# Project Healthy Children

Project Healthy Children (PHC) 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?

### A note on this page's publication date

Most of our investigation of PHC took place in mid-2015, and we last requested updates from PHC about its activities in July 2015. However, we are publishing this page in September 2016. Therefore, much of the content on this page is outdated (i.e., it may not reflect PHC's current plans, the current status of its programs, etc.).

Published: September 2016; Updated: March 2017

Since publishing this review, we have published notes from conversations with PHC in March 2017, October 2017, and June 2018.

## Summary

What do they do? Project Healthy Children (PHC, projecthealthychildren.org) aims to reduce micronutrient deficiencies by providing assistance to small countries as they design and implement food fortification programs. (More)

Does it work? We believe that food fortification with certain micronutrients can be a highly effective intervention. However, we have not seen enough monitoring data for the fortification programs that PHC works on to have a strong sense of how effective its programs have been so far. This may be largely because the programs are just reaching the stage where official monitoring data is expected to be systematically collected. We discuss questions about PHC's effectiveness below. (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 PHC's work to date. (More)

Is there room for more funds? In July 2015, PHC was in the process of raising $200,000 to continue its national fortification programs until the end of 2016, and$300,000 to continue its small-scale fortification programs. After 2016, PHC may decide not to continue to operate under its current model; it may move from focusing on the design and implementation of fortification programs to focusing on monitoring and evaluation of such programs. If PHC makes this transition, the number of countries that it can start monitoring in will depend on the amount of funding it is able to raise. PHC believes it would have the capacity to use $1 million in funding or more. (More) What are GiveWell’s next steps? PHC has successfully completed the first phase of our investigation process and has been named a standout charity. Depending on PHC’s planned future activities, we will either stop our investigation at this stage, rather than prioritizing its work as a potential top charity, or try to briefly answer our remaining questions and determine whether it is worth moving forward with a full review of PHC with a potential top-charity designation in mind. ## What does PHC do? Project Healthy Children (PHC) aims to reduce micronutrient deficiencies by providing assistance to countries as they design and implement food fortification programs.1 The majority of programs that PHC works on are large-scale, national fortification programs,2 where PHC works with a nation's government to help it pass and enforce laws mandating micronutrient fortification, among other activities.3 More recently, PHC has also started a small-scale fortification initiative to reach people in rural and remote areas, who may not have access to centrally processed foods.4 PHC may decide not to continue to operate under its current model after 2017. Instead, it may shift toward focusing on monitoring or other aspects of fortification programs.5 The remainder of this section provides more detail on: ### National fortification programs When developing a national fortification program, PHC told us that it first helps the government to create a National Fortification Alliance that includes the key stakeholders in passing and enforcing fortification laws (such as ministries of health, bureaus of standards, food producers, and academia). It said that it then guides this alliance through the process of creating a food fortification plan for the country,6 and provides technical assistance to the government to help implement the plan. PHC told us that this process has four key components: creating country-specific standards for fortification (including which foods should be fortified, with which micronutrients, and to what levels), passing policy and legislation to mandate fortification, helping industry to start fortifying, and assisting government with monitoring and social advocacy.7 #### Overviews of national fortification programs In February 2015, PHC was working on national fortification programs in Rwanda, Burundi, Malawi, Zimbabwe, Liberia, and Sierra Leone,8 though the program in Sierra Leone had only recently started.9 Overviews of PHC's work with these programs are in the following footnote.10 For the remainder of this review, any discussion of PHC's national fortification programs should be understood to refer to the five established programs in Rwanda, Burundi, Malawi, Zimbabwe, and Liberia. #### How does PHC choose countries to work in? PHC told us that so far it has only worked in countries to which it has been invited; PHC believes that for fortification programs to be sustainable after its departure from a country, the government has to be ready to make the programs a priority.11 PHC told us that it has worked with small countries (typically populations of less than 15 million) that either do not have food fortification programs in place but are interested in developing them, or that have programs in place that are faltering in some way. PHC told us that these countries have generally been passed over by larger agencies, which tend to focus on countries with larger populations.12 We have not tried to verify this claim. Before starting work in a country, PHC said that it conducts a high-level assessment, and if warranted, a more in-depth situation assessment to determine whether to work with the country.13 A situation assessment aims to analyze whether deficiencies exist and what foods are good candidates for fortification, and assesses the functionality of government, industry structure, and how the cost of foods could be impacted.14 PHC said it conducts situation assessments by reviewing existing nutritional data and policies and interviewing relevant individuals to learn about the countries' existing work on nutrition.15 PHC does not have the capacity to conduct independent micronutrient deficiency surveys when evaluating countries, so it relies on existing data for its situation assessments.16 To obtain consumption data for its situation assessments, PHC told us that it either uses data from existing sources or conducts rapid on-the-ground surveys.17 We have not reviewed PHC’s country-level situation assessments in detail. #### Program timeframes and costs PHC told us that it typically spends between five and eight years working with a country to develop its food fortification program. The country’s political stability and the government’s ownership of its program both affect how long PHC expects to work with a country. For example, in February 2015, PHC anticipated that it would likely only spend four years working in Liberia since the government had provided strong leadership for the program. In contrast, PHC said that it has been in Rwanda since 2007 due to high turnover in its government, necessitating PHC’s continued presence.18 PHC told us that it spends roughly$70,000 per country per year, which decreases to around $50,000 per year when it is transitioning out of a country.19 For more information about PHC’s spending, see the ‘Spending Breakdown’ section below. #### Organizational structure PHC uses a country coordinator model, in which one member of PHC's staff acts as a country coordinator for either one or two countries in which PHC works.20 Country coordinators function as technical consultants to governments throughout the design and implementation phases of food fortification programs.21 PHC told us that country coordinators are often physically co-located with countries' ministries of health so that they are perceived as part of the government.22 In February 2015, PHC had four country coordinators (one for Tanzania, one for Liberia, one for Rwanda and Burundi, and one for Malawi and Zimbabwe23) as well as three additional staff: its founder who donates his time, a Chief Operating Officer, and an office manager.24 ### Small-scale fortification PHC has a small-scale fortification program called Sanku that works to help small- and medium-scale mills to fortify grain.25 This program aims to reach people in rural and remote areas that do not consume the centrally processed foods that are fortified through large-scale fortification programs.26 PHC told us that the international community has not focused on small-scale fortification because of perceived difficulties with monitoring and human error.27 PHC's programs use a device that PHC believes overcomes these problems by sitting on top of small-scale mills and automatically dispensing a micronutrient premix.28 PHC told us that 56 of these devices have been installed in three regions in Tanzania, as part of a pilot program funded by USAID.29 We do not know how many people are being reached by these mills. Sanku has stated that a single dosifier can fortify flour for up to 100,000 people daily, and that the cost of each Sanku Dosifier can range from$0 to $4,000.30 ### Spending breakdown PHC told us that it spends roughly$70,000 per country per year, which decreases to around $50,000 per year when it is transitioning out of a country.31 PHC told us that these costs largely cover salaries for staff, travel costs, taxes paid to countries, consulting fees, advocacy and monitoring work, and funding for national fortification alliance meetings.32 We have seen expenditure data for PHC for 2010-2011, 2011-2012, 2012-2013, and 2013-2014, and a budget for 2015. The table below shows a summary of expenditures from 2010-2014; the budget for 2015 is confidential, but not dissimilar to PHC's past expenditures.33 #### PHC's expenditures by type Expense 2010-2011 2011-2012 2012-2013 2013-2014 Total expenditures 2010-2014 % of expenditures 2010-2014 Salaries34$296,974 $322,532$454,312 $534,548$1,608,366 59%
Travel $58,179$101,547 $93,240$120,777 $373,743 14% Small-scale fortification materials$41,210 $34,386$38,736 $102,305$216,637 8%
Professional and consultant fees $40,362$13,303 $30,578$52,229 $136,472 5% Accommodation$46,012 $47,351$54,045 $30,162$177,570 6%
Other35 $46,906$56,940 $50,155$73,370 $227,371 8% Total$529,643 $576,059$721,066 $913,391$2,740,159 100%

