Pakistan National Food Fortification Strategy

Ministry Logo, WFP Logo, NFA Logo
Pakistan
National Food Fortification Strategy
March 2017
Pictures of Wheat Flour Fortification, Salt Iodization and Oil & Ghee fortification. Three
Boxes
National Fortification Alliance

Ministry of national Health Services, Regulations and Coordination
Government of Pakistan
A strip of Logos from MI, GAIN, FFP, UNICEF, WHO, AusAid at the bottom
After this inner page with the same writing but only NFA and Ministry logos
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TABLE OF CONTENT
CONTENTS PAGE
Foreward Iii
Acknowledgement Iv
Abbreviations v
Executive Summary 1
I. Background to National Fortification Strategy 3
Human and Economic Impact of Vitamin and Mineral Deficiencies in 3
Pakistan
Introduction to Food Fortification 4
II. Situation Analysis 6
1- Salt Iodization 7
2- Wheat Flour Fortification with Multiple Vitamins and Minerals 9
3- Oil Fortification with Vitamin A and D 12
III. Scan of Opportunities and Barriers 14
1a: Market and Industrial Environment: Opportunities 14
1b: Market and Industrial Environment: Barriers 16
2a: Public Policy Environment-Opportunities 20
2b: Public Policy Environment Barriers 22
3a: Project Environment: Opportunities 25
3b: Project Environment: Barriers 26
IV. Strategic Framework: Goals, Objectives, Outcomes, Outputs 28
Scope of National Food Fortification Strategy 28
Goals 29
Objective 29
Outcomes 29
Outcome 1: Enabling Public Policy & Regulatory Environment 30
Established
Outcome 2: Provinces with Capacity for Food Control Inspection and 30
Enforcement
Outcome 3: Food Industry: Aware, Equipped and Trained for 30
Implementation
Outcome 4: Available Supply of Affordable High Quality Fortificants and 31
Other Inputs
Outcome 5: National Surveillance, Monitoring & Evaluation Systems in 31
Place
Outcome 6: Options for Populations who cannot Access Fortified Flour, 31
Oil and Salt
Outcome 7: Strengthening NFA: Platform for Multi Sectoral Advocacy, 32
Communications and Public Education
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FOREWARD
We have made progress in health sector over the years. Malnutrition still affects millions of
Pakistani population in various ways, but it is particularly devastating to new born babies,
children and women. Malnutrition also impairs educational achievement and economic
productivity, costing the Government and families enormous amounts of money. Given the
widespread prevalence of various micronutrient deficiencies in Pakistan, food fortification, is a
preventive, long term and one of the most cost effective intervention to overcome these.
Food fortification programs require the collaboration of the public and private sector and a
regulatory environment in which appropriate government legislation is enacted and systems
exist through which compliance can be effectively monitored and enforced. However, overall
success also requires closer attention to strategies for improving the indicators of malnutrition.
National Fortification Alliance (NFA) under the Ministry of National Health Services, Regulations
& Coordination (MoNHSR&C) has developed Pakistan National Food Fortification Strategy to
guide and give strategic direction to the food fortification interventions aiming for the
prevention and control of micronutrient deficiencies and overall malnutrition in Pakistan.
This strategy will provide an overarching framework for developing a strategic plan and
comprehensive fortification programs in which several staple food products could be fortified
with key micronutrients necessary for adequate health and proper growth and will serve as a
guide at both policy and implementation levels. The goal of this strategy is to create enabling
national environment for sustained salt, wheat flour and oil fortification programs implemented
by private sector and public agencies and departments within various provinces
I extend my sincere appreciation to all those who contributed to the development of this
document. The consultant and members of the NFA Core group are commended for a job well
done. I cannot overemphasize the role played by the National Fortification Alliance in
coordinating the development of this strategy. All these actors truly deserve our recognition
and gratitude. Finally I must appreciate the support extended by the Ministry of NHSR&C in
accomplishing this task.
Dr. Baseer Achakzai

Director Nutrition/NPM
Secretary National Fortification Alliance
Ministry of National Health Services,
Regulations & Coordination
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iii
Acknowledgment
This strategy document is a result of collaboration between the National Fortification Alliance
(NFA) of Ministry of National Health Services, Regulation & Coordination (MoNHSR&C) and
United Nations World Food Programme (UN-WFP).
The Ministry of National Health Services, Regulation and Coordination (MoNHSR&C) gratefully
acknowledge the support of author and main contributor Dr. Jack Bagriansky and Dr. Khawaja
Masuood Ahmed. Dr. Jack Bagriansky is a Principal of JBPHN, LLC and a consultant to a range of
public health and development agencies and Dr. Khawaja Masuood is the National Coordinator
at National Fortification Alliance of Pakistan, Ministry of National Health Service, Regulation and
Coordination.
Under the overall guidance and technical support of Ms. Cecilia Garzon, the strategy benefitted
from technical inputs of Ms. Melanie Galvin, Ms. Rabbiya Hamdani, Dr. Qaiser Munir Pasha, Dr.
Tausif Janjua, Dr. Masood Abbasi, Dr. Ahsanullah Bhurgri, Mr. Munawar Hussain and Ch. Faiz
Rasool.
Dr. Baseer Khan Achakzai, Director Nutrition, Ministry of National Health Services, Regulation
and Coordination provided the leadership, guidance and support in the successful completion
of this strategy. Strong and continuous support was provided by Mr. Aslam Shaheen, Chief
Nutrition/ SUN Focal Point of the Ministry of Planning Development & Reforms.
Ministry of National Health Services, Regulations & Coordination (MoNHSR&C) acknowledges

the support of Government of Australia for providing financial assistance through the UN-WFP
in having this vital document formulated.
Ministry of National Health Services, Regulations & Coordination (MoNHSR&C) acknowledges

the cooperation of all the NFA core group members and partners (MI, UNICEF, WHO, FFP, GAIN,
DFID) for their valuable technical support to this strategy and strenuous efforts to make lasting
changes in the lives of the people of Pakistan.
Finally we acknowledge the overwhelming support of the Minister of State for NHSR&C, The
Secretary MoNHSR&C and Director General Health which was a driving force in completion of
this document.
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ABBREVIATIONS:
NFA: National Fortification Alliance

