Fortify Health

Planning your Retreat: How to Prepare for Your Next Team Retreat or Offsite

3/10/2023

Team retreats or offsites provide a unique opportunity to build connectedness, motivation and communicate with your whole team. However, they can be a daunting event to prepare for and often do not live up to their potential. In this post, we share some tips on how to prepare content for a team retreat.

Recently, Fortify Health held a full team retreat in Bhopal, India. Fortify Health is a non-profit organisation with the mission of enabling access to micronutrient-rich wheat flour to reduce and prevent iron-deficiency anaemia. Altogether 36 teammates from across India and the world gathered for a three-day retreat, which was then followed by a smaller, 2.5 day leadership retreat. In a feedback survey, participants gave a score of 4.8 out of 5 (likert scale) on the statement, ‘I feel much more energised and motivated for my work after the retreat.’

We've learned many valuable lessons as we prepared for our recent retreat, and we'd like to share them with you in this blog post. Here, we provide a high-level process for preparing for your next team retreat and some of the lessons we learned along the way. It must be noted that we are far from experts when it comes to event planning. However, event planning can often be very expensive, and we hope our experiences may be able to support you in the future.

We break the process of preparing content for a retreat into the following four key steps:
1. Ideation
2. Agenda Development
3. Content Preparation
4. Retreat Time

Step 1: Ideation

Goal Setting: As with almost any task, a clear understanding of the goals or purpose of the retreat is critical. Fortify Health leadership brainstormed a list of goals and then synthesised these into a prioritised list of five goals: connectedness, strategic alignment and clarity, understanding, collaboration and motivation. Lessons learned:

a) Referring to the goals frequently throughout the retreat was an effective way to contextualise the event.
b) It would have been helpful to put weights (and not just prioritise) the goals. We observed during debrief that different leaders had put different weights on the goals which led to differences in how successful we thought the event was.

Brainstorm Sessions: Work with your team to brainstorm a long list of sessions that you may wish to run. In some cases, the specific content of the session may be uncertain, but you may have ideas on the format of sessions (workshops, town halls, speeches etc.) These sessions should align with the goals you have set out and may be both formal and social in nature. Lessons learned:

It was helpful to articulate the key takeaways we wanted from sessions. In many cases, the team was uncertain how to reach the takeaway, but over time the actual content became clearer.
In future, we could have been even more thoughtful about brainstorming social activities that aligned with our goals.

Step 2: Agenda Development

Develop high-level agenda: Now you can think about the flow of sessions and how to choose the sessions you wish to run. Prepare a spreadsheet to visualise the time you have available during the retreat. For our retreat, we broke down the time into 30-minute blocks and colour-coded sessions based on: personal-time, mandatory content sessions, optional sessions, social time and breaks / buffers. Lessons learned:

The visual, colour-coded timeline helped us understand whether we needed more breaks or if we had more time to include more sessions.
Consider the flow of content and thematic flow of sessions. In the Fortify Health retreat, we wanted to focus a major component of our time on the organisation’s 5-year strategy. To do this, we started with a session on the high-level overview of the strategy, followed by department level sessions, and finally, individual sessions focused on each person's role in the strategy.

Iterate and finalise the agenda: Take feedback and iterate on your agenda. At this point, worry less about the content of the individual sessions and more on the overall flow of the retreat. Lessons learned:

Invest heavily in creating a safe and trusting environment at the start of the retreat. It can be helpful to provide a structured, get to know you activity where team members are able to engage in deep and meaningful conversations without time constraints.
We found it helpful to put more content heavy sessions in the morning and more participatory sessions in the afternoon.
Put in more breaks and buffers than you may actually need. Sessions have a tendency of running long, sessions do not start on time, and often sessions take longer to deliver than you expect. If everything does go to schedule, break times are a great time for team members to consolidate learnings and develop connections.
Think about the logistics of the sessions - will people need to move between sessions? What audio-visual equipment will need to be available for each session? Is there enough time for people to walk back to their rooms if the need to?

Step 3: Content Preparation

Individual session preparation: Time to prepare the sessions themselves. We took guidance from teachers who are experts in preparing content for groups. We started by delegating session preparation to different team members who were then asked to prepare a lesson plan. This lesson plan broke each session into 5-minute sections and was colour-coded for different types of engagement within the session: presenter-led, moderated discussion, individual work and facilitated group work. The aim was that each session would have a combination of different types of activities to ensure that engagement was maintained.

After lesson plans were signed off, session leads prepared slides and other materials. Some speakers created scripts, while others simply used their slides as talking notes. Finally, each session lead provided details to the operations team on logistic needs for their sessions.

Leading up to the retreat: The team held a call to review the preparation for each session in detail. We recommend holding this call at least a week before the retreat commences. This call took over 2-hours, but built confidence that everything was in place and contingencies were taken into account. Lessons learned:

Think about everything that could reasonably go wrong and create a plan. For example - What will you do if the internet stops working? Do you have backup speakers in case someone falls in or travel plans fall through? How will you handle team mates arriving late to sessions?
Think about not just the content of sessions, but also the logistics for the sessions. This includes thinking about who will sit where, room layout, and print-outs or other materials that participants may need.

Step 4: Retreat Time

By the time you reach the retreat venue, all speakers and organisers should feel confident about the content flow. However, we all know that there will be last minute curveballs and unexpected occurrences. We found it helpful to get to the venue early to scope out the space and think about whether our logistic plans still made sense. We recommend holding a quick briefing before the retreat starts to ensure everyone is on the same page.

At the end or start of each day, we found it helpful to regroup as a leadership and operations team to debrief. During the debrief we would share learnings and feedback and iterate on our plans.