#### PHC's expenditures by national fortification program

PHC has shown us rough projections for total spending in each country where it has a national fortification program.36 These estimates seem to roughly approximate PHC's actual spending per country.37

Country Projected years of engagement Projected cost
Rwanda 2007-2015 $707,664 Liberia 2009-2016$447,429
Malawi 2010-2015 $345,357 Burundi 2012-2016$291,873
Zimbabwe 2014-2016 $236,607 Sierra Leone 2014-2016$205,700

#### PHC's expenditures on small-scale fortification

More recently, PHC has spent a significant amount of its budget on its small-scale fortification initiative in Tanzania. In 2014, PHC spent approximately 50% of its overall budget on small-scale fortification (not all spending on small-scale fortification is included under “Small-scale fortification materials” in the table above; e.g., some salary costs were also allocated toward small-scale fortification), and in 2015 PHC predicted spending approximately 25% of its overall budget on small-scale fortification.38

### Which micronutrients and foods does PHC work with?

PHC typically works to add the following micronutrients to staple foods:39

• Iodine is added to salt
• Iron, zinc, folic acid, and vitamins A, B1, B2, B3, B6, and B12 are added to flour
• Vitamin A is added to cooking oil and sugar

The specific micronutrients and staple foods used can vary based on the country and on regional standards.40

In 2015, PHC said that all established national fortification programs that it was working on had drafted or adopted fortification standards that include the iodization of salt, fortification of both wheat and maize flour with iron, zinc, folic acid, and vitamins A, B1, B2, B3, and B12, and fortification of cooking oil and sugar with vitamin A.41 The small-scale fortification initiative Sanku provides mills with a micronutrient premix that PHC told us is based on national nutrient standards and needs.42

### Shift toward monitoring and evaluation

PHC may decide not to continue to operate under its current model (providing technical assistance to governments to adopt and implement fortification programs) after 2017. It told us that few countries remain that need PHC's assistance in developing national fortification programs. PHC is considering shifting to focus on helping countries improve their ability to monitor their fortification programs, since it said many countries need assistance in this area.43 PHC told us that without effective monitoring, there is not only no way to tell whether a program is being implemented as planned, but also that historically programs lacking strong monitoring often do not meaningfully reduce micronutrient deficiencies.44

In July 2015, PHC was in the process of exploring two options: becoming a stand-alone organization focused on monitoring, or being absorbed by another organization to act as its monitoring arm.45 It planned to solicit feedback on these options from other organizations in the field, and come to a decision later in 2015.46 PHC told us that its small-scale initiative would likely continue as a stand-alone program regardless of the direction of PHC's large-scale fortification work.47 We have not yet followed up with PHC about which activities it expects to focus on in the future.

## Does it work?

To evaluate PHC'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. We have completed intervention reports on salt iodization and vitamin A supplementation (but have not yet investigated vitamin A fortification). Our research into the other micronutrients that PHC fortifies with (folic acid, iron, zinc, and B vitamins) is ongoing.
• Does PHC work in areas where micronutrient fortification could have a large impact? Generally, we would guess that PHC works in countries with relatively high levels of micronutrient deficiencies, since it tends to work in countries where the average income per person is very low and major health problems are relatively common. PHC has sent us third party surveys reporting high levels of micronutrient deficiencies and reporting that people commonly consume the types of foods that PHC aims to fortify, but we have not yet vetted these surveys or attempted to review their methodologies.
• How much progress has been made on fortification in countries where PHC works? How much of that progress should we attribute to PHC? It seems that all of the countries where PHC works have taken steps toward mandating fortification but, as of July 2015, we had not yet seen evidence that food producers in PHC countries were fortifying their products with the appropriate levels of micronutrients. We also have not seen micronutrient deficiency data that was collected recently enough to evaluate the possible effect of fortification programs on health outcomes. So, overall we do not have strong evidence that major progress has been made on fortification in countries where PHC works, though there are some signs of potential progress. Since our investigation of PHC has been relatively limited to this point (more), we are unsure what portion of progress on fortification in PHC countries we should attribute to PHC’s work.

We also briefly consider the evidence for the impact of PHC’s small-scale fortification programs and PHC’s track record for monitoring and evaluation activities (since it may shift toward focusing on such activities in the future). In both cases, our information is fairly limited.

Details follow.

### Does PHC work in areas where micronutrient fortification could have a large impact?

#### Are there micronutrient deficiencies in the areas where PHC works?

We would guess that PHC works in countries with relatively high levels of micronutrient deficiency, since it tends to work in countries where the average income per person is very low and major health problems are relatively common. However, we do not have a confident view of the magnitude of any particular micronutrient deficiency in countries where PHC works.

PHC has shared with us third party surveys reporting pre-existing levels of deficiencies for a number of the nutrients it works on in three of the countries that it has operated in.48 We have not vetted the data or attempted to understand the underlying methodology of the micronutrient deficiency surveys, and we have not attempted to find micronutrient deficiency data for the other two major countries that PHC has worked in. The data that PHC has shared with us can be found in the following sources:

#### Do people consume the foods that PHC helps to fortify?

PHC has sent us quantitative data reporting that foods that PHC helps to fortify are relatively widely consumed, although there seems to be large variance across foods and countries. We have not independently vetted the survey data that PHC has sent us and we have not attempted to understand the underlying methodology of the surveys in detail. We do not see strong reason to doubt that the staple foods that PHC aims to fortify are commonly consumed, though we are unsure what portion of people’s food consumption in PHC countries comes from small-scale producers. Small-scale producers may be less likely to comply with fortification standards due to high costs and technical challenges.

PHC summarizes its view of the coverage of different food staples in each country where it has a national fortification program in the following source: PHC costing board book with country projections 2014.49

### How much progress has been made on fortification in countries where PHC works?

#### Is food fortification mandatory and being enforced in countries where PHC works?

Our understanding is that by July 2015, all five countries where PHC had established national fortification programs had created fortification standards that were in various stages of becoming mandatory and enforceable, but that none of these countries had reached the final stage in which legislation is officially signed (see the table below for more detail). In three countries, PHC anticipated that legislation would be passed in the coming months;50 we have not yet followed up with PHC to see if these events have happened as planned. We do not yet have much evidence about whether fortification mandates are being enforced; we discuss what we know about whether foods are being fortified to standard below.

We would guess that PHC has played some role in the drafting and passing of this legislation, but we have not yet made a significant effort to understand specifically how much of the progress on passing legislation may be attributable to PHC versus other actors, since we have not seen much evidence about whether fortification mandates are being enforced.

PHC has told us that prior to its work, none of the five countries in which it has well-established national fortification programs had any legislation for fortified products.51 PHC told us that for many countries, as soon as standards are agreed upon and published in an official government journal, domestic producers must start fortifying their product; we do not know whether these rules are being enforced and do not know whether signing the legislation may lead to additional enforcement for domestic producers.52 PHC told us that standards are not enforceable for importers until the legislation has been officially signed.53

The table below shows our understanding of the status (as of July 2015) of legislation in the five countries where PHC was running a national fortification program. All information is based on what PHC has told us; we have not independently verified these claims.

Country Project started54 Standards drafted? Standards published in a government journal? Legislation officially signed?
Rwanda 2007 Yes Yes55 No - PHC anticipated that this would occur in August 2015.56
Malawi 2009 Yes Yes57 No - PHC anticipated that this would occur in December 2015.58
Liberia 2010 Yes Yes59 No - PHC anticipated that this would occur in September 2015.60
Burundi 2012 Yes Yes61 No62
Zimbabwe 2013 Yes No - PHC anticipated that this would occur by December 2015.63 No64

#### Is food being fortified to standard?

In July 2015, there was not enough monitoring data collected from industry to make an assessment of PHC's progress towards getting industries to implement fortification. PHC has shared with us its estimates of how much fortification is occurring in the countries where it works (see following footnote for details).65 However, we have not seen monitoring data to support these estimates.