PSQCA: Pakistan Standards and Quality Control Authority
PFA: Provincial Fortification Alliance
GoP: Government of Pakistan
MoNHSR&C: Ministry of national Health Services, Regulations & Coordination
DFP: District Focal Point
MI: The Micronutrient Initiative
GAIN: Global Alliance for Improved Nutrition
FFP: Food Fortification Project
DFID: Department for International Development, UK
PFMA: Pakistan Flour Mills Association
PVMA: Pakistan Vanaspati manufacturers Association
RNI: Recommended Nutrient Intake
SAM: Severe Acute Malnutrition
MAM: Moderate Acute Malnutrition
RUTF: Ready to use Therapeutic Food
RUSF: Ready to use Supplementary Food
LNS: Lipid base Nutrient Supplement
QA: Quality Assurance
QC: Quality Control
MOI: Ministry of Industries
GST: General Sales Tax
USI: Universal Salt Iodization
WFF: Wheat Flour Fortification
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Executive Summary:
More than half of Pakistani women and two thirds of children suffer micronutrient deficiency.
Widespread vitamin A, vitamin D, zinc, folic acid and iron deficiency anemia in Pakistan
represents a severe public health problem with significant impacts on morbidity and mortality,
including more than 50 thousand deaths of children less than 5 years of age. Consequences
include slow physical and cognitive development, inferior school performance and decreases in
productivity of adults representing an economic burden of $3.5 billion annually which is almost
1-2% of Pakistan’s GDP.
Food fortification, the addition of vitamins and minerals to common foods is an effective,
affordable and safe measure to lower the burden of micronutrient deficiency. The industrial,
market and regulatory environment in Pakistan is favorable for implementation of wheat flour
fortification with iron and multiple micronutrients, oil and ghee fortification with vitamins A and
D and salt iodization. Well-organized and financed Projects currently aim to develop national
scale for salt, flour and oil fortification. Ambitious realistic objectives include reaching:
 > 70% or ~125 million citizens who consume oil and ghee produced by industrial scale
processors with 39% of daily requirements for vitamin A and 31% for Vitamin D.
 > 50% or ~90 million citizens who consume flour from the nation’s industrial roller mills
with 95% RNI for Vitamin B12, 68% for folic acid, 38% for iron and >100% for zinc.
 > 90% or ~170 million citizens with 90% daily iodine requirements via iodized salt.
Food fortification is a multi-sectoral enterprise requiring participation of multiple government

agencies; private enterprises; research institutions; media and other champions to assist in
securing political support as well as consumer acceptance. In Pakistan, this environment is
complicated by devolution of governance responsibilities to the provinces. In this context, the
essential role of federal agencies is to provide policy guidance, technical support, tax and
financing support as well as nation-wide monitoring, surveillance and communications. Federal
agencies have important mandates, capacities, and other ‘value-added’ contributions to make:
 Issuing national product standards consistent with global best practice and Pakistan
context.
 Harmonizing provincial programs to achieve efficiencies of scale and ensure open trade.
 Providing expertise of technical agencies offering food science, laboratory services,
industrial development, monitoring and other expertise.
 Developing tax and tariff support and customs services for imported inputs to
fortification.
 Applying full capacity of national statistics and monitoring agencies to document
distribution and impact of fortified products.
 Capitalizing on national media to marshal political will and to inform consumers.
 Building platform for national policy development, training, information sharing and
collaboration to enhance provincial policy, planning and implementation.
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The organizational channel for this federal role is the National Fortification Alliance (NFA)
convened by the Ministry of National Health Services, Regulations & Coordination
(MoNHSR&C). NFA opens channels for collaboration among: national-international, federal-
provincial, intra-government agencies, and public-private sectors. Key objectives for NFA are to
support ongoing USI, flour and oil fortification Projects to achieve their 5-Year policy regulatory,
quality and financial targets as well as to sustain the following coverage targets: >90% of iodized
salt; >70% of fortified oil and ghee; >50% coverage of fortified wheat flour. Achieving these will
involve a mix of the following Outcomes and Actions on the part of NFA and participating
institutions:
Enabling Public Policy & Regulatory Environment: Develop required standards for imported
inputs; product fortification standards; national technical dossier; grain policy and tax reform;
purchase and distribution of fortified foods by social protection programs.
Provinces with Capacity for Food Control Inspection and Enforcement: Provide support to build
capacity of provincial food control agencies; services of national food laboratories; integration
of fortification into over-all provincial food control structure, activities and annual budgets; and
special research to inform challenges to ongoing salt, flour and oil fortification Projects.
Food Industry Aware, Equipped and Trained for Implementation: Collaborate with ongoing salt,
flour and oil Projects to develop communication and training programs; advocate for optimum
role of industrial development agencies; build capacity of industry associations; undertake
research to address obstacles and inform ongoing salt, flour and oil fortification Projects.
Supply of Affordable High Quality Fortificants and Other Inputs: Develop capacity for sustained
cost-efficient import, distribution and financing of fortificants to producers; opportunities for
domestic companies to add value and other inputs to fortification; capacity for sustained
equipment maintenance and/or replacement of fortification hardware.
National Surveillance, Monitoring & Evaluation Systems: Coordinate federal technical
institutions in developing comprehensive national level monitoring; support fortification
Projects and provincial programs in monitoring; convene periodic reviews to disseminate
national data, provincial experiences and lessons learned.
Options for Populations who cannot Access Fortified Flour, Oil and Salt: Develop research
opportunities to address special needs of rural, poor and high-risk consumers who cannot
regularly access fortified foods including: additional food vehicles; bio-fortification; multiple
micronutrient powders; and small scale chakki fortification.
Strengthened NFA: Platform for Multi Sectoral Advocacy, Communications and Public Education:
Provide opportunities to review program experience; develop regular sustained national
budget; coordinate donor resource mobilization; develop national level communications
including mass public education; and develop regular sustained domestic financing for NFA
activities.
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I. Background to National Fortification Strategy
Human and Economic Impact of Vitamin and Mineral Deficiencies in Pakistan:

Various reports and surveys suggest that more than half of Pakistani women and two-thirds of
children under 5 years of age suffer
National Prevalence of Selected Micronutrient Deficiencies1
from vitamin and mineral
% (NNS 2011) 000,000
deficiency. According to the World
Vitamin A Deficiency: Children 56.0% 12.3
Health Organization (WHO) under 5Y
thresholds, widespread vitamin A, Zinc Deficiency: Children under 5Y 36.5% 8.0
vitamin D, zinc, folic acid and iron Anemia: Children under 5Y 62.1% 13.6
deficiency anemia in Pakistan Anemia Women Reproductive Age 50.5% 25.6
2
represents a severe public health Iodine Deficiency Disorders 12% 0.6 (births/y)
problem with significant impacts on morbidity and mortality. 3 A recent analysis undertaken
with support of UN-WFP projected the human and economic cost of the status quo, the current
prevalence of micronutrient deficiencies in Pakistan. The report concluded that the
developmental consequences of micronutrient deficiencies including slow physical growth,
cognitive development and inferior school performance along with decreased productivity of
adults represent an economic burden of 1-2% of Pakistan’s GDP.4 5At current prevalence of
micronutrient deficiencies established in the National Nutrition Survey 2011, the consequences
that have been identified include:
 Anemia and folic acid deficiency among pregnant women are associated with ~34,000
deaths among infants annually.
 Vitamin A Deficiency and Zinc Deficiency among children 6-59 months of age are associated
with ~23,000 deaths annually.
 Reduced mental activity, school achievement and future adult productivity emerging from
iron deficiency anemia among children less than 24 months of age and infants born with
iodine deficiency represents a $1.3 billion drag on the national economy annually.
 Depressed job performance among easily fatigued anemia adults working in manual labor
at present represents a yearly loss of more than $650 million.6
The annual economic burden emerging from current rates of micronutrient deficiencies is
estimated at nearly $3.5 billion per year.7 Moreover, micronutrient deficiencies are considered
a contributing factor to stunting, underweight and other indicators of acute and chronic
malnutrition in Pakistan. This human and economic burden of micronutrient deficiencies is
largely preventable via an integrated portfolio of micronutrient interventions that include
pharmaceutical supplementation, nutrition education and food fortification.
1
Pakistan National Nutrition Survey 2011
2
Roughly derived as 50% of NNS 2011 survey samples < 100µg/dL.
3 Pakistan National Nutrition Survey 2011
4 Bagriansky, J. Economic Consequences of Micronutrient Malnutrition in Pakistan, Unpublished, World Food Program 2017
5 IBID
6 IBID
7 IBID
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Introduction to Food Fortification:
Addition of vitamins and minerals to common foods like salt, wheat flour and cooking oil was
first implemented in Europe and North America in the early 20th century, where it played a key
role in the virtual elimination of many micronutrient deficiencies. Over the past 50 years,
expanding commercial food markets and increasingly sophisticated food industries enabled
fortification to expand in developing countries. Today 125 countries have salt iodization
programs8, 83 have mandatory wheat flour fortification with multiple micronutrients9 and 59
countries have standards for edible oil fortification with vitamin A and/or D.10 Effectiveness,
safety and affordability of fortification has been well documented.
 While documentation is available for decades of fortification, most recently, a national

program in Costa Rica was found to lower anemia and iron deficiency among children by
75-80%.11
 A recent global review found folic acid fortification has decreased incidence of spina bifida
(spinal cord birth defect), anencephaly (brain development disorder) and other neural tube
birth defects by 30-70%.12
 Global recommendations and technical guidelines for effective fortification from World
Health Organization are in place.
 Low industrial fortification costs of $1-3 per metric ton (depending on fortification vehicle,
micronutrient/s and addition level), often less than 1% of the wholesale price, have been
documented throughout the world – usually financed by an invisible price rise, a few
pennies per person per year.
High burdens of vitamin and mineral deficiencies along with documented effectiveness and low
costs of adding micronutrients like iron, folic acid, vitamin A, vitamin D, iodine and zinc, suggest
food fortification to be a cost-effective public health intervention. Recently, the Copenhagen
Consensus, a panel of economists including 4 Noble Prize winners, ranked a full portfolio of
development investments based on their cost-effectiveness and economic return.
Micronutrient supplementation and fortification represent two of the top three investments.13
A century of global experience indicates key success factors for sustained implementation and
public health impact of food fortification that include:
 Consumption is widespread and sufficient to deliver significant nutrition protection to

populations at risk of micronutrient deficiencies.
 Small affordable impact on price with no unacceptable changes in product taste,
appearance and other qualities to ensure consumer acceptance.
8 Mannar, V, Making salt iodization truly universal by 2020, IDD Newsletter, May 2014
9 http://www.ffinetwork.org/global_progress/index.php
10 http://www.gainhealth.org/programs/initiatives/#global-tracking
11 Martorell R, et al. Effectiveness evaluation of the food fortification program of Costa Rica: impact on anemia prevalence and
hemoglobin concentrations in women and children1–5. Am J Clin Nutr 2015:101(1):210-7.

12 Fifteen Years of Fortifying With Folic Acid Reduces Birth Defects; Averts Healthcare Expenses, Flour Fortification Initiative,
2016
http://www.ffinetwork.org/about/stay_informed/publications/documents/FolicAcidBackground.pdf
13
http://www.copenhagenconsensus.com/post-2015-consensus/nobel-laureates-guide-smarter-global-targets-2030
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 Technically proficient industry, with financial and technical capacity to adapt fortification
processes into its ongoing business model.
 Mandatory standards and credible enforcement indicating government commitment and
political will to create a level playing field for fortifying producers.
 Adequate monitoring, evaluation and communication to all appropriate stakeholders to
ensure benefits are widely appreciated.14
When these conditions are largely in place, food fortification programs hold significant promise
to lower the human and economic burden of malnutrition.
14
Guidelines on Food Fortification with Micronutrients, WHO/FAO 2006
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Section II Situation Analysis
A range of feasibility studies indicate that the market and industrial conditions for successful
food fortification in Pakistan largely comprise 3 food vehicles, i.e. wheat flour with iron, zinc
and folic acid and other micronutrients; fortification of cooking oils including ghee with vitamin
A and D; and salt iodization. Regular consumption of these food items is widespread, sufficiently
high and often on a daily basis. Relatively large processors and sufficient technical and financial
capacity, supply to large segments of the population varying from nearly universal for oil and
salt and more than half of all Pakistani consumers for wheat flour. The regulatory environment
under the devolution, required by 18th Amendment in Pakistan’s Constitution, is being re-
established and new provincial legal instruments are in process, or in some cases nearing
completion. Although Pure Food Rules issued at the federal level and adopted by all the
provinces are still technically mandatory, enforcement processes are not considered sufficiently
stringent – and province-level standards and regulations are ultimately required. Recognizing
fortification as a key ‘public good’ in 2016, the Government of Pakistan moved to share in the
modest financial burden of fortification by exempting imported fortificants (for salt, wheat
flour, Oil/Ghee) from import taxes and duties.
Current Regulatory Status for Wheat Flour, Salt Oil and Ghee Fortification
Minimum Addition Unit Compound Legal Instrument
Flour
Vitamin B12 0.008 mg/kg Vitamin B12 0.1%
Approved by PSQCA and Review
Folic Acid 1 mg/kg Folacin/ Folate
in Process at Punjab Food
Iron 15 mg/kg Na Fe EDTA
Authority
Zinc 30 mg/kg Zinc Oxide
Salt
Iodine 30PPM @ production mg/kg Potassium Iodate PSQCA, Pure Food Rules
20PPM @ market
30PPM @ production mg/kg Potassium Iodate Sindh legislation
Oil& Ghee
Target Range
Vitamin A 39,000 33-45,000 IU/g Vitamin A palmitate Pure Food Rules, 1965
Approved by PSQCA
Vitamin D 3,750 3-4,500 IU/g Vitamin D2/D3 Under Review by Punjab Food
Authority and PSQCA
Other fortification food vehicles will require additional feasibility assessments and in most
cases, further research and development. However, the situation analysis below indicates that
while program barriers remain, salt, wheat flour and oil & ghee fortification hold substantial
promise for establishing sustained implementation, with significant public health impact, in the
short to medium term.
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1. Salt Iodization
Market and Industry Environment:

Salt consumption is widespread throughout Pakistan with only minor variations in consumption
among regions and income groups, and hence, it provides an ideal environment for food
fortification. Average salt consumption in both urban and rural areas is estimated at 7.6 grams
per person per day in National Household Income and Expenditure Survey and 10 grams per
day by USI program planners. This level of consumption suggests that salt iodization delivering
target 15ppm iodine to the household level is sufficient to deliver 76%-100% of daily iodine
needs (RNI) for woman of reproductive age.
The national salt supply is obtained almost exclusively from domestic deposits and processed
by a relatively large but decentralized industry comprising around 1400 enterprises: ~ 70 large
producers supply about one-quarter of national needs; ~ 300 medium sized enterprises with
possibly 30-40% of the national market, and more than 1000 small producers representing 30-
40% of consumption. 15 This suggests that classic and proven iodization approaches are
appropriate for roughly 60-70% of the national supply emerging from 350-400 large and
medium scale enterprises. Experience from salt iodization programs throughout the world as
well as Pakistan suggests that iodization of remaining 30-40% of salt from hundreds of smaller
producers has been more challenging, requiring significant and sustained support. However,
many of these producers are geographically concentrated and thus, enabling efficient channels
for communication and capacity building. About two-thirds of the national production is
concentrated in Punjab with another 30% in KP and Sindh provinces. Moreover, small-scale
producers are reportedly cooperative with ongoing USI projects in Pakistan.16
Public Policy and Regulatory Environment:

At national level, PSQCA standard for iodized salt is in place and Provincial Pure Food Rules
technically apply to all provinces. Sindh has a provincial legislation in place. Khyber
Pakhtunkhwa, Punjab and Balochistan also mandate salt iodization, not as mandatory
legislation, but administratively via amendments to existing provincial Pure Food Rules.
However, penalties for non-compliance under Pure Food Rules are ambiguous with wide
discretion left to local authorities.
Therefore, credible enforcement will require additional regulatory amendment and reforms.
The foundation from strengthening the regulatory environment in all provinces has been
established with salt iodization specified in provincial nutrition policies and nutrition strategies.
However, once mandatory instruments are established at the provincial level, provincial food
authorities 17 and other designated food control agencies will require significant support to
elaborate legal mechanisms into clear, transparent and enforceable procedures and protocols.
Moreover, in most of the cases, provincial agencies lack the technical and human capacity,
accountability and motivation as well as regular financing for strict enforcement of mandatory
USI.
15 Estimated based on Review of the KIO3 Supply Chain Mechanism, WFP, May 2015
16 Personal Communication, NFA National Coordinator
17
currently in place in Punjab while other provinces are moving to replicate this structure
12
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Project Environment:
Since the 1980s, multiple initiatives by Government of Pakistan (GoP) with the support of a
range of donors, worked to develop national salt iodization, including establishing model salt
iodization districts, which reached >90% coverage. However, these efforts were not sustained.
By the turn of the millennium, household consumption of iodized salt was estimated at only
17% (PIDE 2001). As a consequence, 76% of mothers and 63% of under-five children remained
iodine deficient.18
In 2005, a revitalized salt iodization effort was initiated by the Federal Ministry of Health, GoP,
with the support of the Micronutrient Initiative (MI) and UN-WFP. In collaboration with the
Provincial Departments of Health, District Health offices and the development partners, the
program focused on an intensive and strategic ‘supply-side push’ focusing on the 90 districts
where possibly 100% of the national salt supply is produced. The Project provided equipment
to ~ 1400 salt producers, supplied potassium iodate fortificant, and provided extensive capacity
building, training and external quality assurance. The program engaged local governments in
developing political commitment and supported the appointment of District Focal Points (DFPs)
for salt iodization and established Project Offices in coordination with the local governments.
Project staff, in close cooperation with district health offices conduct bi-monthly inspection and
product testing at>1400 large, medium and small salt enterprises. In addition to providing
external quality assurance for producers, this process provides capacity building and
’mentoring’ of local government personnel.
Initial evaluations indicate significant success. A third party evaluation of program conducted in
the year 2010 found 36% of salt with adequate iodization at the point of production (more than
30ppm of iodine) – with another 27% with moderate level of iodization of 15-29ppm and 30%
with insufficient levels of added iodine 1-14 ppm. Significantly, only ~ 1% was found to have no
added iodine.19 As per National Nutrition Survey 2011, household utilization of iodized salt rose
from 17% in 2001 to 69% in the year 2011 – and indicators of iodine deficiency fell from 76% to
36% among mothers and 63% to 36% among children under 5 years of age. 20Ongoing project
monitoring by MI/WFP Project Staff, supported by district health counterparts, suggests 65%
adequate iodization at production (>30 ppm iodine).
Intensive technical and financial inputs from MI and WFP have enabled dramatic improvements
in coverage of adequately iodized salt in Pakistan. However, improving iodization from 36%-
65% range to the USI Project objective of 90% adequately iodized salt will require considerable
effort and investment. However, the MI and WFP will not be able to sustain this level of effort
and are working to develop exit strategies. Currently, the Project is working in close
collaboration with NFA to sustain current iodization achievements, improve the quality
performance of producers and simultaneously implementing an exit strategy that includes:
18 National Nutrition Survey Report, Government of Pakistan 2001

19 Ahmed K. Masuood et al Achieving UIS in Pakistan, IDS Bulletin Volume 44 Number 3 May 2013 
20
National Nutrition Survey Report, Government of Pakistan 2011
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 Advocacy and technical assistance to finalize needed provincial mandatory legal
instruments as well as to elaborate supporting regulations.
 Continued capacity building of enforcement agencies at provincial and district level
while phasing-out monitoring by Project staff.
 Supporting a revolving fund mechanism already in place, to ease the transition from
facilitated fortificant supply to full industry/market availability and financing of
fortification.21
 Building capacity of private sector to establish efficient import and distribution of KIO3
to all salt enterprises– often in collaboration with provincial and local governments to
support needs of smaller and less financially capable salt enterprises.
Initial data from 2012-2013 suggests that iodization activity diminished as the exit strategy
including withdrawal of subsidy on KIO3 was implemented, with adequately iodized salt
declining modestly from 65% to 46%-58%.22 Despite recent improvements, the challenges of
improving and expanding iodization while simultaneously implementing a Project exit strategy
are steep. Nevertheless, a recent analysis of nutrition opportunities in Pakistan found that “Salt
iodization is one of the best candidates for further up-scaling and strengthening. It does not
require any further situation analysis and it could benefit all age groups of population across
the country with minimum investment and without fearing about health risks.” 23
2. Wheat Flour Fortification with Multiple Vitamins and Minerals