We hope that this guide will help you as you prepare for your next team retreat! If you have any questions, feel free to reach out at tony.senanayake@fortifyhealth.global

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2020: Fortify Health's year in review

1/5/2021

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2020 has been a strange year for everyone and every organisation. Fortify Health’s own milestones may not be as concrete as in previous years, and instead our lessons from 2020 became our milestones - it was not the year we expected, yet we made the most of it. All things considered, we've learned and grown a lot as an organisation and as a team, and a major highlight has been the strength of our team and what this means for Fortify Health going forward. As travel restrictions ease, we’re hopeful that 2021 will bring further opportunity and growth.

We asked our team to share what some of their most helpful lessons and milestones have been from 2020, both on an organisational level and at a programmatic level. Below is a summary of our 2020 growth based off of all of the team’s inputs.

Organisational lessons and milestones

1) We've all learned to work collaboratively and empathetically with a completely remote team

Issue: Before March 2020, we engaged in relatively few team socials, and different departments rarely crossed paths.
Actions taken: In 2020, we enhanced this by incorporating weekly internal learning presentations in the first lockdown, and we've now incorporated more socials into our working weeks. We've also built a culture of prioritising personal wellbeing in professional decisions, and empathy toward productivity drops (which is bound to happen in a global pandemic!). Thanks to consistent dedication from our Operations team, we also conducted our first team satisfaction survey, and it was promising to learn that our team feel overall well-supported and excited by the organisation.
Looking forward: In 2021 and further, we aim to continually improve team wellbeing, productivity and team culture, building on team cross-socialising, improving feedback loops, and building out our satisfaction survey further.

2) We've implemented deep work and time boxing for improving productivity

Issue: Six months ago, we tended to have calls almost every day, and did not set boundaries with our own work time. We learned that this was perhaps not the most conducive method to ensuring everyone is able to work at their most productive level, since deep work requires time boxing from distractions/regular interruptions.
Actions taken: Since then, we've set aside 2 days per week free of calls and meetings (if desired), and with minimised responsiveness on Slack and emails. This is the case with both internal and external contacts (where possible) and we've seen a marked improvement in productivity on deep work tasks. On non-deep work days, we’ve begun time boxing slots for emails and Slack, rather than checking whenever a notification pops up. We've also become more proactive at setting Slack statuses and internal communication on Slack to indicate updates that might be relevant to the rest of the team.
Looking forward: Internal communication is the pillar of our remote working productivity, and we are continually learning and improving on our internal interactions.

3) We've put a strong focus on mentorship and implementation of consistent documentation across the team

Issue: Documentation can be a tricky task to make consistent when team members come from different sectors and working environments. Learning to document efficiently was a popular learning for most of Fortify Health's team, many of whom shared documentation as one of their biggest personal learnings for 2020.
Actions taken: Fortify Health places a high priority on quality documentation from meetings, mill visits, strategy documents, and timelines. It's really improved our ability to learn about the activities of other departments, and improved our team capacity to transfer knowledge between one other, while building organisational slack. Documentation has also proven essential for transitioning partnerships between team members, onboarding new joinees, and preserving institutional memory: this becomes increasingly crucial as our team grows. Our Country Director and CEO have placed a strong emphasis on leading by example in terms of documentation and organisation, and spend time supporting others in their documentation.
Looking forward: In 2021, organisational slack is something we hope to improve even more, and we can try this by incorporating more cross-training into our work (i.e. training people in different departments in another skill). To learn more about organisational slack and cross-training (see the Knowledge Sharing section), feel free to take a look at the links.

4) We've set up systematised operational processes/systems

Issue: Setting up systematised operational processes is often foregone in the early stages of a startup, since they don't always feel urgent. Fortify Health is no exception; we (perhaps mistakenly) deprioritised this early on, because a) none of us were operations specialists in the early stages, and b) we were always prioritising program, partnerships and GiveWell work.
Actions taken: As Fortify Health's team expands, these systems are absolutely essential. Over 2020, we set up a hiring SOP, a vendor management manual, premix management tutorial and manual, an SOP on how to work with mills, we've refined our travel policy, and we've completed our operational manual. We've also set up a performance evaluation system, which is crucial for any organisation looking to continually support its team and growth. A special thank you goes out to our Operations team and Country Director for their dedication to building these operational systems for a fairer, more productive work environment. Since our first operations hire in late 2019, we've seen a rapid improvement on our operational processes.
Looking forward: Systematised operational systems reduce coordination time and give everyone clarity on what to do, how to plan ahead, how to coordinate better, and how to improve. They also reduce the need for directed attention to things which can be automated. We're still in the early stages of building these systems, and we look forward to seeing how they grow and become more efficient over 2021.

Programmatic lessons and milestones

1) We've built in-house technical capacity thanks to a stellar program team

Issue: Prior to 2020 building mill partnerships had required much more coordination and time to reach the stage of a successful partnership.
Actions taken: This year, we've truly learned the value of technical milling expertise in our team and have built a team of two strong program specialists. Our program team has been absolutely essential to Fortify Health’s future existence. Their contributions have dramatically improved our capacity and speed to build partnerships with mills and milling institutions for our open market strategy, as well as improved in-house learnings about milling and quality control among other team members. We were also able to work with CFTRI for the first time: the Program team brought both expertise and strong interpersonal skills to the table to confirm an essential association. Because of this association with CFTRI, we're in conversation with some large mills, and we partnered with a new mill within a week - our fastest partnership! We've also been able to sign a mill partner contract despite travel restrictions and the pandemic in India, which was a positively unexpected milestone.
Looking forward: Once travel restrictions lift and a vaccine is rolled out, we're looking forward to further progress on our mill outreach thanks to our program team.