Monitoring data

By July 2015, PHC said it had undertaken the majority of the steps necessary to prepare to collect monitoring data in each of the five countries where it was conducting a national fortification program.66 However, it said it had only reached the stage of collecting data in Liberia, and only one quarterly report on industry implementation was so far available.67

Our impression is that the results in Liberia’s first quarterly report implied that neither domestic producers nor importers were consistently fortifying to standard, but PHC told us that these results were inconsistent with external testing, and that the report uncovered a problem with the laboratory's centrifuge.68 PHC has since purchased a new centrifuge for the laboratory, and is optimistic that this will solve the testing issues.69 In July 2015, the next quarterly report was expected between July and September.70 We have not followed up with PHC to see if this report was released as planned, and if its results showed fortification up to standard.

When does PHC expect more data?

PHC expected the first quarterly report from Malawi in the next few months following July 2015.71 In PHC's progress benchmarks document,72 PHC writes that it anticipates that quarterly data collection would begin in Rwanda by November 2015,73 in Burundi by January 2016,74 and in Zimbabwe by January 2016.75

#### Have deficiencies in the countries where PHC works been reduced?

We have not seen any data on whether PHC's programs successfully lead to a reduction in levels of micronutrient deficiencies.

PHC told us that it plans to support countries in administering micronutrient deficiency surveys after fortified foods have been on the market for a sufficient period of time.76

We have seen evidence that in some cases, micronutrient deficiencies have been reported to be falling over time prior to fortification; for example, in Rwanda, iron deficiency in children reportedly fell from 69% in 2000 to 48% in 2008, and iron deficiency anemia in women reportedly fell from 43% to 27% in the same time period,77 though PHC has told us that no fortification other than the iodization of salt was occurring in Rwanda in these years.78 Because of this, it may be difficult to know how much of a decline in micronutrient deficiencies to attribute to food fortification.

#### Has PHC successfully exited fortification programs?

Once a national fortification program has matured, PHC aims to hand the program over to the government and discontinue assistance.79 By July 2015, PHC had not reached this step in any of its national fortification programs that were started since PHC began full-scale operations in 2010.80

PHC reports on four qualitative metrics that it has deemed essential for the successful implementation of food fortification programs:81

1. Are all identified industries and importers producing and importing the fortified foods at the required standards?
2. Are samples and / or results from all identified border points and all identified staple food producers being obtained on a regular basis?
3. Are noncompliance measurements being followed up on?
4. Are surveillance mechanisms put in place to ensure that 80% of the population is consuming fortified foods?

Each indicator has a set of benchmark questions that measure progress towards the indicator.82 PHC reviews these on a quarterly basis to determine how to help each country move its fortification program forward.83

In July 2015, PHC wrote that it had not yet met any of these four indicators in any of its five national fortification programs.84

For more information on PHC's qualitative metrics and its documentation of its progress in country programs, see PHC combined metrics July 2015 and PHC combined metrics (version 2) August 2015.

### What fortification programs would have existed in PHC's absence?

We do not have a strong sense of what fortification programs would have existed in the absence of PHC. We provide the below information as context that may be helpful in beginning to consider what fortification programs may have existed in the absence of PHC.

#### Case study in Liberia

The national fortification program that we have the most information about is that in Liberia. PHC told us that Liberia had been passed over by larger organizations because it was import-dependent,85 but that while PHC was in conversations with the Liberian government a large domestic producer was established, creating an opportunity for a fortification program.86 We have not attempted to vet this claim.

One factor that complicates attribution of impact is that PHC told us that a variety of organizations have provided some support to Liberia’s fortification program:

• PHC told us that UNICEF conducted a micronutrient deficiency survey with PHC's help.87 PHC also said that UNICEF has a mandate to ensure that salt is iodized to standard in Liberia, though it lacks the resources to implement that mandate.88
• PHC told us that GAIN donated a dosifier to the National Standards Lab and conducted external testing on at least one industry.89
• PHC told us that there are many local organizations involved with fortification, and that Helen Keller International also provided some initial assistance but then reduced its role.90

It seems that international organizations have also supported micronutrient fortification programs in countries nearby Liberia; we have not yet investigated how PHC’s support for fortification programs may differ from the support offered to nearby countries. Since PHC started work in Liberia in 2010,91 USAID has funded Helen Keller International to implement a project to initiate food fortification in West Africa.92 This project involves Liberia and 14 surrounding countries (Benin, Burkina Faso, Cape Verde, Cote D’Ivoire, Gambia, Ghana, Guinea, Guinea Bissau, Mali, Niger, Nigeria, Senegal, Sierra Leone and Togo).93 USAID reports that 12 of these 15 countries now have mandatory legislation for fortifying cooking oil, and that 14 now have mandatory legislation for fortifying wheat flour.94 We have not vetted these reports.

Overall, PHC told us that there are many local organizations working on fortification in Liberia, but that there is little international involvement, with the exception of UNICEF.95 PHC believes that without its assistance, it is unlikely that there would be a food fortification program in Liberia.96 We have not yet investigated the case of Liberia deeply enough to reach a view on the likely counterfactual of PHC’s work.

#### Fortification in countries where PHC considered working

The Food Fortification Initiative (FFI) published a map showing the progress in fortification of wheat and maize flour from 2004 to 2014.97 Two of the three countries where PHC had started a national fortification program by 2010 (Rwanda and Liberia) show mandatory fortification. The three other national fortification programs (Malawi, started in 2009, Burundi, started in 2012, and Zimbabwe, started in 2013) do not show mandatory fortification.98

As points of comparison, PHC has told us that Namibia, Uganda, and Zambia approached PHC at a time when it did not have the capacity to start new programs. PHC also informally spoke with the Democratic Republic of the Congo (DRC), but did not believe that it had the capacity to work with a country of that size.99 Of these countries, FFI's map shows Uganda as having mandatory fortification in 2014, Zambia as having no fortification, and Namibia and the DRC as having over 50% voluntary fortification.100 We have not vetted the data from this map.

PHC has also told us that UNICEF has started fortification work in some countries that PHC had previously decided not to work in due to insufficient capacity.101

The above information suggests that countries sometimes make progress on fortification without PHC’s support (even if they have requested its support). However, our information about fortification in these countries is limited, and we have not vetted the data in FFI progress map 2014. If we were to further analyze the impact of PHC’s work, we may investigate progress on fortification in non-PHC-supported countries in more depth.

### Has PHC's small-scale fortification initiative effectively fortified foods and reduced micronutrient deficiencies?

The bulk of PHC’s work to date has focused on large-scale fortification, so we have generally focused this review on the track record of its large-scale fortification work. However, recently PHC has also begun supporting small-scale fortification.

Overall, we have not yet seen enough information to make a confident assessment of whether PHC's small-scale fortification initiative is effectively fortifying flour, and we do not know how many people are likely to be affected by small-scale fortification in the areas where PHC currently works.

In July 2015, PHC told us that 56 fortification devices had been installed in mills as part of PHC's small-scale fortification initiative, Sanku.102 Sanku states that one device can fortify flour for up to 100,000 people daily.103 We do not know how many people are typically being reached by an average small-scale mill using one of Sanku’s devices.

PHC has told us that it has tested the flour produced at these mills and confirmed that the device is consistently fortifying flour within the required range of error.104 It has sent us documents describing a testing procedure, and results from testing for two mills.105 We have not seen results from tests at other mills.

The test results we have seen seem to show that the fortification devices can function effectively if the right procedures are followed, but we do not know if the appropriate procedures are consistently being followed correctly. For example, the test for determining and setting the dose rate is listed before the test for confirming the dose rate;106 if tests are performed in this order, that would seem to indicate that the series of tests provides evidence that the device is functional, but less evidence as to whether flour was being fortified to standard prior to the series of tests. We have not seen regular monitoring of small-scale mills that indicates whether the device is typically being used correctly.

### Does PHC have a track record for the type of monitoring work that it might do in the future?

Based on the information that we have seen, it is our impression that PHC does not yet have a track record on the monitoring work that it might shift to focus on in the future.