Pakistan is the largest country where wheat is the staple grain of nearly the entire population.24
Consumption, on average ~300 grams per person per day, is relatively consistent across urban,
rural and income segments, suggesting wheat flour fortification can deliver significant
protection from vitamin and mineral deficiencies – from 38% to more than 100% for the 4
micronutrients being considered.25 However, an estimated 40% of the national supply, mainly
to rural areas, is from possibly tens of thousands of small-scale stone mills (chakkis) where
existing and proven technical and financial models for sustainable fortification remain to be
developed.26 Nevertheless, classic fortification techniques can be applied at ~1000 industrial
scale roller mills, supplying a roughly estimated 60% of national consumption, mainly to urban
and peri-urban areas.27
While there are a large number of mills to be equipped, supplied and monitored, 50-60%
population coverage represents a very feasible objective because these ~1000 larger mills are:
officially registered enterprises, members of official trade associations, (PFMA, Chamber of
21 Current payments to revolving fund include surcharge to enable financing of iodization equipment, as it requires replacement.
22 Project Concept Note (PCN) Dr. Tausif Akhtar Janjua, 2014
23 Nutrition Mapping and Proposing Options for Scale up in Pakistan, TRF, 2012
24 http://www.world-grain.com/News/News-Home/Features/2014/9/Profiling-Pakistans-milling-industry.aspx?p=1
25
Food Balance Sheets, UN FAOSTAT, http://www.fao.org/faostat/en/#data
26 Personal Communication, Food Fortification Project
27 Even though most are members of a formal milling industry associations, developing fortification including 1000 roller mills
represents a significant challenge compared to other countries in Asia. In Bangladesh ~300 mills supply 93% of national wheat
consumption; in Indonesia about 20 mills produce virtually all domestic flour.
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Commerce & Trade), and geographically concentrated. A recent analysis suggests that 85-90%
of all roller milling is in 39 districts, including 28 in Punjab, with 5 districts, accounting for one-
third of all roller milling. 28 This concentration of milling enterprises suggests further that
industry capacity building and government regulatory efforts can be strategically and cost-
effectively concentrated at the point of production. Over the past decade, donors and
international agencies including WHO/EMRO, GAIN, UNICEF and The MI have introduced
fortification to Pakistan’s millers. Although fortification from these efforts were not sustained
in most of the cases, but have contributed to lesson learning. In addition, industry has some
capacity and is generally aware of consumer benefits as well as issues involved with the
implementing fortification.

GoP has worked with multiple partners to develop the potential for fortification at Pakistan’s
roller mills, developing government awareness and some capacity among relevant agencies as
well as basic regulatory instruments. A national wheat flour fortification standard was issued by
PSQCA in the year 2008. Based on recent WHO recommendations on fortification standards
and the recommendations of the Regional Advisory Group for Central Asia, revisions to the
standard have been proposed by National Fortification Alliance and are endorsed and adopted
by PSQCA. These include a more bio-available iron compound (NaFeEDTA) appropriate to the
Pakistan context, along with folic acid, zinc and Vitamin B12. Federal government policy support
for food fortification is also elaborated by duty and tax exemptions for imported fortificants and
premix through the strenuous efforts of NFA with support from partners like GAIN. This would
lead to considerable reduction in fortification cost making a strong case for industry to absorb
it in the long run.
The full spectrum of provincial mandates, necessary in decentralized post-18th Amendment

food law, are not in place. All provincial nutrition strategies include language specifying the
need for wheat flour fortification, laying a foundation for future mandate and regulation.
Punjab, home to the lion’s share of national wheat milling, is considering mandatory adoption
of the NFA recommended standard. Although these over-arching mandates are essentially in
place, some institutional structures and roles remain ambiguous and activities of provincial
regulatory authorities may potentially overlap with federal authorities, in standard setting,
enforcement and regulation. Once provincial regulatory mandates are in place, food control
authorities would require significant support to strengthen the technical and human capacity,
accountability and motivation as well as regular financing for strict enforcement of mandatory
WFF. This task is complicated by overlapping and sometimes unclear roles and responsibilities
of various federal and provincial agencies that oversee registration and licensing of mills as well
as compliance with food quality and safety requirements.
Public grain policy in Pakistan presents a significant challenge to implementing and sustaining
fortification. Government grain purchase, distribution and subsidy schemes, which vary
considerably from province to province, have two main goals: ensure farmers receive a
minimum price that will serve to guarantee that the country remains self-sufficient in wheat
28
Bagriansky, J Consultant Report to The Micronutrient Initiative, April 2015
10 15
production; and to enable government intervention to mitigate price rises in the lean months
leading up to the next harvest.29 While mills purchase the predominant share of wheat supply
from private channels, both the market supply and price is significantly impacted by subsidized
wheat provided by provincial governments. This low cost wheat supply is distributed to
privately owned mills based on a quota system where subsidized grain is assigned based on the
capacity of a mill. The availability of this sought-after subsidized wheat supply tends to distort
industry objectives – with many mills emphasizing the grain trading side of the business over
actual flour milling activity. This market distortion leads to an over-supply of official registered
mills, as some remain in operation only to qualify for the subsidized supply. This over-supply
leads to excess capacity with most mills operating at a low proportion of their potential milling
capacity – and creates a range of business and financial pressures, including several obstacles
for the fortification program.
 A larger than the necessary number of mills to train, supply and monitor.
 With little incentive to invest in modernization, technical capacity is relatively low.30
 An officially established ex-mill price per bag of flour means costs of fortification cannot
be recouped from the market without government action/ approval.
Debate over public grain policy will undoubtedly continue among industry and government
stakeholders though all with distinct objectives and agendas. 31 While fortification does not
require a full market reform, but at least it requires some modifications to enable individual
mills to recoup the incremental costs of fortification – either slightly raising the ceiling price
enabling the cost to be passed on to the market or providing incentives to fortify, such as
preferred access to grain supply in return for documentation of quality fortification.
Since year 2000, a number of development agencies have supported planning, research and
development as well as commercial implementation of flour fortification. However, in most of
the cases, as donor’s technical and financial support ended, the project was not sustained. Most
recently, major support from DFID through Food Fortification project (FFP) will enable a
comprehensive set of activities over 4-5 years to establish and sustain wheat flour fortification
at the country’s roller mills. The project is being implemented by the Micronutrient Initiative
and Mott MacDonald in collaboration with NFA, PFAs, key government departments at National
and Provincial level, and Pakistan Flour Mills Association (PFMA). Additional support to specific
analytical studies and evidence generation is being provided by GAIN and WFP. The FF Project
aims to achieve more than90% quality and sustained fortification of all wheat flour from roller
mills via support for:
 Establishing updated federal standards, provincial legislative mandates, regulatory

processes and other appropriate policy reforms.
 Building capacity for inspection and enforcement for appropriate provincial and district
29McKee, D, Pakistan What Flour Milling Profile World Grain, 2013

