosovo to see if the monitoring system that it helped to develop is being used.64 • FFI said it held workshops to increase regional collaboration, train government officials on monitoring, and ensure that fortification remained high on the Kosovo government’s priority list.65 We have not yet tried to investigate the potential impact of these workshops through means other than talking to FFI. FFI said that in early 2016, UNICEF staff in Kosovo requested that FFI’s technical coordinator, Quentin Johnson, visit the country because Kosovo was experiencing new challenges with fortification.66 After visiting the country, FFI told us that Johnson confirmed that Kosovo was experiencing the following challenges:67 • Government subsidies for micronutrient premix ended. Many small producers were unwilling to pay for the premix themselves so they stopped fortifying. FFI said premix is unusually expensive in Kosovo due to high taxes on the imported premix. • Milling costs were already high due to high electricity costs, leading to reduced interest in spending additional money to implement fortification. FFI said it was unsure what specifically led UNICEF to notice these issues.68 FFI said that in the future it may try to support Kosovo by sending its staff to advocate for a tax exemption for micronutrient premix and by presenting Kosovo officials with a cost-benefit analysis to incentivize them to continue with fortification.69 It told us that this type of support is fairly similar to the kind of support it has provided to Kosovo in the past.70 Micronutrient deficiencies and food consumption patterns Kosovo’s population is about 1.8 million people.71 FFI told us that the last nutrition survey that it is aware of from Kosovo was done in 2010.72 The survey reports that anemia prevalence among school children in Kosovo was ~16%,73 and anemia prevalence among pregnant women was ~23%.74 We have not attempted to vet these figures or understand the methodology of the survey. FFI told us that it has not seen any data on neural tube defects in Kosovo and that it is not aware of any birth defect registry system in Kosovo.75 We have not requested detailed information on food consumption patterns in Kosovo, so we do not know if it is available. Monitoring As part of its work on tracking the status of fortification across the world, FFI told us that each fall it asks stakeholders in all countries with fortification programs to provide estimates of the percentage of industrially milled wheat flour, maize, and rice that is being fortified.76 FFI told us that it does not usually ask people who respond to these inquiries to provide the source for their estimates, so it usually does not have underlying documentation.77 FFI told us that its partners in Kosovo reported that in 2014 about 56% of Kosovo’s flour was produced in 82 industrial mills (as opposed to small scale mills that do not fortify) and that industrial mills were fortifying about 89% of their flour.78 FFI’s partners reported that in 2015 about 70% of Kosovo’s wheat flour was produced in 82 industrial mills that fortified about 75% of their flour.79 We have not independently vetted these estimates and do not know the underlying methodology that was used to produce them. Bottom line Based on the information that we have collected so far, we do not have a strong sense of whether FFI had a substantial positive impact on the fortification program in Kosovo. Additionally, we do not have a strong sense of whether the fortification program in Kosovo in general has been successful and cost-effective. ### Impact of FFI’s other activities We have not yet attempted to investigate the potential impact of other work done by FFI, such as its work on keeping a record of global progress on fortification and its work supporting workshops that aim to persuade government officials to start and maintain fortification programs. ## What do you get for your dollar? If successful, it seems plausible that micronutrient fortification programs, such as those supported by FFI, could be as cost-effective as our other priority programs. However, understanding the cost-effectiveness of FFI's work is complex because of the role FFI plays in the countries in which it works. We have not yet attempted a formal cost-effectiveness analysis of FFI’s work at this preliminary stage of investigation because we did not want to invest the time in such an analysis while we had many major remaining sources of uncertainty, such as: • Magnitude of health benefits of micronutrient fortification: We are still in the process of analyzing the evidence supporting the health benefits of micronutrients. • Uncertainty about impact of FFI's past work: As discussed above, we do not have a strong understanding of the impact of FFI's past work. • Relative impact of FFI's future work: Are future projects likely to be more, less, or similarly cost-effective as past projects? ## Is there room for more funding? In brief: • FFI sent us a list of projects that it would support with additional funding (see FFI's Funding Gaps List). FFI estimates that it could use about$460K in additional funding per year for new staff and a further ~$1.6 million to support new projects. Details on these activities are below. • We do not have a strong sense of whether FFI is likely to gain or lose funding from other funders in the future, though its budget seems to have been fairly stable (in the range of ~$1.6M-$2M) between 2014 and 2016.80 ### FFI’s plans for additional funding FFI sent us FFI's Funding Gaps List, which lays out what FFI says it would do with additional funding. FFI told us that this document is roughly ordered by priority (i.e., the funding gaps that FFI would expect to fill first are at the top of the document). FFI's Funding Gaps List contains two types of funding opportunities: (a) new staff that FFI would hire or activities that it would undertake if it had a certain amount of additional annual funding, and (b) one- to three-year projects that FFI would undertake with sufficient funding.81 The document contains about$560K in annual funding gaps for new staff and ~$1.6M in funding gaps for specific projects.82 Examples of longer-term activities that FFI says it could undertake with additional annual funding are: •$140K per year: Hire a dedicated staff person to support wheat flour fortification efforts in many countries in Eastern Europe.83