As of July 2015, PHC had only recently reached the stage of data collection in its national fortification programs: in July 2015, its seven progress benchmark questions for "data collection" all had status listed as 'No' for each of its national fortification programs.107

### Possible negative and offsetting impacts

• Are there negative effects of micronutrient fortification? We are aware of some potential negative effects of micronutrient fortification on health, such as potential increased cancer rates associated with folic acid fortification and potential increased malaria rates associated with iron fortification. We plan to discuss these effects further in our forthcoming reports on folic acid fortification and iron fortification.
• If PHC did not work on these fortification programs, would a different organization take its place? PHC has told us that in some cases it has declined to work with countries due to limited capacity, and other organizations have later started work in those countries.108 The possibility of other organizations achieving similar results to PHC (or potentially better results) could offset the expected impact of PHC’s work. We do not have a strong enough sense of the fortification landscape to know how likely this seems, but we have the impression that PHC collaborates with other related organizations to determine how it can have the most positive impact, which somewhat mitigates this concern.109
• Are there negative effects on industry of mandating micronutrient fortification? PHC aims to mandate fortification only in situations where it will not raise the price of the food by more than 2%. As an example, in Liberia, PHC decided to make sugar fortification standards voluntary for industry (at least on a temporary basis), to keep the price from rising beyond PHC's limit.110

## What do you get for your dollar?

If successful, it seems plausible that micronutrient fortification programs such as those supported by PHC could be as cost-effective as our other priority programs.

However, we have not yet attempted a formal cost-effectiveness analysis of PHC’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.
• Whether foods are being fortified at appropriate levels: As discussed above, we have not yet seen monitoring data about what portion of producers are fortifying foods at appropriate levels.
• Attributing impact to PHC: If we were to have better information about how many producers were successfully fortifying, we would then want to improve our estimate of how much credit for fortification we ought to attribute to PHC. Some factors that complicate this analysis are that different organizations often collaborate on fortification programs and it is difficult to know what would have happened in the absence of PHC’s assistance.
• PHC’s future plans: PHC’s future work may be very different from its past work (more), so we would want to better understand its future plans before attempting to estimate the impact of additional funds given to PHC.

## Is there room for more funds?

In brief:

• When we last spoke with PHC in July 2015, it was considering substantially changing how it operates by 2017, which makes it difficult for us to predict how the bulk of additional funding would be used. One major option that PHC was considering was shifting toward focusing on monitoring and evaluation of fortification programs (rather than implementing fortification programs), including the possibility of being absorbed by another organization to do monitoring work.111 In July 2015, PHC was planning to solicit feedback from other organizations in the field about which kinds of activities would be most useful for PHC to work on, and it expected to make a decision about where to focus in the next three to four months.112
• Though its future core activities were still being determined, PHC told us that it had two funding gaps for its work in 2016: 1) $200,000 that would be used to support its current national fortification programs through the beginning of 2017,113 at which point PHC expects that it would be able to end its involvement in its national fortification programs,114 2)$300,000 to continue its small-scale fortification work.115 We do not have a strong sense of how likely it is that other funders would fill these gaps, but PHC told us that it was actively fundraising to meet these needs.116
• In the longer term (i.e., likely beginning in early 2017), PHC expects that if it were to focus on monitoring and evaluation work, it would be able to use up to about $1 million in additional funding to launch this work. It expects that this amount of funding would enable it to begin doing this work in over six countries.117 PHC told us that it would need to identify additional sources of funding to conduct this work because it did not expect to ask for more funding from its past major donors.118 Note that PHC 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.

## Major questions for further investigation

• What is the current coverage of fortified foods in the countries that PHC works in? So far we have seen very little monitoring data from the programs that PHC works with, and we do not have a strong understanding of how successful they have been in terms of effectively fortifying foods that have reached the populations in need. While national fortification programs have the potential to be highly cost-effective, there could be a large difference between what is legislated by a national fortification program and the reality of what is being effectively fortified.
• How much of the progress in fortification in countries where PHC works should we attribute to PHC? Since our investigation of PHC has been relatively limited to this point (more), we have not yet attempted to do detailed case studies of PHC’s impact. Such case studies would consist of trying to understand what would have likely happened if PHC had not intervened in particular countries and understanding the monitoring data from particular countries in more depth. To see examples of such case studies, see our reviews of Iodine Global Network and the Global Alliance for Improved Nutrition’s universal salt iodization program.
• What are the health benefits of micronutrient fortification at the levels at which PHC fortifies? We have researched some, but not all, of the micronutrients with which PHC fortifies.
• Have micronutrient deficiencies been reduced in the areas where PHC works?
• What programs will PHC focus on in the future, and how effective will these be? We have little understanding of what PHC's future work will consist of after 2017, or how effective its work is likely to be.

## Our investigation process

As we stated in our 2015 plans, we are interested in evaluating additional charities that work on micronutrient fortification. To date, our investigation process has consisted of:

• Two conversations with Laura Rowe, the Chief Operating Officer of PHC.119
• Reviewing documents PHC sent us after these conversations, and in response to our queries.

## Sources

Document Source
Copenhagen Consensus micronutrient fortification 2015 Source (archive)
FFI country profiles 2015 Source (archive)
FFI progress map 2014 Source (archive)
GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015 Unpublished
GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015 Source
PHC 990 form 2010 Source
PHC 990 form 2011 Source
PHC 990 form 2012 Source
PHC Before and After analysis regarding PHC's impact 2013 Source
PHC Before and After analysis regarding PHC's impact 2015 Source
PHC BioAnalyt test results for Sanku 2014 Source
PHC budget 2015 (unpublished) Unpublished
PHC Burundi factory assessment report 2014 Source
PHC combined metrics (version 2) August 2015 Source
PHC combined metrics February 2015 Source
PHC combined metrics July 2015 Source
PHC considerations on food fortification in Malawi 2010 Source
PHC costing board book with country projections 2014 Source
PHC country statistics 2012 Source
PHC email from Laura Rowe (unpublished) Unpublished
PHC finances 2013-14 Source
PHC fortification impact studies 2012 Source
PHC fortification monitoring tool for Liberia with dummy data 2014 Source
PHC information about monitoring tool 2014 Source
PHC Liberia fortification guidelines 2014 Source
PHC Liberia QA Report 2015 (unpublished) Unpublished
PHC Malawi FRAT findings summary draft 2009 Source
PHC Malawi FRAT report 2010 Source
PHC Malawi situation assessment 2010 Source
PHC Rwanda consumption study 2009 Source
PHC Rwanda industry assessment 2009 Source
PHC Rwanda industry structure 2009 Source
PHC Rwanda market pricing survey 2009 Source
PHC Rwanda overview and context 2009 Source
PHC Rwanda situation assessment cover page 2009 Source
PHC Sanku cutsheet 2015 Source
PHC Sanku quantitative test procedure for small-scale mill fortification 2013 Source
PHC Sanku test results 2015 Source
PHC Sanku white paper 2014 Source
PHC website, importance of micronutrients 2016 Source (archive)
PHC website, Liberia 2016 Source (archive)
PHC website, project highlights 2016 Source (archive)
PHC website, small-scale fortification 2016 Unpublished
PHC website, what we do 2016 Source (archive)
PHC Zimbabwe's incorporation of monitoring indicators with dummy data 2015 Source
USAID Fortify West Africa Factsheet 2015 Source (archive)
WHO Guidelines on food fortification with micronutrients 2006 Source (archive)

• 1.

"Project Healthy Children (PHC) provides technical assistance to small countries as they design and implement food fortification programs." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 1.

• 2.

GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015 (not included in the published notes, but mentioned in the same conversation)

• 3.
• 4.

"Despite the increasing adoption of large-scale fortification programs throughout the developing world, however, a large portion of individuals living in rural and remote areas do not have access to centrally processed foods and therefore do not benefit from large-scale fortification programs.
"Sanku, our small-scale fortification program, addresses this critical gap, reaching some of the most vulnerable members of the population." PHC website, what we do 2016

• 5.
• 6.