30It has been reported that milling for the feed industry, which is not subject to government grain policy, is more modern an
efficient than flour milling for human consumption.
31 Mysbah Balagamwala, Haris Gazdar, Agriculture and Nutrition in Pakistan: IDS Bulletin Volume 44 Number 3 May 2013 
16
11
government agencies.
 Developing fortification capacity at ~ 1000 roller mills including provision of start-up
equipment and temporary subsidies for fortificant premix.
 Intensive external quality assurance provided by Project staff with participation of
provincial/ local government personnel (modeled on modified USI Project
methodology).
 Developing domestic capacity to import or manufacture as well as distribute and supply
fortificant premix.
 Implementing an exit strategy targeting full transfer of financing for food control and
enforcement functions to relevant government authorities by the end of the Project
and a phased approach to transferring financing of fortification to individual mills.
3. Oil Fortification with Vitamin A and D

Estimates for average vegetable ghee consumption range considerable from 22.7 g/day to 52
g/day.32 Even at the lower-end estimate, fortification complying with federal standards (target
of 39,000 IU/kg vitamin A33) can deliver 39% of daily needs (RNI) for a woman of reproductive
age.34
Potential coverage of fortified oil/ ghee in the current market and industrial environment has
been extensively surveyed very recently and available data suggests that industry is sufficiently
centralized and technically proficient to cost-effectively implement the quality fortification
processes. The national supply of commercial cooking oil and ghee is produced by 100-120
processors refining from both domestic and imported oilseeds. Almost all the refined oil/ ghee
producers are members of the Pakistan Vanaspati Manufacturer’s Association (PVMA), an
industry association. The industry is geographically concentrated with more than 90% of the
national supply produced in just 13 districts, 40% in Karachi.35 Given long standing national
fortification standards, there is sufficient awareness of and capacity for fortification amongst
industry – but little compliance. A recent survey of member companies of PVMA found only
15% of producers with a dedicated blending vessel capable of fortification, 65% that claim to
fortify via batch process, and 20% with no fortification equipment at all.36 Nevertheless, building
capacity of 100-120 processors is considered technically feasible in the short term and not
requiring major investments in equipment and capacity or changes to ongoing industry business
models.

Fortification of edible oil and ghee was legislated at federal level in Pakistan in Pure Food Rules
from the year 1965. This legislation continues to apply to provincial food laws in post-18th
Amendment context, as Pure Food Rules were adapted by provinces long before devolution.
32
Pakistan Food Fortification Scoping Study, MQSUN Pakistan Food Fortification Study Team, 2014
33 Law provides a range of 33,000-45000 IU/g Vitamin A and 3,000-4,500 IU/g Vitamin D along with these specified “targets.”
34 Authors calculation based on 75% retention of added retinol palmitate
35 Authors calculation
36
National Institute of Food Science and Technology University of Agriculture Faisalabad, August 2014
12
17
However, penalties for non-compliance under these Pure Food Rules are left to discretion of
local authorities and not considered sufficient for strict enforcement. New standards
recommended by PSQCA and Punjab Food Authority will make it compulsory to add Vitamin D
as well as Vitamin A in oil and ghee. While no comprehensive data exists, most stakeholders
agree that under the current Pure Food Rules regulatory environment, very little oil and ghee
manufacturers comply with mandatory requirements. There is no documentation of inspection
or enforcement available at the point of production and a recent survey found very few samples
in compliance with levels specified by the standards.37 GAIN with USAID support is conducting
an assessment of Vitamin A and D levels in major brands in the country.
Therefore, while the mandatory legal mechanisms are technically in place, fully implementing
public communication, regulation and enforcement will require a full advocacy and capacity
building effort parallel to the effort required for more recently designated fortification food
vehicles like salt and wheat flour. However, most provincial nutrition strategies specify oil
fortification as an important nutrition intervention, providing a promising environment to
establish provincial mandates, elaborate regulations and protocols as well as building technical
and financial capacity of public agencies to enable enforcement of oil fortification mandates.
Along with wheat flour fortification, the 4 to 5-year DFID funded Food Fortification Project (FFP),
offers the opportunity to comprehensively address barriers to oil fortification with vitamin A
and D. The Project aims to achieve compliance with national standard of 33-45 thousand IU/g
Vitamin A and 3-4500 IU/g vitamin D in more than 90% of cooking oil and vegetable ghee
production from about 120 registered producers. The implementation strategies are parallel to
the flour fortification project with the exception of a narrower geographic target for industry
and no support for capital and other start-up expenses for industry.
37
IBID
18
13
III Scan of Opportunities and Barriers
A relatively favorable industry and market environment, maturing public policy and regulation,
along with a comprehensive and well financed portfolio of fortification projects, offers
opportunities to establish scaled-up wheat flour, oil/ghee and salt fortification over the next 4
to 5 years. While the promise is significant, establishing fortification will require significant
efforts by a range of stakeholders to address technical obstacles as well as to ensure transfer of
planning, implementation and financing to sustainable domestic sources/ public financing. The
analysis summarized in the table below is elaborated in the pages that follow.
Market and Industrial Environment: Opportunities Market and Industrial Environment: Barriers
 Lower coverage of less affluent and rural

 Feasibility of Wide Coverage and Protection
households.
 Geographic Concentration of Relevant
 Large number of enterprises
Industries.
 Capacity for import and distribution of fortificant
and other Inputs
 Some Industry Awareness and Capacity  Flour Milling Industry partially focus on Grain
Trading
 Potential Consumer Resistance
Public Policy Environment: Opportunities Public Policy Environment Barriers
 Remaining Clarification of Roles and Responsibilities

 National and Provincial Fortification Alliances
at national/ provincial level
 Maturing Provincial Policy Environment  Potential Non-Harmonized Regulatory Approaches
 Relevant Federal and Provincial Standards and  Technical Capacity of Provincial Food Control
Mandates Near Completion Authorities
 Import Duties and Fees Exempted (for all
 Remaining domestic GST other taxes
fortificants)
 Government Support via Public Purchases for  Provincial grain policy and subsidy schemes, and
wheat. controlled wheat flour prices.
Project Environment: Opportunities Project Environment: Barriers
 Mature, Coordinated and Well-Financed  Possible failure to Sustain Projects as National