• $120K per year: Hire a dedicated staff person to support wheat flour and rice fortification in China.84 Examples of one- to three-year projects are: •$500K over three years: Support rice fortification work in Africa, particularly West Africa.85
• $350K over three years: Support wheat flour and rice fortification in Papua New Guinea.86 •$150K per country: Hire a country coordinator to support grain fortification in Bangladesh and/or Mongolia.87

FFI told us that it now expects to be able to fund $100,000 of annual rice coordination work (the funding gap at the top of its wishlist) out of existing resources.88 It told us that all of the other funding gaps in FFI's Funding Gaps List remain unfunded.89 Thus, it seems that its remaining gap for activities that require annual funding is about$460K.90

Note that FFI will receive $100,000 from GiveWell upon publication of this interim review (as part of our "top charity participation grants," funded by Good Ventures), which could be allocated toward the above funding gaps. ### FFI’s existing funders As noted above, FFI spends roughly$1.6M-$2M per year. FFI told us that it receives about half of its funding from government contracts.91 It said that the bulk of the rest of its funding comes from the charitable giving of major agribusinesses and regranting from other micronutrient nonprofits (such as GAIN, Micronutrient Initiative, and UNICEF).92 FFI told us that it would like to put more effort into fundraising in the future.93 ## Our investigation process As we stated in our 2016 plans, we are interested in evaluating additional charities that work on micronutrient fortification. To date, our investigation process has consisted of: • Four conversations with Scott Montgomery, Director, and Sarah Zimmerman, Communications Coordinator, of FFI.94 • Reviewing documents FFI sent us after these conversations, and in response to our queries. ## Sources Document Source 2016 Strategy Review presentation Source Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 Unpublished Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 Unpublished Conversation with Scott Montgomery, February 19, 2016 Unpublished Country Network Objectives spreadsheet Source E-mails about FFI's work in Kosovo, May 10, 2016 Unpublished FFI spending and budget 2014-2016 Source FFI's Funding Gaps List Source Food Fortification Initiative website, “About Us” Source (archive) Food Fortification Initiative website, “Global Progress” Source (archive) Food Fortification Initiative website, “Staff team” Source (archive) GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 Source Kosovo Fortification spreadsheet Source Kosovo Nutrition Survey 2010 Source Regional Work Activities spreadsheet Source Solomon Islands External Monitoring Manual Source Solomon Islands Import Monitoring Manual Source Solomon Islands Internal Monitoring Manual Source Solomon Islands Monitoring Framework summary Source Solomon Islands Premix Order Unpublished Solomon Islands Summary presentation Source Solomon Islands Vitamin Assay Source • 1. “The Food Fortification Initiative (FFI), formerly the Flour Fortification Initiative, is an international partnership working to improve health by advocating for fortification in industrial grain mills. We specialize in wheat flour, maize flour, and rice. The support we provide through multi-sector collaborations includes: • Advocacy resources on the benefits of fortification • Technical assistance in planning, implementing and monitoring fortification programs • Tracking progress at the country and global levels We primarily support national stakeholders in the public, private and civic sectors. Key leaders are government officials, industry leaders, civic sector advocates, and staff of non-governmental organizations. The nutrients most commonly used in post-harvest grain fortification are iron and folic acid, a B vitamin. Other nutrients that can be added are zinc, vitamin A, vitamin D, and other B vitamins such as niacin, thiamine, riboflavin and B 12.” Food Fortification Initiative website, “About Us” • 2. • 3. • 4. • 5. Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 6. GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 (not included in written notes, but FFI staff reviewed this page prior to publication) • 7. “Which activities FFI conducts in a particular country depends on several factors, including how much funding it has available and how many other organizations are supporting fortification in that country. FFI’s activities in a particular country could range from supporting all aspects of fortification on its own (including hiring on-the-ground employees to assist governments and producers) to supporting one aspect of fortification (e.g., drafting legislation, advocacy) while other organizations and partners support most of the other aspects of the program.” GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 • 8. • 9. FFI told us that a few examples of its past and current work include: • Helping South Africa to switch from using the incorrect iron compound in its fortification program to using the correct one. • “For example, South Africa