PATH’s work in fortification
PATH has been working on fortification in India since 2005. The team currently comprises three full time staff. Although PATH is a large organisation with projects in 68 countries, fortification in India accounts for under 10 percent (estimate) of the India budget, which is otherwise heavily focused on vaccination and tuberculosis. PATH’s present work on fortification centres around rice fortification, which involves manufacturing fortified rice kernels (FRKs), and blending them with regular rice kernels. PATH has operations in Gujarat and Chandigarh, and their biggest presence is in Karnataka, where they are working in six state-level Akshaya Patra Foundation kitchens under the Midday Meal (MDM) scheme. The typical kitchen feeds between 100,000 and 150,000 children per day, six days per week. Akshaya Patra operates in Andhra Pradesh, Assam, Chhattisgarh, Gujarat, Karnataka, Odisha, Rajasthan, Tamil Nadu, Telangana, and Uttar Pradesh.
To ensure nutritional effectiveness, they partner with behaviour change communication (BCC) experts, Karuna Trust, who implement BCC in schools and educate teachers/children on WASH and nutrition. PATH also partners with Sight and Life to research and develop BCC materials and strategy.
Supply chain for the FRK: PATH’s fortified rice kernels are produced by third party vendors by warm extrusion of rice flour and micronutrient premix. Then FRKs are transported to the Akshaya Patra kitchens, where they are mixed with the regular kernels using blending technology (at a 1 FRK: 100 regular rice kernel ratio) and distributed in meals to schools across Karnataka. Quality assurance occurs in a FSSAI certified lab every six months and is also completed voluntarily each month. The costs for the FRK depend on which micronutrients are provided, ranging from approximately 55 INR (0.85 USD) per kg for iron, folic acid, and vitamin B12 to approximately 100 INR (1.55 USD) per kg for the full set of nine micronutrients included in the FSSAI approved standards. Back of the envelope calculations suggest that the cost of FRK alone per beneficiary receiving 100g of blended rice 240 days per year is about $0.20 (iron, folic acid, B12) and $0.37 (all nine micronutrients). Children in grades 1 to 5 are meant to receive 100g of blended rice, whereas children in grades 6 to 10 receive 150g; therefore their FRK costs per beneficiary are approximately $0.30 and $0.56 respectively. PATH’s model includes partnership with the state government to provide technical support and also demonstrate introduction of rice fortification wherever required by subsidising the FRK costs for a limited time and then transferring the project to the state government for scale-up through the state’s own resources.
Fixed costs: The primary fixed cost associated with PATH’s MDM rice fortification projects is the procurement and installation of blending equipment. At the facilities we visited, this equipment cost approximately 70,000 USD for a kitchen serving 100,000 students six days a week while school is in session.
Operating costs: PATH continues to provide technical support to various organisations along the supply chain, particularly to the FRK producers to improve the quality of their FRK. The implementation team responsible for on-site blending and management would consist of five people, costing approximately 13,000 to 15,000 USD per year.
Overall costs: Amounted to approximately $400,000 over two years to equip and provide fortification in an MDM Akshaya Patra kitchen in Karnataka. PATH estimates an investment of 2.5 to three million USD would be necessary to scale up fortification in all Akshaya Patra kitchens across the eleven states in which they work. A Public Distribution System (PDS) rice fortification pilot would be more expensive than an MDM pilot and might require one to two million dollars for one state over a three year project if it could then be continued by the government.
Concerns: We remain concerned that the dosing of the micronutrients may be inadequate considering that these standards were developed around a platform for universal fortification rather than one daily meal for school-age children, though this is a common concern across projects by various actors across the states. Other organisations have concerns about the fitness of the FRK used in other schemes, which are best summarised under the Food Fortification Initiative section of this document.
General information: Our conversations included information on the supply chains themselves, barriers to implementation in PDS, the political processes to gain approval for fortification demonstration projects and endurance of these programmes under state support. PATH indicated that states would require an in-state demonstration project before mandating a full coverage fortification effort in a particular government programme (or the open market). Increased coverage of fortification will need to occur at the state level (even with the support of the central government’s FFRC/FSSAI). PATH sees limited importance to producing more evidence that fortified rice provides health benefits given that evidence exists and the central government is supportive. We also developed a deeper understanding about the production of FRKs, quality improvement, and market strategies. PATH believes each state will require independent efforts and it must be done properly to avoid generating enduring negative beliefs about rice fortification.
Why focus on rice over flour: Rice is more centrally processed and more widely consumed across India. No behaviour change is necessary for rice fortification, whereas a shift away from chakki mills would be necessary for widespread flour fortification to work. The most vulnerable people may already be those with most limited access to industrially milled flour. However, fortified rice is more expensive and the appearance of FRKs may lead to consumer rejection on the market.
Guiding us: We asked how we could best contribute over a few years with a reasonable budget. They suggested implementation of a rice fortification demonstration project in MDM (two years) or PDS (three years), with the former being more feasible as a first project.
PATH suggested that Fortify Health could contribute by:
* Higher risk working with these state governments, but potentially higher impact if these are lower on PATH’s radar