2) We're starting to address behaviour change and the most vulnerable communities by increasing team capacity in government and marketing

Issue: At the beginning of 2020, we hadn't placed a lot of focus on marketing outreach to mills, consumer / industry behaviour change or government programs. We've learnt that in-house expertise and focus on these areas is a very important value-add to our ability to build strong partnerships.
Actions taken: In September 2020 we hired a Partnerships Manager and a Business Development Manager, and since then, we've been able to make visible initial progress on these areas, including:
1. a) a promising visit to the Secretary of the Tribal Development Department in Mumbai (led strongly by our Partnerships Manager since September), and
2. b) the development and implementation of a brand new marketing strategy, and development of new communications materials for mill outreach to support our open market work (strongly headed by our Business Development Manager since October).
Looking forward: In 2021, we're looking forward to scaling up our engagement with government, potentially furthering our work with the Tribal Development Department and in the other government safety net programs, and strengthening our open market outreach with a strong marketing strategy. If some of these projects progress quickly, we look forward to hiring more team members to further strengthen our marketing and partnerships work.

3) We've overcome M&E barriers by procuring the iCheck

Issue: Over 2020 and previously, we were struggling to understand where in the quality assurance process mistakes were being made (at the lab-level, premix vendor level, or the mill level, or none), and improving team capacity to measure this has been a big weight lifted.
Actions taken: Thanks to regular contact with our expert advisor, Laura Rowe, and our M&E team’s diligence and attention to detail, we've been able to successfully procure and train in using the iCheck, allowing us to more accurately and quickly conduct iron testing.
Looking forward: In 2021, we're looking forward to having more robust, reliable quality assurance processes in place, and quicker feedback loops on the quality of fortified wheat flour. This will improve efficiency in terms of time and emotional toll. We're also looking forward to expanding the M&E team soon!

4) We've started to receive recognition as a legitimate player in the fortification sector thanks to more emphasis on communications

Issue: Previously, we hadn't prioritised our communications work; it can often seem important but never urgent, which resulted in its consistent deprioritisation among a small team. This year we've learned that communications work is essential for our recognition and that strong branding can be a USP.
Actions taken: In the latter half of 2020, we worked on several areas of our communication that led to wider spread engagement and recognition. We:
1. a) developed a new communications strategy and timeline for 2021 headed by the CEO, which included higher specificity and quantity of output than in previous years.
2. b) strengthened our relationship with important fortification players through improved follow-ups on communication, and improved print materials. For example, we applied to and were accepted into the POSHTIK network in December 2020
3. c) expanded our outreach to effective altruism circles by presenting in 2 conferences: EA Student Summit and EAGxAsia-Pacific
4. d) increased social media engagement (such as Fortify Health's 3rd birthday)
5. e) put new print material development into motion to demonstrate our work and mission more effectively with partners (e.g. miller brochure, organisational brochure, organisational brief)
6. f) began to prioritise sharing our organisational learnings: see our Inside Insights brief for the first in a series
Looking forward: In 2021, we hope to dramatically increase our portfolio of communications outputs, and stick by the more robust, strategic communications timeline with specific audience targetting. We also hope to build our capacity for communications by hiring a new Communications Officer! Hopefully these combined will result in a much stronger approach to communications from all angles: written content, print design, online campaigns, and comms strategy.

So to summarise, 2020 was a year of building more robust organisational systems, strengthening our team capacity to set us up for a faster-paced 2021, and learning. Our team, despite almost doubling in size over the course of 2020, has even reported being especially busy compared to the previous year, because setting up these systems, incorporating new strategies and coordinating hiring takes significant time, planning, discussion and effort.

What next?

In 2021, we have a lot to look forward to! We're excited to grow our team capacity (hiring for several new positions!), increase our number of mill partnerships, expand M&E activities, scale up our government and marketing work, build our brand further through improved communications, and potentially conduct another round of fundraising with GiveWell. 2021 will be busy, collaborative, and productive, in the best of ways - and all with the intention of improving lives at-scale!

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“Putting brakes on anaemia: how to safeguard the health and rights of women and girls through fortification”

7/11/2020

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The theme of this year’s World Population Day has been aptly named 'Putting the brakes on COVID-19: how to safeguard the health and rights of women and girls now.' The COVID-19 pandemic continues to wreak international havoc, affecting millions across the world. According to the Director General of the World Health Organisation, Dr. Tedros Adhanom Ghebreyesus, the worst from the pandemic is yet to come, which all the more highlights the importance of being vigilant and resilient to counter the virus. However, as with most large-scale crises, it is having a disproportionate impact on the people who are poor and marginalised, especially women and children.

The impact of COVID 19 on economy, health system, food supply and nutrition

The disease and the accompanying restriction on movement is taking a toll on the economy and impeding the functioning of the general health service system and food supply;

