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Food Fortification Initiative

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The Food Fortification Initiative (FFI) does not meet all of our criteria to be a GiveWell top charity but is a standout charity. 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; Updated: March 2017

Since publishing this review, we have published notes from our conversation with FFI in October 2017.

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 promoting flour and rice fortification and providing assistance to countries as they design and implement 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 and has been named a standout charity. We do not plan to do further work on FFI as a potential top charity 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 promoting 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 communications 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 but working exclusively on projects in Africa.
  • 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