"PHC begins its work in a country by creating a National Fortification Alliance, which typically includes the country’s ministries of health, commerce and / or trade, agriculture, and / or education; bureaus of standards, staple food producers and importers, consumer associations, and academia. PHC then guides this alliance through the process of creating a food fortification implementation plan for the country." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 4.

• 7.
• "PHC’s technical assistance focuses on four elements: 1. Policy and legislation 2. Country-specific standards creation and regional harmonization 3. Industry implementation 4. Government monitoring and social advocacy" GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 1.
• Country-specific standards creation.
• PHC told us that it assists the government in drafting food fortification standards: "PHC works with country governments to draft food fortification standards. These standards are based on deficiency levels and food consumption patterns. These standards also have to be close to existing regional standards to minimize any barriers to trade with other countries in the region." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 2.
• PHC told us that it only mandates standards when the price of a good will not increase by more than 2%: "Sugar, which is not produced domestically in Liberia, was omitted from the mandatory program because importers were unable to comply with standards and keep the price increase under PHC’s two-percent limit." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 2.
• Policy and legislation. PHC told us the following about its work on policy and legislation:
• "PHC also works with country governments to write and pass legislation that makes the food fortification programs mandatory.
"Mandatory food fortification programs have two advantages over voluntary programs:
1. Mandatory programs level the playing field in terms of cost for producers and importers adopting fortification.
2. Mandatory programs allow countries to correctly calculate the amounts of micronutrients that should be added to foods to reduce deficiencies in their populations. These calculations can only be truly effective if countries can assume that all sources of a particular food will contain the designated amount of micronutrients. Mandatory programs are an effective way to ensure nutritional impact."
• Industry implementation. PHC told us that "PHC helps food producers revamp their production lines to accommodate the fortification process, source the required vitamins and minerals to add to the food, and design and implement internal testing and quality control procedures." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 2.
• Government monitoring and social advocacy.
• PHC told us that it helps countries integrate fortification monitoring into their existing food monitoring systems, and ensures that countries have trained inspectors as well as the necessary equipment to collect and aggregate data: "PHC assesses countries' existing food monitoring systems and helps countries integrate fortification monitoring into these systems…After collecting this information, PHC collaborates with regional consultants specializing in how to sample and test fortified foods to train countries' food inspectors. PHC also ensures that countries have equipment in the field and in the lab that allows their inspectors to test foods for micronutrient fortification levels. PHC also ensures that countries have data compilation tools available to collect and aggregate the data generated by their food inspectors. Countries typically do not have their own compilation tools, so PHC creates a unique monitoring workbook for each country that it works with. These workbooks automatically generate graphics based on data entered by inspectors and clearly display where compliance with the country's food fortification standards does and does not exist." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 2.
• PHC said it also does some work on social advocacy for food fortification (e.g., educating consumers about fortified foods), sometimes in collaboration with other organizations. As examples, in PHC's national fortification campaign in Liberia:
• 8.

GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015 (not included in the published notes, but mentioned in the same discussion)

• 9.

Inferred from a private version of PHC combined metrics July 2015, which showed the progress made on each national fortification program and listed Sierra Leone as pending.

• 10.

Note that all of the below information is based on what PHC has told us and PHC's website; we have not independently verified these claims.

• "RWANDA (SINCE 2007)
• Conducted a Fortification Rapid Assessment Tool (FRAT) survey to identify fortification vehicles
• Guided formation of country's first National Fortification Alliance (NFA)
• Supported drafting and validation of country-specific fortification standards and drafting of Ministerial Decree to mandate fortification for maize and wheat flour, cooking oil, sugar, and salt
• Supported the adoption of a national fortification logo and logo guidelines
• Trained Ministry of Health and Bureau of Standards food inspectors on the sampling and testing of fortified foods
• Conducted an industry assessment and engaged industry in specific scale-up efforts
• Supported the country's largest maize flour producer to begin fortification
• Currently supporting government in the design of monitoring and reporting systems
• Currently working with the Consumer's Association and MoH in the design of advocacy campaigns
• Currently ensuring all other staple food producers are ready to fortify once the decree is signed”
• "Currently, fortification is taking place by the country's [Rwanda’s] largest maize flour producer. Others are awaiting the decree . . . Legislation/Legal Requirements . . . Waiting final signing by the new Food and Medicine Authority. Slated for Aug 2015." PHC Before and After analysis regarding PHC's impact 2015, Pg 1.
• "MALAWI (SINCE 2009)
• Assisted in the revitalization of the country's National Fortification Alliance (NFA)
• Evaluated current fortification reporting systems; developed a comprehensive database and reporting tool that tracks compliance data and trained staff on its use
• Assisted in revising fortification standards and Gazetting the standards for maize and wheat flour, cooking oil, sugar, and salt
• Drafted a national micronutrient strategy adopted by the Office of the President and Cabinet (OPC)
• Facilitated food inspector trainings and drafted national logo guidelines
• Currently helping to ensure sufficient monitoring mechanisms are in place using PHC’s Fortification-specific Management Information System with the goal of effectively tracking and improving upon product compliance to national standards"
• "LIBERIA (SINCE 2010)
• Used WFP survey data to infer consumption of staple products and propose vehicles for fortification
• Assisted in drafting protocols for a national micronutrient deficiency study
• Guided formation of country's first NFA
• Supported drafting, adoption, & harmonization of country-specific standards, a national logo, and logo guidelines for maize and wheat flour, cooking oil, and salt
• Assisted country's only wheat flour producer and country's largest flour and oil importers to produce and procure fortified products that meet national standard
• Supported the training of Ministry of Health and Commerce inspectors on sampling and testing protocols
• Currently working with the wheat flour producer to ensure effective internal monitoring is in place
• Currently working with the National Standards Laboratory and importers to ensure products continue to meet national standards, advocacy campaigns are designed, and monitoring and surveillance systems are in place"
• "BURUNDI (SINCE 2012)
• Facilitated the creation of the country's first NFA
• Guided the leadership of the NFA in the design of logo and logo guidelines
• Facilitated the Gazetting of EAC standards for maize and wheat flour, cooking oil, sugar, and salt
• Facilitated the drafting and passage and national legislation making fortification mandatory throughout the country
• Facilitated the training of Bureau of Standards staff on a national sample collection and testing plan
• Working with the Bureau of Standards to streamline inspection and testing processes and to ensure an effective monitoring and surveillance system are in place
• Working with domestic industry to facilitate fortification scale-up"
• "ZIMBABWE (SINCE 2013)
• Assisted in the drafting of national regulations for maize and wheat flour, cooking oil, sugar, and salt
• Supporting partners in the design of fortification logo and logo guidelines, and drafting of advocacy campaigns
• Working with government to map food inspection process and provide the necessary training to inspectors
• Working with government to provide scale-up assistance to staple food producers
• With government, developing a comprehensive database and reporting tool for monitoring using Zimbabwe’s already-existing online health management system"
• Sierra Leone: PHC has more recently started work on a national fortification program in Sierra Leone. We do not have information about PHC's work in Sierra Leone, but we believe it to be in the early stages. We inferred this from the below:
• 11.

"PHC only works in countries in which they are invited. Governments have to be ready to independently run and prioritize food fortification programs for the programs to be successfully implemented over the long term.
"Countries typically hear about PHC through word of mouth or from another organization. Burundi heard about PHC from Rwanda, and Sierra Leone heard about PHC from Liberia." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 3.

• 12.

"PHC works with small countries (typically populations of less than 15 million) that either do not have food fortification programs in place but are interested in developing them, or that have programs in place that are faltering in some way. For example, PHC was invited by the Government of Malawi to assist in strengthening their already-existing program. PHC focuses on small countries generally overlooked by larger agencies." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 3.

• 13.

"Once a country approaches PHC for assistance with its food fortification program, PHC conducts a high-level assessment, and if warranted, a more in-depth situation assessment, to determine whether to work with the country." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 3.

• 14.