1. Impact on the economy:
1. The World Bank predicts a 5.2% contraction of global GDP due to decrease in investments, erosion of human capital through lost work and schooling and fragmentation of global trade and supply linkages. The pandemic will plunge most countries into recession, with per capita income contracting in the largest fraction since the late 19th century. According to the International Monetary Fund (IMF), the global economy is expected to contract by 6.5% in 2021 when compared to what it was in January 2020. IMF predicts that the Indian economy will contract by 4.5% in 2021, and according to the eminent economist and the former chief statistician, Dr. Pronab Sen, India’s unemployment rate will increase to 8.5% if the stimulus package in India is not widened.
2. Women are mostly engaged with the informal economy, and many may fall into poverty, due to the disruptions posed by the lockdown.
2. Impact on routine health services:
1. Routine health services have been impacted across the country with most of the critical health services from immunizations to mental health affected. There has been a disruption in the distribution of iron and folic acid (IFA) tablets, which is critical in preventing anaemia. These will have deleterious effects on the outcomes of major infectious and non communicable diseases, as well as malnutrition. According to a study published in the European Respiratory Journal, India could see an additional 95,000 deaths due to tuberculosis. It is expected that within 6 months, 300,000 children in India may lose their lives, largely due to disruption in immunisation services and lack of nutritious diet.
3. Impact on food supply and nutrition:
- Analysing the data from Centre for Monitoring Indian Economy (CMIE), the University of Chicago estimates that more than 80% of Indian households will see a dip in their incomes due to the restrictions and the subsequent loss of livelihoods. This translates to less purchasing power and increased inability to access a diverse variety of food items including fruits, vegetables, dairy and meat products. The dietary diversity in India was poor even before the pandemic. According to the Comprehensive National Nutrition Survey, only 21% of children aged 6 to 23 months were fed an adequately diverse diet (CNNS, 2018). The crisis that has unfolded would only make things worse.
- The lockdown has also disrupted the food supply system at all levels. Farm work has been impacted by the lack of labour and disruption in the transportation system. Food processing has been impacted due to the closure of factories.
- The effects of the lockdown and subsequent disruptions will cause people to rely more on monotonous nutrient poor diets and shift away from fruits, vegetables and animal source foods, which are the main sources of essential micronutrients in diets. In the face of drastic declines in income, vulnerable households will quickly give up nutrient-rich foods in order to preserve their caloric intake.

What is anaemia?

Anaemia is a condition, which particularly affects women and young children, whereby the number of blood cells or the haemoglobin concentration is lower than normal. We need haemoglobin to carry oxygen around the body, and if a person has too few or abnormal red blood cells, or not enough haemoglobin, there will be a decreased capacity of the blood to carry oxygen to the body’s tissues. This results in symptoms such as fatigue, weakness, dizziness and shortness of breath, among others. In children, this can hamper their cognitive abilities affecting the learning outcomes. Anaemia also impacts worker productivity and psychosocial well being.

The most common causes of anaemia include nutritional deficiencies, particularly iron deficiency, though deficiencies in folate, vitamins B12 and A are also important causes; haemoglobinopathies; and infectious diseases, such as malaria, tuberculosis, HIV and parasitic infections. Iron deficiency is one of the most common forms of anaemia caused due to the lack of iron in the diet. Studies suggest that iron deficiency is the cause for somewhere between 25 and 40% of all anaemia in preschool children and women of reproductive age.

The burden of anaemia on women and children

Globally half a billion women of the reproductive age (15 to 49 years) are anaemic, including almost 40% of pregnant women of the same age group. It continues to be one among the major causes of maternal mortality worldwide, making this a major global health problem. In India, almost half of all women of reproductive age are anaemic (NFHS 4, 2016).

Figure 1: Prevalence of anaemia among children (%) below 6 years of age in India, Source: NIN, 2016

Figure 2: Prevalence of anaemia among women of reproductive age (%) in India, Source: NIN, 2016

From Figures 1 and 2, it is clear that there is a high burden of anaemia in India across regions, with states in the north and east being the worst affected. The condition also seems to have an intergenerational impact, with effects carrying over through families. Anaemia is a major contributor to maternal deaths in the country. Anaemia among pregnant and lactating women is set to rise because of the disruption in health services and widespread diet shifts, thereby leading to increased maternal mortality in the future. In India, the central and state governments have promisingly accelerated activities and interventions through the “POSHAN Abhiyan” and “Anaemia Mukt Bharat”, yet there is now a prevailing concern that the achievements made in addressing anaemia and other micronutrient deficiencies may be hampered or reversed, due to the COVID-19-caused disruption in the routine health and nutrition services across India.

The importance of fortification

A varied array of interventions exist that are designed to prevent and correct iron deficiency anemia. These include dietary improvement, fortification of foods with iron, iron supplementation, and other public health measures, such as control of intestinal parasites. Two of the biggest challenges, however, with iron supplementation programs are irregular supply of good quality tablets and compliance by recipients (Malhotra et al 2015; Mora 2002). Dietary diversification, which is considered a longer-term approach, may be the ideal way to improve a population’s diet, however, the amount of time it requires to make such a change and the inherent contextual factors that affect it (sociopolitical, economic, cultural, behavioral, to name a few) likely make dietary diversification an approach that needs to take place alongside other approaches that can more quickly ensure improved nutrient intake. Findings from CNNS survey conducted in 2016-18 indicate that 42% of children 6-23 months of age were fed the minimum number of times per day for their age, only 21% were fed an adequate dietary diversity, 6.4% received a minimum acceptable diet, and only 8.6% consumed iron rich foods.

One evidence-based and easily implementable means of addressing worsening food insecurity and malnutrition is food fortification. The emerging situation points to the heightened need to increase the focus on health and nutrition, and to adopt strategies that are cost-effective and impactful. Governments should scale up preventative interventions in communities that are food insecure and have limited access to diversified diets.

Food fortification, the addition of essential micronutrients to staple foods, has been declared as the most cost-effective, safest (Hurrell 2010), and most practical approach to increasing iron intake on a widespread and sustained basis (Gera 2012) that exists today. It does not require major behavioural changes on the part of the consumers, since the micronutrients are carried by staple foods that are commonly consumed by the people. It can also be implemented through the existing distribution networks and supply chains. The most recent systematic review (Imhoff-Kunsch et al., 2019) found that iron fortification can, on average, reduce anaemia by 34% if the anaemia is due to a lack of iron in the diet.

