The urgent need to improve compliance of national fortification programmes

Blog written by Greg S. Garrett & Corey Luthringer, Global Alliance for Improved Nutrition

The micronutrient fortification of staple foods and condiments plays a significant role in the prevention of micronutrient deficiencies across entire populations -- including in women of reproductive age and adolescent girls. The intervention has gained global traction. Over 150 countries are implementing salt iodization programmes, 82 countries have mandated at least one kind of cereal grain fortification and dozens more have large-scale fortification programmes which focus on fortifying edible oils, sauces and condiments. These figures represent tremendous success in scaling up a proven, highly cost effective and very sustainable nutrition intervention.

However, there is a critical gap between fortification legislation and compliance which is affecting impact.

GAIN-supported staple food fortification programmes in 25 countries report results of external quality assurance and quality control activities. Among programmes reporting the external pass rate ranges from 18% to 97%, and averages 45-50%. When factoring in available national data, market surveys as well as anecdotal observations from other programmes, the average pass rate appears lower – around 40%. This average serves only as an inference but indicates a systemic problem with compliance. In addition, many of these non-compliant fortified foods are labelled as compliant thus misleading consumers on vitamin and mineral content. There will be limited health impact of fortification programs when foods are not adequately fortified.[1]

Why is poor compliance so widespread?

There are five underlying issues leading to poor compliance. First, food laws and regulations related to monitoring, inspection, and enforcement are too often fragmented and not appropriately set within legal frameworks, leading to a lack of or weak enforcement. GAIN recently conducted a survey of regulatory monitoring agencies in 17 countries and 65% of respondents cited the need for clear regulations as their top priority for encouraging better compliance. As noted by various studies of industry behaviour towards complying with legal requirements, an important component for compliance is the perception that both detection and prosecution is probable and that similar treatment will be given to all thus levelling the playing field.[2]

Second, food safety and quality control practice and culture does not prioritize fortification, especially where resources are limited. Preventing food contamination that presents high safety risks typically has a clear budget line while lower safety risks including under-fortification or checking quality parameters of foods is often under-budgeted. Over 40% of government respondents cited the need for better regulatory agency financing and over 80% noted that their current funding is not sustainable over the next five years.

Third, there is political risk in enforcing compliance with regulations. Even where resources and capacity exist, regulatory agencies are often unwilling to enforce regulations due to perceived or real resistance from interest groups. Over 60% of respondents believe this lack of willingness is a major barrier to enabling compliance and note that this results in penalties that are not severe enough to encourage adequate fortification.

Fourth, just as there is a cost for governments to monitor fortification programmes, there is a cost to industry to fortify. There are industries which lack appropriate internal budget and expertise to fortify and thus their product may not always comply. But there are other industries which purposely under-fortify or do not fortify at all with impunity and thus save costs for their businesses.

Lastly, because fortified food is a type of credence good -- or a good that consumers cannot easily evaluate in order to demand a higher quality -- consumers must trust what is stated on packages in relation to vitamin and mineral content. Far too often regulatory monitoring agencies and consumer protection groups are not actively protecting consumers from under-fortified or non-fortified foods, or fraudulent labelling.

What can be done to improve compliance?

First, improved legislation, regulations and enforcement regimes are needed to ensure clear and consistent enforcement mechanisms are in place. Regulation on paper will not improve fortification compliance without real incentives as well as strong consequences which drive under-fortified foods out of markets.

Second, effective regulatory monitoring and enforcement will notably require more robust national budget allocations. There is a need for more inspectors, more training, and improved laboratory micronutrient testing capacities. Resources must be applied strategically and focus on essential proven elements of monitoring fortification programmes.[3]

Third, the potential of civil society or ‘third parties’ is largely untapped in monitoring fortification programmes. There have been a handful of creative examples of consumer associations supporting compliance of fortification. Civil society can be a powerful watchdog, improving consumer awareness of the health benefits of fortified products and the names of those industries passing off their non- or under-fortified products as good consumer choices.

Lastly, all of these recommendations need to be underpinned by leadership and accountability in the public and private sectors. The challenges outlined here can be easily overcome with sustained leadership and commitment. Numerous governments in lower and middle income countries have demonstrated impressive commitment to improved nutrition by establishing national fortification programmes. It is of paramount importance that many of these countries revisit their fortification programmes and ensure they are effective, sustainable and achieve their optimal health impact moving forward by improving compliance with national standards.

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[1] van den Wijngaart A, Bégin F, Codling K, Randall P, Johnson QW. Regulatory monitoring systems of fortified salt and wheat flour in selected ASEAN countries. Food and Nutrition Bulletin. 2013; 34(2 (supplement)): S102-S111.[2] Yapp C, Fairman R. Factors affecting food safety compliance within small and medium-sized enterprises: Implications for regulatory and enforcement strategies. Food Control. 2006; 17: 42-51.[3] Wirth JP, Nichols E, Mas'd H, Barham R, Johnson QW, Serdula M. External mill monitoring of wheat flour fortification programs: An approach for program managers using experiences from Jordan. Nutrients. 2013; 5: 4741-4759.