already has fortification legislation and monitoring in place, but currently fortifies wheat flour with a non-bioavailable type of iron that has little public health impact. FFI is helping South Africa switch to the correct iron compound, which is a difficult process. Countries like South Africa that use the wrong iron compound may be doing so due to outdated advice, or possibly in an attempt to save money (a non-bioavailable iron compound is often slightly cheaper than the correct compound).” GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 • In some countries where Project Healthy Children and Global Alliance for Improved Nutrition (GAIN) were working, FFI said it provided technical advice on how to draft details in the legislation and trained people on monitoring. GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 (not included in written notes, but FFI staff reviewed this page prior to publication) • One example at the fairly intensive end of the spectrum of FFI's work was in the Solomon Islands where it employed a full-time staff member to sit in the Ministry of Health and support the government’s work on fortification. This work is described in more detail in this section. • FFI told us that it developed an online quality control "internal/external" monitoring tool that can be used by industry and governments to monitor fortification. It told us that it is running a workshop in West Africa to train fortification-related technical capacity. • “USAID has given FFI funding to run a regional workshop to train additional fortification technical capacity for West Africa, with the intent of broadening the base of expertise in the area and reducing reliance on the current small number of global experts. FFI will train workshop participants to use an online quality assurance and quality control (QA/QC), internal/external monitoring tool that it recently developed with support from the Global Alliance for Improved Nutrition. FFI may also do this kind of training in other regions where it is needed.” GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 • 10. Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 11. • 12. ““The Food Fortification Initiative (FFI), formerly the Flour Fortification Initiative, is an international partnership working to improve health by advocating for fortification in industrial grain mills. We specialize in wheat flour, maize flour, and rice.” Food Fortification Initiative website, “About Us” • 13. “FFI focuses on cereal grains and does not work with other food vehicles. If a country's government wants to fortify a different vehicle (e.g. salt, oil), FFI does not have the relevant expertise itself but would likely be able to connect the government to other groups that do work with the desired vehicle.” GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 • 14. • 15. Conversation with Scott Montgomery, February 19, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 16. FFI spending and budget 2014-2016 • 17. FFI spending and budget 2014-2016 • 18. “FFI has performed detailed strategy diagnostics in each of its major regions. FFI started this process by gathering fortification data for all of Africa and creating profiles for each country, which included: • Compiling facts about each country, including the relevant history that led to the country's current political and social situation. • Tracking every fortification partner (to FFI's knowledge) working in Africa by country. • Tracking disease burden by country. • Tracking consumption of cereal grains by country. • Examining the industrial milling complex in the country (which FFI sees as an essential component of sustainable fortification solutions). FFI has also done strategy research in Asia and Eastern Europe. In India, FFI did a more comprehensive study that included mapping the wheat and rice supply chains of the major states and identifying possible opportunities both by state and by market channel. Based on its strategy research, FFI has created a "priority matrix" of countries and Indian states, which takes into account the potential impact of fortification, the best cereal grain vehicle (e.g., wheat, rice, maize) to target, and how easy or difficult implementation is likely to be. This process allowed FFI to understand the opportunities in each country and determine where to direct its focus. FFI produces regional work plans, based on a strategy document developed using its diagnostic data, which outline the types of fortification activities it aims to support and/or accelerate in each country.” GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 • 19. “In determining whether to enter a country, FFI's first step is to understand the country's pattern of wheat, maize, and/or rice availability. A useful preliminary litmus test is that if per capita availability of cereal-based grains is over 75 grams per day, effective fortification is likely possible. If it is significantly lower than this, FFI needs a more detailed understanding of consumption patterns to determine whether fortification is feasible, because the amount of vitamins and minerals that can be added to cereal grains without affecting sensory properties, e.g., the color of bread, etc., is limited.” GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 • 20. “FFI next examines the country's industrial milling complex, which it sees as essential to effective fortification practices. For example, although maize availability in Africa is high in terms of grams per day, in many African countries maize flour is produced primarily by mortar and pestle or by local village mills, approaches that are not conducive to sustainable or cost-effective fortification.” GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 • 21. “Once FFI has