At Fortify Health, we work towards mainstreaming fortification of wheat flour (with iron, folic acid and vitamin B12) in the open market, as well as through the government safety net programmes (SNPs). Wheat is one of the commonly consumed staples in India. Indians consumed 98 million tonnes of wheat in 2019 (until September 2019), up from 95 million tonnes in 2018. Wheat flour fortification is very cost effective. At Fortify Health, we work with the millers in the states of Maharashtra and West Bengal, and facilitate fortification of their products by providing them with equipment and micronutrient premix, and by setting up monitoring and evaluation systems to ensure implementation quality as per established standards of Food Safety and Standards Authority of India (FSSAI). We are also in conversations with various government departments and agencies at the state and central levels to introduce fortified atta in government safety net programmes.

Scaling up fortification to address anaemia

Looking at the gravity of the situation with regards to anaemia and its worsening effects of women and young children due to the pandemic, it is imperative that the governments and policy makers work towards making fortified foods universally available through all distribution channels. Food fortification along with other complementary strategies will go a long way in addressing anaemia and other micronutrient deficiencies.

Scaling up fortification is more urgent and expeditious now than it was pre-COVID-19. Given the disruptions in food supply chain and transportation, there could be an increase in consumer preference towards food products with stable shelf life such as maize, rice and wheat flour compared to those which are perishable like vegetables and fruits. Given this context, it is important that these staples are fortified with vitamins and minerals so that deficiencies of these micronutrients can be prevented.

Addressing the entry barrier for fortification: One of the challenges that policy makers could face is ensuring a level-playing field for businesses for fortification. Most of the smaller mills which are Small and Medium Enterprises (SMEs) have been negatively impacted due to drop in the revenue and cash flows as a result of the lockdown and disruptions. This will prevent smaller mills from taking up fortification due to the costs involved in setting up fortification and the procurement of micronutrient premix. This is where Fortify Health’s initiative of supporting the millers in covering their entry and recurrent costs gain importance and this is a model that can be emulated at scale.

Addressing the health services gap: It is also important to note that the disruption in the provision of IFA tablets from health centres will result in increasing the risks of anaemia among women and young children and given the way in which the cases of COVID 19 is increasing, we can safely assume that the health service system will stretched for many more months to come. Fortification of staples with iron and folic acid will fill this critical gap and therefore, it is important to increase focus on this strategy.

Generating awareness around the consumption of fortified foods: The awareness regarding fortified is generally low in India. There is, therefore, a need to make people aware about the benefits of consuming fortified foods. The Food Fortification Resource Centre (FFRC), an autonomous body under the Food Standards and Safety Authority of India, is working towards creating more visibility for fortified foods through advertisements and media campaigns. Fortify Health aims to work with millers, FFRC, state-level Food and Drug Administration (FDA) and other like-minded organisations to increase awareness about the consumption of fortified foods.

In alignment with the efforts towards ‘Putting the brakes on COVID-19: how to safeguard the health and rights of women and girls now’, we must also include “Putting brakes on anaemia: how to safeguard the health and rights of women and girls through fortification.”

Written by Dr Muneer Mammi Kutty, Strategy Lead at Fortify Health

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2019 in review: Our achievements and our learnings

1/23/2020

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2019 was a significant year for Fortify Health. It was our first full year of operations in India, and therefore, a year of important growth. 2019 was not just a year of achieving, but also a year of intensive learning, refining and retrying. As with any startup, the learnings we take from our troughs provide us with the wisdom to reach our peaks.

Here are 7 of our most important moments and subsequent learnings of 2019:

1. We signed contracts with four mills to start fortification

In 2019, we signed four contracts with three mills in Maharashtra and one in West Bengal. The projected output of fortified flour across the four mills, once fortification is launched and scaled-up in all four of them, will be approximately 105.4 metric tonnes (MT) per day.

Learnings: Through the process of building partnerships with mills, we have learned that in-person visits to new mills are much more successful than cold calling new mills. We’ve also learned that delays to contract signing and installation of equipment are an inevitable part of onboarding mills, usually owing to external factors relating to the miller, and we now know to factor these in to our timeline predictions. We are now hiring accordingly to ensure that we have sufficient capacity in-house to work around these delays and to conduct regular technical and follow-up consultations in-person with millers.

2. We started fortifying flour in our first mill

In June 2019, we installed a microdoser in our first partner mill (Mill 001), based in Mumbai. In the same month, Mill 001 was supplying fortified flour to consumers, and fortifying 0.4 MT per day of wheat flour. By the end of 2019, Mill 001 confirmed they will scale up fortification to their other brands and packages in Mill 001, after a successful trial with the initial amount of 0.4 MT per day, which is 40% of their current daily production.*

Learnings: As a team of non-millers, beginning fortification in our first mill gave us the opportunity to better understand how to effectively incorporate fortification practices into existing mill operations of this size and how to improve the precision of dosing premix into flour. We also learned how we can transfer knowledge of our work in one mill to our work with other new mills, and also how we can’t in various cases, given the setup of mills is incredibly varied. We also quickly learned the necessity of working with a technical consultant, who has significant technical understanding of mill equipment and fortification machinery.

3. We nurtured our first government partnerships

At the beginning of 2019, our relationship with government was minimal, since we were a brand new organisation and, therefore, had no established track-record of fortification. Thanks to the consistent diligence of Fortify Health’s partnerships and programmes team, we built some strong initial relationships with government partners in Maharashtra over the course of 2019; through this, we have made some initial progress towards partnering with local government departments in trial projects that will allow safety net programs to have continued access to fortified flour. In 2020, we will work towards the implementation of these trial projects.