"PHC conducts its situation assessments by:

• Analyzing detailed micronutrient deficiency data to understand the types and severity of deficiencies in the population.
• Analyzing food consumption data, or data that describe the types and quantities of food that people typically eat, to understand which foods might be candidates for fortification.
• Assessing government functionality and profiling ministry officials involved in fortification and / or nutrition work to better understand how ministries work together.
• Assessing industry structure to identify the number of producers and importers of staple foods and from where staple foods are typically imported.
• Conducting a market analysis of how fortification would impact the cost of various foods."
• 15.

"PHC conducts situation assessments by reviewing existing nutritional data and policies and by interviewing relevant individuals to learn about the work the country has already done in the nutrition and / or food fortification arena and to better understand how fortification might fit (or not fit) into the existing landscape." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 3.

• 16.

"PHC is typically able to rely on existing micronutrient deficiency data for its situational assessments. PHC does not have the human or financial capacity to conduct independent micronutrient deficiency surveys." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 4.

• 17.

"In terms of obtaining consumption data, PHC will conduct rapid on-the-ground surveys, obtain data from already-existing consumption data sources, or conduct implied consumption analyses from existing sources. In a few cases PHC has administered the Fortification Rapid Assessment Tool (FRAT), which is a questionnaire that collects consumption information specifically pertaining to effective fortified food staples. In other cases, PHC makes estimations about consumption based on other data, such as informal market assessments or general household expenditure surveys." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 4.

• 18.

"PHC typically spends between five and eight years working with a country to develop its food fortification program. Two factors—the country’s political stability and the degree to which it takes ownership of its program—usually determine how long PHC remains involved. For example, PHC will likely only spend four years in Liberia because individuals in Liberia’s government have provided strong leadership for its program. Conversely, PHC has been in Rwanda since 2007 because there has been a great deal of turnover in its government, which necessitates PHC’s continued presence." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 4.

• 19.
• 20.

"In each country of operation, PHC places or co-places one, single Country Coordinator whose role it is to act as a catalyst and provide guidance to government and industry in support of a national program…One country coordinator will split his or her time between two countries as PHC transitions out of one and into another." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 7-8.

• 21.

"Country Coordinators function as technical consultants to governments throughout the design and implement phases of food fortification programs." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 7.

• 22.

"Country coordinators are often physically co-located with countries' ministries of health so that they are perceived as part of the government." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 7.

• 23.

"One country coordinator operates in each of the following countries or country clusters: Tanzania, Liberia, Rwanda/ Burundi, and Malawi/ Zimbabwe." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 7.

• 24.
• 25.

"PHC's small-scale program, Sanku, has designed an effective model that will enable small and medium scale, village-level mills to cost-effectively and sustainably fortify their grain." PHC website, small-scale fortification 2016 (this webpage is no longer public)

• 26.

"Despite the increasing adoption of large-scale fortification programs throughout the developing world, however, a large portion of individuals living in rural and remote areas do not have access to centrally processed foods and therefore do not benefit from large-scale fortification programs.

"Sanku, our small-scale fortification program, addresses this critical gap, reaching some of the most vulnerable members of the population." PHC website, what we do 2016

• 27.

"The international community has been skeptical of small-scale efforts because of difficulties monitoring and the propensity for human error." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 11.

• 28.

"PHC’s programs use a device that fits small-scale mills, dispensing vitamin mineral premix according to established standards and at a rate based on the decreasing weight of the grain in the hopper as it passes into the grinder. Software that comes with the device calculates the loss of weight and is preprogrammed with national standards." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 11.

• 29.

"Fifty-six of these devices have been installed in three regions in Tanzania through a pilot program, part of a rural agriculture initiative funded by USAID." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 11.

• 30.
• "Each project and program we aim to partner with is unique. Depending on the business model chosen, the Sanku Dosifier can range from US$0 -$4,000. Other dosifiers on the market cost US$7,000 - US$10,000."
• "A single dosifier has the potential to fortify flour for 100,000 people daily"

PHC Sanku cutsheet 2015, Pg 1.

• 31.
• 32.