determined that a country offers a good opportunity for a fortification program, the next important step is gaining political support. FFI aims to create a political coalition by connecting with the Ministry of Health (MOH) and, ideally, other government departments (e.g. the Ministry of Finance, Ministry of Agriculture, etc.). FFI also attempts to get the support of the highest level of local government (e.g. the Chief Minister in Indian states). In particular, FFI aims to identify and partner with capable individuals in the government that are passionate about improving nutrition. FFI also works closely with the government to understand its mechanisms (as the ideal fortification program structure can change significantly depending on how a particular country's government is set up).” GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 • 22. GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 (not included in written notes, but FFI staff reviewed this page prior to publication) • 23. “Which activities FFI conducts in a particular country depends on several factors, including how much funding it has available and how many other organizations are supporting fortification in that country. FFI’s activities in a particular country could range from supporting all aspects of fortification on its own (including hiring on-the-ground employees to assist governments and producers) to supporting one aspect of fortification (e.g., drafting legislation, advocacy) while other organizations and partners support most of the other aspects of the program.” GiveWell's non-verbatim summary of a conversation with Scott Montgomery, March 2, 2016 • 24. • 25. • 26. FFI told us that early in its work in the Solomon Islands it established a national fortification committee that scheduled regular meetings between FFI, the government, and the milling industry. In the course of its work, FFI told us that it realized that to fully meet the nutritional needs of most of the population in the Solomon Islands, rice would need to be fortified as well. Then, it told us that it aimed to help the government to pass legislation and clarify standards that would mandate rice fortification for importers and domestic producers. Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 27. Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 28. FFI told us that other staff providing support to the Solomon Islands included Scott Montgomery (Director), Becky Tsang (Technical Officer for Asia), Karen Codling (Executive Officer for Asia), Quentin Johnson (Training and Technical Support Coordinator), Sarah Zimmerman (Communications Coordinator), and Helena Pachon (Senior Nutrition Scientist). Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 29. • FFI told us that its total cost estimate of ~$350,000 included:
• ~$275K for project funding that FFI has specifically allocated to the Solomon Islands to date • ~$40K for a rough estimate of the value of the time that central staff contributed to the project
• ~$35K in expected future spending to conclude work on rice fortification in the Solomon Islands over the course of the next year Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • Other costs that FFI said were not included in this estimate include: • Millers paying for fortificants (premix) and spending additional time to implement fortification. Millers also incurred small costs to put new logos on their products advertising that they’re fortified. • Additional cost of government regulators’ time (both import regulators and food inspectors). Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 30. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 31. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 32. • “Neural tube birth defects (NTDs) such as spina bifida affect an estimated 27 pregnancies per year in the Solomon Islands” Solomon Islands Summary presentation, Slide 5. • ”Percent of people with anaemia in the Solomon Islands”: “44.3 (Women of child-bearing age)”, “60 (Pregnant women)”, “48.5 (Children under 5 years)” Solomon Islands Summary presentation, Slide 4. • 33. See “Summary of current data – wheat flour availability” and “Summary of current data – rice availability”, Solomon Islands Summary presentation, Slides 11-12. • 34. “Use the 2009 World Health Organization (WHO) wheat and maize flour fortification recommendations to identify an appropriate category for the Solomon Islands: • Solomon Islands Wheat Flour & Rice apparent consumption: 206-329 grams/capita/day • WHO Fortification recommendations for 150-300 grams/capita/day” Solomon Islands Summary presentation, Slide 15. • 35. Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 36. Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 37. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 38. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 39. • We discussed monitoring procedures with FFI as part of Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) and Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication). • FFI sent us a summary of its monitoring framework for the Solomon Islands: Solomon Islands Monitoring Framework summary. • "There needs to be a system that ensures that all wheat flour, rice and salt in the Solomon Islands meets national standards for fortification in the Pure Food (Food Control) Regulations. There are three core components of the proposed regulatory monitoring framework: 1. Internal Monitoring - Delite (and any future wheat flour mills in the Solomon Islands) having an internal quality assurance and quality control system (QA/QC) for fortified wheat flour. 2. Regulatory/External Monitoring - The Environmental Health Division (EHD) of the Ministry of Health audits Delite’s QA/QC system for fortified wheat flour on at least an annual basis. 