Learnings: With frequent political change in state governments, officers are regularly shifted to new departments. This means organisations working with a particular officer may have to start from scratch in establishing partnerships with respective replacement officers, and may involve re-submitting proposals to departments to get permissions for projects. It is helpful to understand this and have experience with it, so that morale does not lessen in such cases and we become more confident with government partnership building.

4. We hired for four new roles
2019 was the year of maintaining and expanding the dream team. We recruited for four essential roles, three of which were made possible by the reassured runway provided by our 2019 GiveWell grant:

Country Director, Dr Urmi Bhattacharya
Monitoring and Evaluation Officer, Akanksha Manwatkar
Operations Officer, Abhishek Kumar
Programme Officer, Kapil Parve (position offered in December 2019, position started in January 2020)

Find out more about the Fortify Health family here.!

Learnings: We learned that hiring is both the most time consuming, and the most important task to get right. It is the team that creates the organisational culture: a strong sense of community and respect is the engine to an organisation’s long-term success. We learned it is, therefore, worth putting significant time into planning, execution and ongoing maintenance of our recruitment process.

Team Fortify Health, November 2019

Brendan on a mill visit, February 2019

5. We said a semi-goodbye to Fortify Health’s Co-founder, Brendan Eappen

The Fortify Health team bode well wishes to Brendan, who started at Harvard Medical School in August 2019. Brendan stepped down from his full-time position as Co-founder and Managing Director of Fortify Health, and now works with us for a couple of hours each week on long-term strategy and M&E guidance. While we miss Brendan’s spontaneous bursts into song and infectious optimism, we are glad that he is still very much involved in Fortify Health’s wider strategic decisions and remains in regular touch with the team. We want to thank Brendan for everything he has done to shape the future of Fortify Health.

Learnings: Once a Fortify Health teamie, always a Fortify Health teamie.

6. We received a $1 million GiveWell incubation grant

The most momentous moment of Fortify Health’s 2019 was the confirmation of our $1 million grant through GiveWell’s Incubation Programme. The Incubation Grant will allow us to continue and grow our operations in Maharashtra and West Bengal for at least two more years: by December 2020, we aim to be fortifying 214.8 MT wheat flour per day across 12 mills of varying production capacities. We also aim to be working with local government divisions to produce and distribute fortified wheat flour to ashram schools in Maharashtra, where children are consistently malnourished.

Learnings: When working alongside a highly considerate and analytical donor, budget about four months for the funding process: the process entails an initial funding conversation, a full analysis with several back and forth conversations, confirmation of grant, and finally, receipt of funds.

7. We refined our monitoring and evaluation strategy and received our first mill data

In 2019 we concretised our plans for how Fortify Health would monitor the fortification process in mills. Monitoring and evaluation (M&E) of fortification in our partner mills includes: a) monthly visits to mills to observe mill practice, b) collecting data on production of fortified flour from mills, c) coordinating quantitative testing of fortified flour for iron in labs, d) facilitating iron spot tests in the mill, e) potential use of in-house testing equipment, called iCheck, and f) working towards obtaining consumption data for fortified flour. We’ve also been collaborating closely with Laura Rowe, Deputy Director at Food Fortification Initiative, to refine and operationalise our M&E strategy. We’d like to thank Laura for all the support she has given Fortify Health from day one, and for continuing to share her expertise and thoughtfulness with us.

Learnings: A significant takeaway from our M&E efforts in 2019 was how challenging it can be to obtain mill data from mills. It can, at times, be a test of time and patience. We learned that it is important to obtain the same information from various sources, so as to triangulate results. Our regular consultations with Laura Rowe have significantly increased our capacity to overcome challenges as they arise.

Here’s to continued growth and continued learning in 2020!

* 0.4 tonnes of fortified flour can be considered at around 3150 people’s average daily consumption. [Calculation: (0.4 MT / day)*(1,000,000 g / MT)/(127g/person/day) = equivalent to 3150 people's average daily consumption. The 2011-2012 National Sample Survey data we have on household consumption for Maharashtra indicates a statewide per capita consumption of 127g / person / day, although our cost effectiveness analysis uses slightly less favourable estimates. It is important to note that this is a somewhat imprecise estimate of how much flour is eaten on average in Maharashtra compared to production of fortified flour, and that our intervention may not affect all of a given beneficiary's flour, and in that case our fortified flour may be eaten by more people but at a lesser amount to per capita daily consumption.]

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Fortify Health receives $1 million GiveWell Incubation Grant

9/21/2019

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We are delighted to share that Fortify Health has received a GiveWell Incubation Grant of ~$1,000,000. This grant will provide the organisation with two years of funding for operations in Maharashtra and West Bengal, from implementation to expanding the team. In Fortify Health’s third year of existence (from mid-2019), the focus is on scaling up implementation.

June 2019 to May 2020: First year of GiveWell Incubation Grant
Over the first year of GiveWell’s 2-year grant, the funding will be directed primarily towards expanding open market wheat flour fortification and building strong partnerships in our two focus states: Maharashtra and West Bengal. Our goals for May 2020 are:

1) to have reached 12 mills in total across the two states, with the projected outcome of 214.8 metric tonnes of fortified flour being produced per day across the 12 mills. (Our premise for selecting and approaching specific mills in specific locations, and how we do this, will be available in an upcoming blog post on mill outreach strategy);
2) to expand our team capacity, doubling the size of our team by May 2020, to manage the increasing scope of our operations across the two focus states;
3) to work with local and state government departments in Maharashtra and West Bengal to support government fortification efforts.

