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“You can wake a sleeping person. But you cannot wake a person pretending to sleep.” - Deepti Gulati, on lobbying
GAIN’s work in India We spoke predominantly on wheat flour fortification with Deepti Gulati, Head of Programs for GAIN India; we learned about the difficulties in wheat flour fortification, but have also not been deterred by them. GAIN India works in oil, milk and wheat flour fortification. GAIN has been successful in expanding oil and milk fortification, and has been working with the national government and advocating for mandatory fortification of oil. GAIN is currently implementing scale-up of oil fortification in eight states: Rajasthan, Gujarat, Maharashtra, Madhya Pradesh, Haryana, Punjab, Andhra Pradesh and Telangana, with an aim of reaching 300 million people with fortified staples over the next four years. Their recent focus on oil and milk has been largely guided by high incidence of vitamin A and D deficiencies in India and its relative ease of implementation, cost-effectiveness, and funding made available by the Bill and Melinda Gates Foundation and Dutch Grant. GAIN suggested that a significant factor in prioritising oil was that ten times as many beneficiaries can be reached per dollar compared with wheat flour projects. GAIN recognises the need to address anaemia, as another major micronutrient deficiency, through wheat flour fortification, which is more challenging. Wheat flour fortification GAIN would like to advocate and work with the State Governments to mainstream fortified wheat flour in India’s Public Distribution System (PDS). GAIN’s project of rolling out wheat flour fortification in districts in Rajasthan was initially successful, but lost traction after the National Food Security Act (NFSA), 2013. Prior to NFSA, the population covered under the “Below the Poverty Line” (BPL) and “AAY (Ultra Poor)” category, comprised about 26 percent of India’s total population. These categories were given wheat grains at a highly subsidised price (at INR 4.35/ kg). Considering the high levels of anaemia, the Government of Rajasthan agreed to provide fortified wheat flour instead of wheat grains to BPL and AAY beneficiaries without charging the conversion cost. However, after the implementation of NFSA, the population coverage increased from 26 percent to over 62 percent and the cost of grains was reduced to just INR 2/kg of wheat grain. At this rate and an increased coverage (almost 2.5 times more than what was covered under BPL / AAY), it became untenable to provide fortified wheat flour instead of wheat grains, under the NFSA. As per the letter issued on 3 November 2014 and its reiteration in another follow-up letter issued on 22 December 2016, the Department of Food and Civil Supplies, Government of India reiterated that the State Governments could provide fortified wheat flour instead of wheat grains under the NFSA, and pass on the reasonable cost of such conversion to the consumer beneficiaries, if the consumers agreed to pay the cost of conversion or if the respective State Governments agreed to bear the conversion cost. At the behest of the Government of Rajasthan, GAIN conducted focus group FGDs in selected districts and submitted a report to the Government which stated that consumers were ready to pay the conversion cost. But the State Government is weighing the political implications before taking a decision to pass on the cost of converting grain to fortified wheat flour, to the NFSA beneficiary consumers. Recently, both the Ministry of Women and Child Development and Ministry of Human Resource Development, Government of India, issued circulars on 10 July 2017 and 2 August 2017, respectively making it mandatory to use fortified wheat flour and fortified edible oil in the preparation of ICDS supplementary food and the mid-day meals for school feeding. GAIN is nudging the private industry into food fortification, as it will give them a market advantage as the government is promoting the use of fortified products in the public funded programmes. GAIN also pointed out that within India, anaemia is universal, cutting across different states and socio-economic groups. Off the cuff estimates by GAIN suggested that in a population where 70 percent of children and 53 percent women suffered from anaemia, wheat flour fortification in states where it is implemented universally, could lead to a drop to around 35 percent when paired with deworming, and that even without deworming, up to a 25 to 30 percent drop may be possible. GAIN also mentioned that there is virtually no risk of excessive iron consumption on consuming fortified wheat flour, as food is self-limiting and it is nearly impossible to consume such huge quantity of food that may lead to excessive iron intake. GAIN sees opportunity for us to provide equipment to rekindle fortification efforts at medium-scale wheat flour producers. Back of the envelope calculations suggest that microdosers costing approximately 2,000 USD each, could be sufficient for a mill producing approximately 1,000 MT of flour each month, benefitting approximately 160,000 people. GAIN sees themselves as funding constrained on wheat flour fortification, where they would like to see projects in 18 states but cannot, for the want of funds. Note: GAIN feels that if the wheat flour industry is funded for micronutrient premix support for one year, on a sliding subsidy, wheat flour fortification for sale in the open market channels, could gain relatively quicker traction but continuation of wheat flour fortification by the wheat flour industry, upon the phasing out of micronutrient-premix support would remain a speculation. If subsidizing premix, we should consider the potential for having the unintended consequence of decreasing willingness to adopt fortification practices without subsidies in surrounding areas. Referencing difficulties in implementation of wheat flour fortification, GAIN shared some of their lessons learned. Both full and sliding subsidies on premix do not work so well for the long term of a programme; they become unsustainable and when the funding for premix stops, interest in continuing fortification by industry has been shown to drop off. Sliding subsidies are still much better than wholly funding premix. It is perhaps advisable to ensure premix is self-funded by governments and industries from the outset. Furthermore, the central government would like to convince states there is sufficient evidence that new evidence generation is not necessary to go ahead with fortification projects. Wheat flour fortification is widely acceptable, that there are no organoleptic changes, and that the industry is responsible and takes pride in investing in nutrition. Even so, prioritisation of fortification at a state level is challenging. A model of supportive regulatory monitoring (rather than punitive) may be the most promising. Flour shelf life remains a concern as unprocessed grains will dominate unless shelf life of wheat flour is improved (if moisture content is lowered). Universal mandatory fortification of staple grains is still far off on account of highly fragmented nature of wheat flour industry, regulatory mechanisms and concerns, but mandatory oil and milk fortification is within reach, perhaps as soon as within the next six to 12 months, as the edible oil and milk industry is fairly well aggregated and organised. Other micronutrients: We also developed a better understanding of why supplementation programmes have not had much traction (requiring behaviour change, education around side-effects, wide-coverage, etc. that has not yet been as successful at scale, as is expected). For example, iron and vitamin A supplementation programmes are estimated to reach only about 55 percent of children. GAIN suggested Fortify Health could contribute by:
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