3. Import Monitoring - The Solomon Island government monitors all wheat flour, rice and salt imports to ensure they meet national standards for fortification. This will require collaboration between EHD, Customs and Quarantine.” • 40. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 41. "Internal monitoring will rely on wheat flour mills having suitable QA/QC systems in place. Delite (and any future flour mills) will keep records to substantiate: • purchase of suitable premix (as indicated by the Certificate of Analysis accompanying each shipment of premix) • appropriate mixing ratios between the premix and wheat flour • other QA/QC procedures that demonstrate that the fortification process is controlled and monitored It is recommended that Delite undertake daily iron spot tests to verify the premix addition to produced flour. It is also recommended that Delite send composite samples of its flour to an external laboratory for testing of iron and folic acid content on a quarterly basis." Solomon Islands Monitoring Framework summary, Pg. 1. • 42. "EHD [Environmental Health Division] will visit each mill on an annual basis – or more often if required under its risk framework - to verify the performance of a mill’s internal QA/QC procedures. This will involve a paperwork audit to ensure that QA/QC procedures are being practiced e.g. verifying the purchase of suitable premix and reviewing the Certificate of Analysis, verifying appropriate mixing ratios between the premix and wheat flour, and verifying that iron spot tests are being carried out on a daily basis and all indicate that the flour has been fortified. During its visit, EHD will collect a composite flour sample for quantitative testing of iron content by a laboratory. Results will be compared with the quarterly laboratory test results obtained by the mill. EHD will provide the mill with a preliminary report of its findings during the visit. A final report will be provided after receipt of the laboratory results, advising the mill of any corrective action needed. EHD will report its findings on an annual basis to the Food Fortification National Committee." Solomon Islands Monitoring Framework summary, Pg. 1. • 43. "Import Monitoring will rely mostly on a review of the Certificate of Analysis for each shipment of wheat flour, rice and salt. The product will be refused entry if it does not meet the national standards for fortification. The fifth shipment of a fortified product will be checked at port of entry using a simple qualitative test to verify the product is fortified with a key indicator micronutrient. Products that fail the test will be refused entry. EHD [Environmental Health Division], Customs, and Quarantine need to agree on their respective roles and responsibilities in this system. These will be as per the Imported Food Control Guidelines, currently under development by the Ministry of Health and FAO." Solomon Islands Monitoring Framework summary, Pgs. 1-2. • 44. See: • 45. • 46. • “This manual recommends that mills in the Solomon Islands undertake daily iron spot tests. It recommends that composite samples be sent to a reliable external laboratory once a quarter to analyse iron and folic acid.” Solomon Islands Internal Monitoring Manual, Pg. 1. • “Once every quarter, send a composite quarterly sample to an external reference laboratory for the quantitative determination of iron and folic acid. Review and file the external laboratory’s findings.” Solomon Islands Internal Monitoring Manual, Pg. 5. • 47. “Your reference: Flour 16/11/15” Solomon Islands Vitamin Assay • 48. • 49. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 50. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 51. Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 52. Conversation with Scott Montgomery and Sarah Zimmerman, March 25, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 53. Googled “Solomon Islands population.” This figure is from 2013. • 54. For example, it told us (in E-mails about FFI's work in Kosovo, May 10, 2016) that: • Its staff member Robert Baldwin frequently visited Kosovo beginning in 2008. • Quentin Johnson, FFI's technical coordinator, conducted a quality assurance/quality control workshop in Kosovo in November 2011. • Kate Wheeler, an Emory graduate student, developed a monitoring plan for Kosovo in the summer of 2012. • A delegation from Kosovo attended an FFI Europe workshop in Turkey in June 2012. • FFI staff visited Kosovo in 2013, 2014, and 2016. • It has provided a variety of support to Agron Gashi, UNICEF’s main staff member working on fortification in Kosovo. • 55. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 56. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 57. • 58. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 59. In particular, FFI told us that it separated the legislation mandating that producers fortify from the technical standards that lay out the specific nutrient levels and compounds that should be used. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 60. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 61. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 62. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 63. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 64. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 65. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 66. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 67. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 68. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 69. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 70. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 71. Googled “Kosovo population” • 72. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 73. "The anemia prevalence in all the children of Kosovo was 15.7%, indicating a mild public health problem of anemia among school children." Kosovo Nutrition Survey 2010, Pg. 20. • 74. "the Hb was below 11.0g/dl, the cut-off for anemia among pregnant women (UNICEF/UNU/WHO, 2001), in 207 women or 23.0% (95% ci: 20.4-25.9), thus revealing a moderate public health problem of anemia among pregnant women." Kosovo Nutrition Survey 2010, Pg. 21. • 75. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 76. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 77. E-mails about FFI's work in Kosovo, May 10, 2016 • 78. • Kosovo Fortification spreadsheet • FFI also told us that there was another test of fortification run in 2014. All of the information that we have about it is from E-mails about FFI's work in Kosovo, May 10, 2016: "The UNICEF supported premix for flour arrived in early 2013, and fortification was officially launched on Feb. 7, 2014. The Institute of Agriculture in Peja tested 409 flour samples for iron and found that only 13% were not fortified." • 79. Kosovo Fortification spreadsheet • 80. See “Spending” section above. • 81. Note that the document also includes other staff positions that FFI would consider filling in the future, but does not provide funding estimates for these positions. • “Other future staff to consider: • Full-time training and technical support resource • Program manager • Development (including fund-raising) coordinator • Cost:benefit analyst FFI's Funding Gaps List, Pg. 4. • 82. See Pg. 3, FFI's Funding Gaps List: “Annual Total: 560,000”, “Non-Annual Total: 1,600,000”. • 83. “Bread and pasta are commonly consumed across Europe, but very little wheat flour is fortified there. Limited funding hampers FFI’s ability to respond to requests for assistance in Eastern Europe. UNICEF is a key partner in Eastern Europe, but other health interventions often are higher priorities to UNICEF staff in this region. With additional funding, FFI would provide a dedicated staff person to help selected countries in Eastern Europe make progress on planning, implementing, and monitoring wheat flour fortification programs. Country examples are Armenia, Kosovo, Moldova, and Ukraine.” FFI's Funding Gaps List, Pg. 1. (See document for cost estimate.) • 84. “China produced 117 million metric tons of wheat in 2011, according to FAO. With relatively minimal export volume, most of these grains are kept in China for domestic consumption. Yet fortification of wheat flour and rice has not been implemented as a strategy to improve nutrition and reduce neural tube birth defects among the country’s 1.3 billion people. The first priority would be a full-time person working in China with key partners to build advocacy and support for fortification.” FFI's Funding Gaps List, Pg. 2. (See document for cost estimate.) • 85. “As of March 2016, 26 countries in Africa had legislation requiring fortification of wheat flour, and eight of these countries also mandated fortification of maize flour. This is up from only two countries (Nigeria and South Africa) with such legislation in 2002. The national requirements often include fortifying salt with iodine and cooking oil with vitamin A. No country requires rice fortification though people in West Africa in particular consume more rice than wheat or maize flour. FFI and GAIN conducted an Africa rice supply chain assessment in 2015/2016. The next step is to execute a plan for rice fortification informed by the supply chain assessment.” FFI's Funding Gaps List, Pg. 2. (See document for cost estimate.) • 86. “Papua New Guinea has a national mandate for rice fortification, but the standard does not include folic acid. Also, wheat flour fortification has the potential to reach a target population here.” FFI's Funding Gaps List, Pg. 2. (See document for cost estimate.) • 87. • “Bangladesh has more than 300 wheat flour mills considered “industrial” meaning they have the capacity to produce at least 20 metric tons of flour a day. Yet fortification efforts in the country currently only include rice fortification – a work place benefit program and a social safety net program. Consumption of foods made with wheat flour is increasing, according to the 2010 Household Income and Expenditure Survey (HIES). Consequently a nutrition strategy for Bangladesh’s future will need to consider wheat flour fortification. FFI would hire a country coordinator to live in the country and collaborate with national leaders to build momentum for grain fortification and ensure that the elements of successful, sustainable programs are in place.” FFI's Funding Gaps List, Pg. 4. (See document for cost estimate.) • ”Mongolia has taken steps toward wheat flour fortification, and the UNICEF country office is supportive, but it is making little progress. FFI would hire a country coordinator to be based in Mongolia and collaborate with national leaders to build momentum for grain fortification and ensure that the elements of successful, sustainable programs are in place.” FFI's Funding Gaps List, Pg. 4. (See document for cost estimate.) • 88. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 89. Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication) • 90. Subtract$100,000 in annual rice coordination work from the total \$560K for the “Annual Total,” FFI's Funding Gaps List, Pg. 3.

• 91.

Conversation with Scott Montgomery, February 19, 2016 (no written notes, but FFI staff reviewed this page prior to publication)

• 92.

Conversation with Scott Montgomery, February 19, 2016 (no written notes, but FFI staff reviewed this page prior to publication)

• 93.

Conversation with Scott Montgomery and Sarah Zimmerman, May 10, 2016 (no written notes, but FFI staff reviewed this page prior to publication)

• 94.