June 2020 to May 2021: Second year of GiveWell Incubation Grant
The second year of funds will be used to continue the mill partnerships and involvement in government programmes achieved in the first year, and to maintain our team. In order to keep expanding in Year 2, we will need to apply for further funding from GiveWell or other sources. Possibility of further expansion and strategy direction are also dependent on new research that may alter effectiveness or cost-effectiveness estimates of fortification. In early 2020, we will refine our strategy for the trajectory of Fortify Health’s operations.

Thank you
The receipt of these funds is a testament to the work of our team over the past two years, who have been driven, dedicated and collaborative along the journey to this milestone. We would also like to thank each and every individual who has supported and advised us along the way, including but not limited to:

Our mentor, Joey Savoie, CEO at Charity Science, and the team at Charity Science;
Our expert advisor, Laura Rowe, Deputy Director at FFI;
The supportive team at Food Fortification Initiative;
Various global health nutrition actors working in India;
GiveWell, for continuing to be a very thoughtful, rigorous, and conscious partner;
Our donor, Effective Altruism Global Health and Development Fund.

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Introducing Our New Country Director

3/14/2019

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We couldn't be more excited to welcome Dr. Urmi Bhattacharya in her new role as Country Director to the Fortify Health team. Urmi joins with extensive experience relevant to fortification, management, and monitoring & evaluation. Prior to joining Fortify Health, Urmi was a Research Manager at the Abdul Latif Jameel Poverty Action Lab (J-PAL) South Asia for four years, where she managed six large scale programmes across five states in India, including two fortification studies. She has also served as the Global Head of Monitoring and Evaluation for Uganda and India at STIR Education. Urmi earned her PhD in Economics from Indiana University in 2012 and has since dedicated her passion and skills towards making high quality education and health systems accessible to all people.

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Introducing Our New Team

11/2/2018

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We’re delighted to announce that over the past few weeks we’ve welcomed on board three new full-time team members. After completing our first ever round of recruitment over the summer months, we’ve hired a Programme Officer, a Partnerships Officer, and a Senior Partnerships Officer.

Introducing:

Shweta, Programme Officer

Shweta has worked as a Research Associate at JPAL South Asia on Non-Communicable Diseases project. She led the RCT study in Mumbai that assessed the impact of reminder call services on compliance to diabetes treatment among elderly populations. Shweta has also worked with the Overseas Development Institute as a Research Intern, studying perceptions of youth on working in the agricultural sector, and its impact on agriculture in Uganda and Ghana. She has completed MSc in Anthropology and Development from the London School Of Economics.

Muneer, Partnerships Officer

Dr. Muneer holds a Master’s in Health Administration from the Tata Institute of Social Sciences, Mumbai and a Bachelor’s in Ayurvedic Medicine and Surgery from Amrita University. Before joining Fortify Health, he was working with Public Health Resource Network in Delhi coordinating the end to end implementation of a nutrition programme in Odisha. His interests include public health, nutrition, anthropology, international politics, history and geography. He is an aficionado of ghazals and Indian classical music.

Shiva, Senior Partnerships Officer

Shiva holds a degree in social work from CSRD- Institute of Social Work and Research, Ahmednagar with academic achievement of clearing UGC, NET. He previously worked with STIR Education as a Senior Program Manager, where he was closely associated with ministries and the education department in Delhi, Maharashtra and Tamil Nadu. He was a also Gandhi Fellow, working on School Leadership Development with the Govt. schools in Gujarat. His interest lies with evidence-based interventions, government partnerships, and policy intervention.

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Fortify Health is delighted to receive GiveWell Incubation Grant

6/21/2018

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Fortify Health is excited to announce that we have received a GiveWell Incubation Grant. This will allow us to continue setting up a micronutrient initiative in India over the next year. GiveWell has recommended a grant to fully fund our budget of $295,217 and has published their review of Fortify Health on their website.

Our intervention takes a two-tiered approach to improving fortification in India. Firstly, we will work with industrial flour millers to facilitate addition of iron, folic acid, and vitamin B12 to wheat flour, offering immediate measures to prevent anemia and neural tube defects (NTDs). Simultaneously (and secondly), we will take a longer-term approach by supporting a state government to develop sound fortification standards, implement an effective monitoring and evaluation system, and progress towards a fortification mandate.

Our brief plans for the next year will be to:

Select a state in which to work (we’ll talk about this more in our next blog post)
Hire a Government Liaison and Technical Lead
Develop relationships with millers and millers associations
Provide premix and equipment to millers who wish to start fortification
Train and support millers in implementing and maintaining fortification
Work with government to develop fortification guidelines and government-initiated monitoring and evaluation of fortification

Once fortification is underway, we will focus more on quality assurance, and monitoring and evaluation of fortification programmes.

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exploring project opportunities in india

3/1/2018

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In January, Fortify Health’s founding team conducted a visit to India. Our aim was to learn about project opportunities to contribute to ongoing efforts in food fortification.

We learned critical information about the food fortification landscape and norms in India, including challenges and progress, as well as identifying specific programmes we could start up. To understand the complexities of fortification in India, it is important to be aware of the Indian government’s safety net programmes and food industry norms. Read our background notes to learn more.

We spoke with key players in fortification, meeting with the government’s Food Fortification Resource Centre and a range of NGOs working in flour or rice fortification: Global Alliance for Improved Nutrition (GAIN), PATH, Food Fortification Initiative, Nutrition International and World Food Programme.

