A blueprint for fortification planning and programming: Lessons learned from an analytical review of existing fortification frameworks

Abstract

With multiple food fortification frameworks, countries can find it challenging to determine optimal methods for planning and implementing food fortification programmes to combat vitamin and mineral deficiencies, especially without additional technical support. To address this challenge, this study aimed to review existing frameworks to determine consistencies, differences, strengths, and weaknesses across the frameworks, and based on the review findings, formulate an enhanced and streamlined fortification framework. Nineteen frameworks were ultimately examined following a comprehensive literature review and key informant interviews. Generally, the reviewed frameworks amply describe motives and methods for the determination of fortification need and feasibility, industry engagement/quality assurance and quality control, and impact evaluations/surveillance. However, there was limited inclusion or discussion throughout the reviewed frameworks around harmonization of fortification with existing micronutrient interventions; fortification policy and/or strategy; enforcement, incentives, and penalties to ensure producer compliance with industry standards; and periodic fortification programme review and reassessment. The findings were used to develop a comprehensive Fortification Blueprint that aims to provide structured guidance and a library of tools and resources to fortification programme managers and key stakeholders to ensure optimal and sustainable programme design.

Keywords: food fortification; fortification design; fortification framework; fortification implementation; micronutrients.

Figure 1

Number of records obtained in January 2021 from searching databases for fortification frameworks and resultant studies included in final assessment. The literature review located 2657 records across the five databases. Only articles published in English with the word ‘fortification’ mentioned in the title were considered for the abstract screening phase. The selection criteria consisted of articles with descriptions of fortification design and/or implementation components, a description or form of a fortification framework, or a discussion of programme successes and/or challenges—resulting in 13 articles from the literature review included in the final assessment/matrix.

Figure 2

Matrix categories by total category score and number of frameworks with a maximum category score. Among matrix categories, ‘Impact Evaluations/Surveillance’, ‘Determining Need and Feasibility’ and ‘Industry Engagement/Quality Assurance and Quality Control’ generated the highest scores with 57, 50 and 50 points, respectively, implying that these categories were the strongest and mentioned the most frequently across frameworks. A second approach to scoring included reviewing categories that generated the largest number of frameworks with maximum scores for the assessed category (four points). Categories with multiple frameworks scoring four points implied that these concepts received greater consideration and offered illustrative explanations when included in a framework. Four categories generated the largest number of frameworks with 4‐point category scores: ‘Impact Evaluations/Surveillance’ (with seven 4‐point frameworks), ‘Political Will/Government Engagement’ (with six 4‐point frameworks), ‘Building Partnerships and Alliances’ (with five 4‐point frameworks), and ‘Marketing Communications’ (with five 4‐point frameworks).

Figure 3

High‐level summary of Fortification Blueprint. The Blueprint aims to serve as a comprehensive and actionable guide for individuals or entities involved in leading or supporting the design, implementation, monitoring and/or reassessment of large‐scale mandatory food fortification programmes. The intended audience for the Blueprint includes all relevant fortification stakeholders, namely, government agencies, supporting organizations, the private sector, civil society groups and academia. The full Blueprint is organized into seven major programming actions with one major cross‐cutting theme. Each action or sub‐action includes live links for relevant tools and resources available on how to operationalize the action. The arrows flowing from ‘Step 7: Review and Reassess’ indicate that upon reassessment of a programme, users should either return to ‘Step 1’ or ‘Step 3’ and proceed to review these steps and all subsequent steps for relevance.