"PHC spends roughly $70,000 per country per year. These costs cover: • Consulting fees for industry assessments and inspector training. • Travel costs for PHC staff. • PHC salaries. • Taxes paid to the countries. • Gap funding for national fortification alliances and national standards labs. • Advocacy and monitoring work. "Gap funding is used to ensure that national fortification alliance meetings are held during the early stages of countries’ fortification programs. The funding covers small items like transportation, room rental, and refreshments, but without these things, the meetings would likely not happen. Country governments or other organizations eventually absorb the costs of these meetings." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pgs 4-5. • 33. All data in this section are from PHC 990 form 2010 (Pg. 10), PHC 990 form 2011 (Pg. 10), PHC 990 form 2012 (Pg. 10), PHC finances 2013-14, and PHC budget 2015 (unpublished). • 34. Includes salaries and wages (including overseas payroll), employee benefits, and payroll taxes. • 35. For 2010-2012, this includes office expenses; depreciation, depletion, and amortization; insurance; communications (2010 only); "other miscellaneous;" and "all other expenses." For 2013, this includes communications; office supplies; "other" (not including small-scale fortification materials); property and equipment; insurance; and utilities. • 36. See 'All country summary' sheet in PHC costing board book with country projections 2014. • 37. See 'Cost' column and 'Actual' column in sheets 'Burundi', 'Malawi', 'Rwanda', and 'Liberia' in PHC costing board book with country projections 2014. PHC's projected spending in each country is shown in the table below: All from 'All Country Summary' sheet in PHC costing board book with country projections 2014. • 38. PHC budget 2015 (unpublished) (This document contains a comparison between PHC’s 2014 and 2015 budgets that we used to estimate how much PHC spent on small-scale fortification in 2014 and 2015.) • 39. "Countries typically add the following micronutrients to the following foods: • Iron, zinc, folic acid, and vitamins A, B1, B2, B3, B6, and B12 are added to flour. • Vitamin A is added to cooking oil and sugar. • Iodine is added to salt." • 40. "Not every country adds vitamin A to flour because doing so is expensive. Adding it to cooking oil and sugar is more cost-effective. However, many countries push to add vitamin A to flour because regional standards require that it be added." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 5. • 41. "Foods Fortified • Iodized salt at 50-80ppm in line with regional recommendations • Wheat and maize flour with iron, zinc, folic acid, B1, B2, B3, B12, and vitamin A, in line with regional standards • Cooking oil with vitamin A, in line with regional standards • Sugar with vitamin A, in line with regional standards" PHC Before and After analysis regarding PHC's impact 2015, Pgs 1, 2, 3, 4, and 5. • 42. "Sanku is also the supplier of the high-grade micronutrient premix that is specifically formulated for use with the Sanku Dosifier. . . National nutrient standards are used in each market Sanku supplies. Based on current consumption patterns, deficiency rates, and approved bioavailable nutrient forms, Sanku's formulated premix ensures enough nutrients are absorbed to fill the identified gap." PHC website, small-scale fortification 2016 (this webpage is no longer public) • 43. "PHC sees an opportunity to transition from helping countries design food fortification programs to helping countries improve their ability to monitor their programs. Few countries remain that need PHC's assistance developing food fortification programs, but many countries need PHC's assistance to improve their existing programs' monitoring systems. These systems are often overlooked when developing fortification programs, or they are planned but not given sufficient resources to operate." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 8. • 44. "[W]ithout effective monitoring, mandatory food fortification programs typically do not meaningfully reduce micronutrient deficiencies and can lead countries to think that food fortification does not work." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 8. • 45. "PHC is currently exploring two options, both of which have been vetted with its board: • Become a standalone organization focused on monitoring – One option is for PHC to remain a standalone organization but focus exclusively on monitoring. • Join another organization – The alternative is for PHC to be absorbed by another organization as a monitoring arm. In either scenario, PHC would maintain its current internal structure (providing consulting services to governments with a country coordinator working locally) but shift its focus from program design to monitoring." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 10. • 46. "PHC plans to solicit feedback on these options from other organizations in the field, and GAIN's global summit should offer an opportunity to do this. PHC hopes to make a decision in the next three to four months." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 10. • 47. From the section on PHC's small-scale pilot program in Tanzania: "PHC is committed to continuing this effort regardless of how the organization may change in 2016/2017." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 11. • 48. • The surveys range from up to eight years before PHC began working in a country to around the time PHC's involvement began: • Some evidence suggests that micronutrient deficiencies may be falling over time, so past surveys could over-represent current deficiencies in the population. For example, in Rwanda, iron deficiency in children fell from 69% in 2000 to 48% in 2008, and iron deficiency anemia in women fell from 43% to 27% in the same time period. • "The incidence of iron deficiency in children remains high although it decreased from 69% in 2000 to 48% in 2008" • "Iron deficient anemia, which contributes to maternal mortality, is a significant issue although it fell from, 43% of women in 2000 to 27% in 2008." Both quotes are from PHC Rwanda overview and context 2009, Pg 3, with both statistics from 2008 referencing '2007-2008 mini-DHS' in a footnote. • 49. See 'Coverage' column in sheets 'Burundi,' 'Malawi,' 'Rwanda,' 'Liberia,' 'Sierra Leone,' and 'Zimbabwe.' PHC costing board book with country projections 2014 • 50. Each quote below comes from PHC Before and After analysis regarding PHC's impact 2015 and is the entry under the column "Current status" and the heading "Legislation/Legal Requirements" for a particular country: • Rwanda: "Waiting final signing by the new Food and Medicine Authority. Slated for Aug 2015." Pg 1 • Liberia: "Pending two Ministry signatures. Slated for completed by Sept 2015." Pg 3 • Burundi: "Pending due to political situation. Only a signature is required." Pg 4 • 51. Each quote below comes from PHC Before and After analysis regarding PHC's impact 2015 and is the entry under the column "Prior situation" and the heading "Legislation/Legal Requirements" for a particular country: • Rwanda: "Nothing in terms of fortified products," Pg 1 • Malawi: "Nothing in terms of fortified products; all voluntary and without compliance with standards," Pg 2 • Liberia: "Nothing in terms of fortified products," Pg 3 • Burundi: "Nothing in terms of fortified products," Pg 4 • Zimbabwe: "Nothing in terms of fortified products," Pg 5 • 52. • 53. • 54. • "HONDURAS (2000-2010)" • "RWANDA (SINCE 2007)" • "MALAWI (SINCE 2009)" • "LIBERIA (SINCE 2010)" • "BURUNDI (SINCE 2012)" • "ZIMBABWE (SINCE 2013)" • 55. "Standards adopted and gazetted." PHC Before and After analysis regarding PHC's impact 2015, Pg 1. • 56. "Legislation/Legal Requirements. . . Waiting final signing by the new Food and Medicine Authority. Slated for Aug 2015." PHC Before and After analysis regarding PHC's impact 2015, Pg 1. • 57. "Adopted and gazetted." PHC Before and After analysis regarding PHC's impact 2015, Pg 2. • 58. "Legislation/Legal Requirements. . . Slated to be passed Dec 2015." PHC Before and After analysis regarding PHC's impact 2015, Pg 2. • 59. "Standards drafted and gazetted." PHC Before and After analysis regarding PHC's impact 2015, Pg 3. • 60. "Legislation/Legal Requirements. . . Pending two Ministry signatures. Slated for completed by Sept 2015." PHC Before and After analysis regarding PHC's impact 2015, Pg 3. • 61. "Standards adopted and gazetted." PHC Before and After analysis regarding PHC's impact 2015, Pg 4. • 62. "Legislation/Legal Requirements. . . Pending due to political situation. Only a signature is required." PHC Before and After analysis regarding PHC's impact 2015, Pg 4. • 63. "Standards drafted and under review. Slated to be adopted by December 2015." PHC Before and After analysis regarding PHC's impact 2015, Pg 5. • 64. "Legislation/Legal Requirements. . . Pending standards review." PHC Before and After analysis regarding PHC's impact 2015, Pg 5. • 65. The industry implementation that PHC told us had occurred in its national fortification programs by July 2015 is presented below: Country Project started Fortification prior to PHC PHC’s estimate of current fortification occurring Monitoring data collected? (All inferred from GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015.) Rwanda 2007 Salt fortified, but at too high a level. ("Salt with iodine at 100ppm (too high based on current WHO potassium iodate recommendations) with coverage of ~98%." PHC Before and After analysis regarding PHC's impact 2015, Pg 1.) The country's largest maize flour producer is fortifying. Others are waiting for the final signing of legislation. PHC Before and After analysis regarding PHC's impact 2015, Pg 1. No Malawi 2009 "Malawi had fortification standards in place for cooking oil, sugar, salt, maize and wheat flour, however the standards were not in line with current consumption patterns or deficiency rates." PHC Before and After analysis regarding PHC's impact 2015, Pg 2. "Most facilities are fortifying their products. Final facilities to come on line once grace period is formally communicated to industry. Slated for Aug 2015." PHC Before and After analysis regarding PHC's impact 2015, Pg 2. No – first quarterly report expected imminently Liberia 2010 Salt fortification required, with little compliance. ("Salt required 50-80ppm of iodine, however, most salt did not comply" PHC Before and After analysis regarding PHC's impact 2015, Pg 3.) "Domestic producers fortifying to standard. Importers need further follow-up." PHC Before and After analysis regarding PHC's impact 2015, Pg 3. Yes – first quarterly report received Burundi 2012 Salt fortified but at too high a level. ("Salt with iodine at 100ppm (too high based on current potassium iodate recommendations) with coverage of ~98%." PHC Before and After analysis regarding PHC's impact 2015, Pg 4.) "Burundi's largest cooking oil facility already fortifying to standard." PHC Before and After analysis regarding PHC's impact 2015, Pg 4. No Zimbabwe 2013 "Zimbabwe had fortification standards in place for cooking oil, sugar, salt, maize and wheat flour, however the standards were not in line with current consumption patterns or deficiency rates." PHC Before and After analysis regarding PHC's impact 2015, Pg 5. "About half of the facilities are currently fortifying." PHC Before and After analysis regarding PHC's impact 2015, Pg 5. No • 66. See the column 'Status' in the section 'Preparing for data collection' for Liberia, Rwanda, Burundi, Malawi, and Zimbabwe in the 'Summary' sheet of PHC combined metrics July 2015. • 67. PHC Liberia QA Report 2015 (unpublished) • 68. GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015 • 69. GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015 • 70. "The next quarterly report is expected between July and September, and PHC is hopeful that most samples will be up to standard." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 5. • 71. PHC email from Laura Rowe (unpublished) • 72. PHC combined metrics July 2015 • 73. PHC combined metrics July 2015, sheet 'Summary,' cells F63 to F65. • 74. PHC combined metrics July 2015, sheet 'Summary,' cells F97 to F99. • 75. PHC combined metrics July 2015, sheet 'Summary,' cells F165 to F167. • 76. "Micronutrient deficiency surveys, which measure the prevalence and extent of micronutrient deficiencies, are generally administered 10-12 months after the fortified foods are available on the market. This lag time gives countries sufficient opportunity to work out any issues in their supply chains. These surveys also should not be administered until countries have ensured that at least 80% of its population is consuming the fortified foods. "PHC will provide desk-side support to countries as they administer their micronutrient deficiency surveys. Ideally, countries would include these indicators in existing demographic and health surveys. For countries that are not able to administer their own surveys, PHC assists in establishing partnerships with other agencies that find fund such studies. "Malawi has scheduled a micronutrient deficiency survey to be conducted in 2015 / 2016. PHC is encouraged by the progress in Malawi and believes this survey will provide important data to capture the fortification program's impact." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pgs. 6-7. • 77. • "The incidence of iron deficiency in children remains high although it decreased from 69% in 2000 to 48% in 2008" • "Iron deficient anemia, which contributes to maternal mortality, is a significant issue although it fell from, 43% of women in 2000 to 27% in 2008." Both quotes are from PHC Rwanda overview and context 2009, Pg 3, with both statistics from 2008 referencing '2007-2008 mini-DHS' in a footnote. • 78. "Prior situation. . .Salt with iodine at 100ppm (too high based on current WHO potassium iodate recommendations) with coverage of ~98%." PHC Before and After analysis regarding PHC's impact 2015, Pg 1. • 79. "As the program matures and as government and industry take on greater responsibilities, work streams can be slowly and seamlessly handed over to government and PHC assistance withdrawn without a void being felt." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 7. • 80. • 81. “PHC has developed four indicators that it deems essential for the successful implementation of food fortification programs: 1. Are all identified industries and importers producing and importing the fortified foods at the required standards? 2. Are samples and / or results from all identified border points and all identified staple food producers being obtained on a regular basis? 3. Are noncompliance measurements being followed up on? 4. Are surveillance mechanisms put in place to ensure that 80% of the population is consuming fortified foods?” • 82. “PHC has developed a set of benchmark questions that measure progress towards each indicator. Examples of benchmark questions related to the first standard include: • Does the country have a sampling plan in place for the food products to be fortified? • Does the country routinely collect fortification data from food inspectors? • Has the country’s food industry appropriately scaled up to accommodate new food fortification procedures? • Are importers aware of the country’s new food fortification standards?” • 83. “PHC reviews these benchmark questions for each of its countries on a quarterly basis to determine how to help each country move its fortification program forward.” GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 6. • 84. See A2 to K7 in 'Summary' sheet of PHC combined metrics July 2015. Note that the first metric listed above ('Are all identified industries and importers producing and importing the fortified foods at the required standards?') has been separated into two metrics in the spreadsheet, now in rows 3 and 4. • 85. "Liberia was passed over by large organizations working in food fortification, including UNICEF, the Global Alliance for Improved Nutrition, and USAID because implementing a fortification program can be difficult in a small country that lacks a consolidated domestic producer and is therefore reliant on imports for most staples." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 1. • 86. "But in 2010, just as PHC began its conversations with the Liberian government, the emergence of a new domestic wheat flour producer provided an opportunity for the development of a food fortification program in Liberia. PHC began work on a program in 2010." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 1. • 87. GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015 • 88. "UNICEF has a mandate to ensure that salt is iodized to standard in Liberia, but it lacks the resources to implement that mandate." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 7. • 89. "Fortification standards are not yet mandatory, but Premier is already fortifying its product. The Global Alliance for Improved Nutrition (GAIN) donated a dosifier (a device that dispenses precise doses of micronutrient premix), as well as testing equipment that has allowed them to fortify their flour to standard. The first bag of premix was also donated with the understanding that Premier would be responsible for procuring additional premix. "As of June, Premier Milling had purchased an additional bag of premix, and external testing by GAIN and by the premix manufacturer confirmed that its product meets the standard." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 3. • 90. "There are many local organizations involved with fortification in Liberia (including the National Consumer Council for Liberia) but with the exception of UNICEF, there is very little international involvement. Helen Keller International provided some initial assistance but has drastically reduced its role." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 7. • 91. • "HONDURAS (2000-2010)" • "RWANDA (SINCE 2007)" • "MALAWI (SINCE 2009)" • "LIBERIA (SINCE 2010)" • "BURUNDI (SINCE 2012)" • "ZIMBABWE (SINCE 2013)" • 92. • "Implementing partner: Helen Keller International" • "Life of Project: January 2011 – September 2016" • 93. "Geographic Scope: Benin, Burkina Faso, Cape Verde, Cote D’Ivoire, Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone and Togo." USAID Fortify West Africa Factsheet 2015 • 94. "12 of 15 ECOWAS countries have mandatory legislation for fortifying cooking oil and 14 out of the 15 have mandatory legislation for fortifying wheat flour." USAID Fortify West Africa Factsheet 2015 • 95. "There are many local organizations involved with fortification in Liberia (including the National Consumer Council for Liberia) but with the exception of UNICEF, there is very little international involvement. Helen Keller International provided some initial assistance but has drastically reduced its role." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 7. • 96. “Without PHC’s assistance, it is unlikely there would be a food fortification program in Liberia.” GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 1. • 97. FFI progress map 2014 • 98. • 99. GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015 • 100. FFI progress map 2014 • 101. GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015 • 102. "Fifty-six of these devices have been installed in three regions in Tanzania through a pilot program, part of a rural agriculture initiative funded by USAID." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 11. • 103. "A single dosifier has the potential to fortify flour for 100,000 people daily." PHC Sanku cutsheet 2015 • 104. "PHC tested flour produced at these mills and confirmed that the product is consistently within the required range of error." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 11. • 105. • 106. See sheet 'test 3' in PHC Sanku test results 2015. • 107. See the 'data collection' section in PHC combined metrics July 2015, sheet 'Summary', for each of Liberia, Rwanda, Malawi, Burundi, and Zimbabwe. Benchmark questions are listed as: • "Have all samples been taken? • Have all samples arrived at the appropriate lab on time? • Have all qualitative tests been complete? • Have all quantitative tests been complete? • Are reports generated on a quarterly basis for all imports? • Are reports generated on a quarterly basis for all industry? • Are reports generated on a quarterly basis for all markets?" For each country, each benchmark has 'No' listed under status. • 108. "PHC has never declined to work with a country because its people did not have sufficient micronutrient deficiencies, but it has deferred work in several countries because it was unable to support additional projects beyond its current portfolio. Other larger agencies have recently started food fortification projects in some of these countries, so if PHC does eventually work with these countries, it may be in a more focused capacity. For example, some countries have shown interest in PHC providing specific fortification monitoring support." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg. 4. • 109. "Taking into account the current fortification landscape, PHC is currently exploring two options, both of which have been vetted with its board. . .PHC plans to solicit feedback on these options from other organizations in the field, and GAIN’s global summit should offer an opportunity to do this. PHC hopes to make a decision in the next three to four months." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 10. • 110. "Sugar, which is not produced domestically in Liberia, was omitted from the mandatory program because importers were unable to comply with standards and keep the price increase under PHC’s two-percent limit." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 2. • 111. • "After its current funding is exhausted, PHC will likely change its model, which has focused on the implementation of fortification in small countries. Most small countries are now covered under existing mandatory fortification programs. However, while coverage is now widespread (GAIN programs cover most of Central Asia, the majority of Africa is covered, and South American programs are generally further along than those in Central Asia and Africa), monitoring those programs will be very important." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 10. • "Taking into account the current fortification landscape, PHC is currently exploring two options, both of which have been vetted with its board: • Become a standalone organization focused on monitoring - One option is for PHC to remain a standalone organization but focus exclusively on monitoring. • Join another organization - The alternative is for PHC to be absorbed by another organization as a monitoring arm." • "In either scenario, PHC would maintain its current internal structure (providing consulting services to governments with a country coordinator working locally) but shift its focus from program design to monitoring." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 10. • 112. "PHC plans to solicit feedback on these options from other organizations in the field, and GAIN’s global summit should offer an opportunity to do this. PHC hopes to make a decision in the next three to four months." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 10. • 113. • 114. “PHC’s current funding ends in late 2016/early 2017. PHC is confident it will be close to implementation in Burundi, Liberia, Malawi, Rwanda, and Zimbabwe by that time." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015, Pg 10. • 115. "PHC is committed to continuing this effort regardless of how the organization may change in 2016/2017. It estimates that it will require approximately$300,000 to continue its current small-scale fortification efforts. It does not have a committed funder, but is seeking funding." GiveWell's non-verbatim summary of a conversation with Laura Rowe on July 21, 2015

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"The type of work that PHC will be able to do in 2017 and beyond will depend on the amount of funding it is able to secure and the actual per-country cost of PHC’s monitoring work, which Ms. Rowe thinks might be less than the per-country cost of PHC’s current projects. If it is able to raise half of its current operating budget, it will likely be able to start its monitoring work in three countries, but likely not at full capacity. If it is able to raise all of its current operating budget, it will likely be able to start monitoring work in five or six countries. If it is able to raise one million dollars or more, it will be able to expand its monitoring work into even more countries." GiveWell’s non-verbatim summary of a conversation with Laura Rowe on February 19, 2015, Pg 9.

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