We have published summary notes from key conversations, which you can find below:

Food Fortification Resource Centre
PATH
Global Alliance for Improved Nutrition
Food Fortification Initiative
Nutrition International
World Food Programme

From these conversations and from our own models and cost effectiveness analysis, we have developed several project proposals for fortification projects we believe to be highly impactful. These will be online and publicly accessible soon.

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Country selection

1/30/2018

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This post provides an update on our progress and explains our decision to explore opportunities to add value to iron and folic acid fortification in India. Having extensively reviewed the academic literature and NGO reports, and having spoken to experts in the field who strongly encouraged us to develop this project even as non-experts, we set out to understand where in the world a new fortification initiative might have the most impact. The approach to our evaluation was driven by data and expert guidance.

For an overview of why we began working on iron and folic acid fortification and for background information about iron deficiency anemia and neural tube defects, please see our previous post.

We began our evaluation with country-level analysis of available data, including disease burden, potential intervention scale, status quo fortification gap of centralized mills, and potential risks (contraindications). These were complemented by estimated parameters for more subjective factors, including conflict, crowdedness, language barriers, and miscellaneous positive factors. These scores were standardized and weighted to compute a composite score for each country. Data are available in this spreadsheet.

Disclaimer

These scores and the suggested weights are certainly not a literal indication of the importance of further fortification efforts in the countries evaluated. While this framework was useful in guiding our location selection, we do not claim that its guidance is absolute nor do we claim that fortification (or access to plentiful nutritious food and good health, for that matter) is any less important in locations with lesser scores. Consider this spreadsheet as a visualization of various factors relevant to determining with limited information where our new initiative might be expected to have the highest potential impact.

Selection criteria

Disease burden was modeled as the combined DALY rate of iron deficiency anemia and neural tube defects.

Potential intervention scale was modeled as the log of the country’s population. As such, larger countries with greater potential scale were nonlinearly compared (e.g. India’s population of approximately 1.3 billion was scored approximately twice as high as Sudan’s population of approximately 40 million). This transformation was deemed reasonably aligned with assumptions of potential scale (e.g. the feasibility of working within one state in India compared to at a national level in a smaller country).

The status quo fortification gap of centralized mills was calculated given data aggregated by the Food Fortification Initiative on staple food consumption, centralization of milling of rice, wheat, and corn, and the amount of that staple that is currently fortified. As such, an estimate of the the centrally produced fortifiable food not currently fortified was used in comparison.

The primary potential risk factor (contraindication) considered was the burden of malaria, expressed by national DALY rate. Existing data and meta analysis suggest that iron supplementation programs are associated with increased risk of malaria contraction in high burden regions lacking malaria services. Iron supplementation differs from iron fortification: supplementation involves consumption of high-dose iron tablets at varied frequency (daily to biannually, depending on program) whereas fortification involves consumption of low-dose trace amounts of iron consumed regularly through fortified staple foods. To our knowledge and informed by expert consultation, data on the impact of fortification on malaria risk is not currently available. Even so, several programs are currently underway under the assumption that the low dose of fortification would not carry the same risk. We believe this is an area of worthwhile exploration and would be happy to work with a health economist or statistician to analyze existing data to produce informative evidence. Given the present uncertainty, we included malaria risk as a contraindicating factor in our location selection.

Political feasibility, the presence of ongoing war or political instability, was subjectively rated to reflect both the feasibility of working with government approval or collaboration, the endurance of implemented programs, and safety establishing projects.

Language barriers were considered to reflect our confidence that we could build partnerships with local organizations and governments. Countries where English is spoken (our native language) scored higher than countries where Spanish, German, or French is spoken (our non-native languages), which scored higher than countries where none of the four languages is spoken.

Crowdedness, the presence of existing actors already doing (or planning to do) work similar to our aims, was assessed by reviewing the governmental and NGO efforts currently underway in countries scoring highest on the aforementioned factors. A subjective score was assigned to each evaluated country.

Miscellaneous positive factors included existing relationships with potential partners or influential people.

Selecting India

Considering these factors, India emerged the most promising location to explore specific opportunities for our work. By comparison to other top candidates, India scored slightly to moderately lower on disease burden, higher on potential intervention scale, higher on status quo fortification gap, substantially lower on malaria risk, slightly lower on political feasibility (the average scores of top locations was heavily skewed by Bhutan), higher on crowdedness, lower on language barriers, and higher on miscellaneous factors.

Put another way, reasons to work in India compared with other top candidates included potential intervention scale, status quo fortification gap, low malaria risk, lower language barriers, and positive miscellaneous factors, even though other top candidates had somewhat higher disease burdens and appeared less crowded.

Across India, 38.3 percent of the population suffers from iron deficiency anemia (compared to 2.3 percent in the US). Anemia affects 55.3 percent of women and 69.5 percent of children in India considering all causes (including anemia resulting from iron deficiency, intestinal worms, etc.).

Expert views

Having connected with several experts working in the field, we have overwhelmingly received encouraging responses to our initiative (and have been grateful for pushback, as well). Despite several actors’ efforts on micronutrient fortification in India, it became clear from conversations with organizations working on fortification in India that there is plenty of room for further focus. Anemia is a substantial problem in India and existing interventions are sparsely implemented.

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Planning your Retreat: How to Prepare for Your Next Team Retreat or Offsite

2020: Fortify Health's year in review

“Putting brakes on anaemia: how to safeguard the health and rights of women and girls through fortification”

2019 in review: Our achievements and our learnings

Fortify Health receives $1 million GiveWell Incubation Grant

Introducing Our New Country Director

Introducing Our New Team

Fortify Health is delighted to receive GiveWell Incubation Grant

exploring project opportunities in india

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