Projects Program
 Sustainable financing and market availability of all
 Revolving Fund Established for KIO3
fortificants not established at target scale.
1a: Market and Industrial Environment: Opportunities
Industry & Market Environment Potential for Wide Coverage and Significant Protection:
Average consumption of oil, wheat flour and salt along with wide reach of larger scale food
industries considered capable of cost effective fortification, offers the promise of significant
population coverage and micronutrient protection. Under the current market and industrial
conditions, reaching current Project objectives for wheat flour, oil/ghee and salt will protect:
 ~ 170 million citizens with 39% of daily requirements (WHO RNI) for vitamin A and 31%
of WHO RNI for Vitamin D.
 ~ 170 million citizens with 90% of WHO RNI for Iodine.
14 19
 ~ 95 million citizens with 95% RNI for Vitamin B12, 68% of RNI for folic acid, 38% of RNI
for iron and 100% of RNI for zinc.38
At average consumption, the added per person annual costs of this nutrition protection are: ~
$0.01 per person per year for salt and oil and $0.24 per person per year for multiple
micronutrient fortification of wheat flour and hence, in total, representing increased consumer
food expenditures of 0.19% per person per year. 39
Response:
 Continue advocacy including a strong and concrete case for costs and benefits of
fortification.
 While there is general consensus among stakeholders on prevalence of micronutrient
deficiencies and the effectiveness of fortification in the Pakistani context, additional market
and industrial research may be necessary to:
o Determine the potential reach of fortified salt, wheat flour and oil key and at-risk
populations segments
o Better understand potential barriers the food industry may face in integrate
fortification technologies, producing consistent high quality fortified food, or
absorbing added fortification costs from the market place.
Projections for Nutrition Protection, Coverage and Cost

Average
Micronutrie Proposed Protection for Target Fortification
Consum
nt Standard Adult Woman Population Coverage Added Cost
ption
PPM g/day % WHO RNI40 % 180M # $/MT $/PP/Yr
Flour
Vitamin B12 0.008 95%
Folic Acid 1 68% ~100
300 50-60% $2.55 $0.24
Iron 15 38%41 million
Zinc 30 182%42
Oil/Ghee
Vitamin A 3943 39% 130
22 70% $1.82 $0.01
Vitamin D 4 31% million
Salt
30 (production)
Iodine 10 90% 90% 170 million $1.73 $0.01
15 (Household)
Geographic Concentration of the Relevant Industries:

Although building capacity, supplying and monitoring about 2600 industrial wheat flour roller
mills, oil/ ghee mills and salt producers, represents a considerable challenge, flour, oil and salt
enterprises in Pakistan are generally concentrated into relatively few districts (except for salt).44
38 Authors calculations based on parameters from Table above.

39 Based on Household Integrated Economic Survey, Pakistan Statistics Division Pakistan Bureau of Statistics Islamabad, 2015
40 Retention and other Assumptions: Vitamin B12 @95%; Folacin 90%; Iron and Zinc 99%; Vitamin A &D 75%; Iodine 90%.
41
For mid-bioavailability diet and adjusted by factor of 2.5 for higher Relative Bioavailability of NaFeEDTA
42 Mid-Bioavailability Diet
43 Average target within ranges for vitamin A and D specified by standards
44 About 2/3rd of the national salt supply is produced in Punjab with another 30% in KP and Sindh provinces. More than 90% of oil
production is from 13 districts mainly in Sindh. 85-90% of all roller milling is in 39 districts, including 28 in Punjab.
20
15
Clustering of food production facilities within province or even within a few districts enables
consolidated and cost-effective channels for capacity building, regulatory activities and supply
and other program logistics targeting the point of production. Current Project strategies
capitalize on this geographic concentration with a supply-side approach that focuses resources
on provinces and districts with high production volumes. While nationwide monitoring and
communication will be required for a successful fortification program, the lion’s share of effort
and expenditure can be targeted to high production districts – lowering costs and simplifying
implementation.
Response:
 Continue and expand the current project supply side focus in building capacity for both
industry and regulatory agencies, including additional/ continued market research to better
understand the concentration of industries and supply chains.
 A supply side focus requires participation of public agencies involved in regulating and
developing health, quality and safety as well as modernization, efficiency and financial
viability of domestic food industries. In Pakistan, multiple sectors are involved including
health, food, science & technology, industry, commerce and often independent inspection
agencies like PSQCA. While most are currently engaged in NFA, PFAs or other fortification
activities, the Ministry of Industry, the public agency responsible for supporting industrial
development and business registration of large-scale industry, is not fully engaged.
Administering the business registration process, usually including inspection of technical
capacity, can be a powerful tool to communicate fortification requirements to industry,
particularly when registration requirements include a working micro-feeder, inventory of
fortificant, or other documentation of fortification capacity (fortification capacity can be
included in HAACP). Registration may be particularly important to flour mills, because this
status is a prerequisite to qualify for subsidized grain.
Contributions of Past Programs to Industry Awareness and Capacity:

Based on past program activities including advocacy, capacity building, market trials and
commercial distribution, the industry awareness is widespread and consumer acceptability of
fortified products is well known. As the more mature USI Project continues to be evaluated,
interim indications of success may provide models for program implementation approaches in
the 5Year DFID financed Food Fortification Project (FFP), covering wheat flour and oil
fortification.
1b: Market and Industrial Environment: Barriers
Domestic Capacity for Sustained Distribution of Fortificant, Premix and other Inputs:
Supply and distribution of fortificant along with maintenance and replacement of feeders,
dosifiers and other technologies has yet to be sustainably transferred to domestic government
or business institutions. Currently, the USI Project has developed capacity of a private company
to undertake these functions for potassium iodate and necessary equipment. Experience
suggests that while larger producers can be successfully and sustainably supplied directly by the
private sector companies, supply to smaller producers requires special packaging, continued
16
21
government support in distribution and monitoring, and possibly continued support for quality
fortificant supplies and equipment maintenance.
While vitamin A/D fortificant mix has been purchased by importers/ distributors as well as large
scale individual oil refiners for decades (albeit not in sufficient quantity), sales and distribution
of bulkier and more expensive flour fortification premix have not yet been developed in the
private sector to cover the national needs. In addition, stakeholders are interested in the
potential for local mixing of micronutrients for wheat flour along with other value-added
functions (for example custom dilution or repackaging of premix for smaller producers).
Response:
 Undertake market research and business development activities to establish required
capacity building, market development support, potential business plans and necessary
government-industry partnerships for different fortificants.
 Another evaluation of current USI model to gain lessons, and if necessary consider other
models for supply of fortificant (KIO3).
Fortification reach into less affluent and rural households:

Current industrial and market structure suggests that oil, wheat flour and salt fortification may
offer substantial but not universal coverage or protection. Although household coverage has
substantially improved, but still ~30% of households are not protected by salt iodization –
presumably more rural and poor consumers who purchase salt from informal producers, the
sector that is least able to implement adequate fortification. While there is no official data on
the market share of larger and formal cooking oil/ghee refineries, an analysis made by the DFID
Food Fortification Project suggests that about 30% of consumption is from small scale informal
unregistered producers crushing from local oil seed, a product which is more likely to be
consumed by the rural poor.45 With an estimated 40% of the flour supply from small-scale mills
(chakkis), particularly in rural areas, proven, effective and sustainable strategies for wheat flour
fortification are not available for about 40% of the population who consume flour from chakki
mills. In summary, current understanding of industry structure has enabled current flour, oil
and salt fortification projects to establish the following coverage objectives:
 As customary for USI programs, Iodized salt program has established the 90% coverage
target.
 Oil fortification projects to target ~ 70% coverage.
 Flour fortification targets 60% coverage, the proportion of national supply produced by
Pakistan’s roller millers.
This incomplete and often inequitable coverage of oil & ghee and wheat flour fortification limits
potential public health benefits – and securing full political support for fortification will require
approaches for addressing the needs of these high-risk populations.
45
DFID Food Fortification Project, Project Documents
22 17
Response:
 Communication to underscore the high prevalence of micronutrient deficiencies not only
among the rural poor but also among urban and some higher income consumers who will
benefit from full implementation of proven fortification strategies. It is important for
stakeholders and policy makers to understand that unlike many other health and nutrition
indicators where the burden falls disproportionately on the rural and the poor, prevalence
of micronutrient deficiencies is relatively evenly distributed among urban and rural
populations, as illustrated in the chart below as well as all wealth quintiles.
 Undertake surveys to better define population who consume from small informal oil
crushers or chakki mills to define: size and geography of these consumers; market and
industrial trends that might shift market shares between larger and smaller producers; and
how they might be targeted through an expanded fortification program in the future.
 Advocacy to develop and/or sustain a more comprehensive portfolio of interventions to

address micronutrient deficiencies – especially targeting consumers who cannot access
fortified flour, including:
o Multiple micronutrient powders targeting children and pregnant women delivered
via public health programs or via developing a private market.
o Expand scope and quality of iron and folic acid supplementation for pregnant and
lactating women. Only about half of pregnant women in the lowest income quintile
receive antenatal care– and less than half are provided with iron syrup or
supplements.46
o Expand current SAM and MAM program distributions of RUTF and RUSF for
distribution to pregnant women and young children, particularly in high-risk areas
that cannot access fortified products.
o Continue research into bio fortification of grains, rice fortification and other
potential fortification vehicles like milk, sugar, complementary foods and other
industrially processed foods.
o Explore potential role of double fortified salt in areas with limited access to iron-
fortified flour.
o Expand access of fortified wheat flour from roller mills to rural consumers’ areas
via market as well as public distribution channels.47
o Undertaking much needed basic and operational research to develop evidence
base for effective and sustained chakki fortification.
Most options listed above require additional development and significant financing. All face
much more significant technical and market barriers to wide coverage and effective protection
than the large-scale fortification of salt, wheat flour and oil. While options should be developed
for any number of reasons, fortification programmers should ‘keep an eye on the prize.’
46Pakistan Demographic and Health Survey 2012-13. National Institute of Population Studies and ICF International. 2013.
47Fortified roller mill flour is typically less expensive than small scale chakki flour and therefore has competitive advantage in
addition to health benefits. However, Public communication and support to expand markets for less expensive roller mill has not
been considered as a feasible option given the livelihood threats to small chakki industry this is not considered a feasible option.
18 23
National, Urban and Rural Prevalence of
Selected Micronutrient Deficiencies (NNS 2011)
Zinc
Women
Vitamin A
IDD
Children
All Anemia
VAD
0 10 20 30 40 50 60 70 80 90 100
Rural Urban National %
Industry Capacity and Focus on Grain Trading as Opposed to Milling:

Government grain policy including grain subsidies and ceiling price for flour encourages the
milling industry to emphasize grain procurement and sales as a major profit center – at the
expense of investing in improved milling or expanded wheat flour markets. Consequently, there
are few investments in mill centralization, improved technology or higher quality products –
and technical capacity is variable. As a result, mills are less prepared or motivated to introduce
new technical processes like fortification - and less enabled to pass along the costs of
fortification.
Response:
 Intensive supply side capacity building for fortification in the short and medium term. This
is going to be targeted by FFP.
 Advocacy for public policy reform to motivate millers to focus on milling, including
incentives on over-all industry modernization for the medium and long term.
Reports of Consumer Resistance:

The marketing literature offers little evidence that consumer demand can “pull” fortification
and influence producers to fortify staple or common foods like flour, oil or salt. However,
consumers can actively reject and undermine a fortification program, particularly when
alternatives or substitutes are available, like chakki flour and rice. There have been several
reports in Pakistan regarding consumer rejection of iodized salt along with over-all suspicion of
‘foreign agenda or family planning’. A recent report suggested that possibly 40% of consumers
actively seek options to iodized salt: “Avoidance of iodine tends to be most common in certain
rural and specific ethnic areas where illiteracy rates are high…. but it reaches across the
nation.”48
Response:
 Research and communications planning to better understand these objections and design
approaches to ensure that at least consumer acceptance or non-rejection (as distinct from
creating positive consumer demand and awareness).
48
Pakistan's mistrust of iodised salt is aggravating a deeper health crisis, The Guardian, Jan 15, 2013
24
19
2a: Public Policy Environment-Opportunities
National and Provincial Fortification Alliances:

As malnutrition represents the failure of multiple sectors, solutions to improve nutrition will
involve multiple sectors. Global evidence suggests that national programs that succeeded in
sustainably reducing malnutrition, utilized a centralized convening body or structure to create
a multi-sectoral nutrition coalition which: secured political commitment, coordinated agency
roles, provided channels of communication and capacity building, and mainstreamed nutrition
indicators in sectoral planning and budgeting.49 In Pakistan, the National Fortification Alliance
(NFA), constituted by the MoNHSR&C, represents a convening structure that provides the
required ‘structural space and authority for coordinating’ across relevant sectors as well as
provinces. The NFA is also a participant in the national Scaling Up Nutrition (SUN) movement
and works to integrate fortification activities as well as micronutrient indicators into the over-
all SUN framework.
The NFA is platform for communication and joint decision making among government agencies
at all levels as well as with private sector, academia and research institutions, development
partners and donors. Along with Provincial Fortification Alliances (PFAs), the NFA works to
leverage high-level commitment coordinate planning and capacity building activities across
relevant federal and provincial agencies, and mainstream fortification into the federal as well
as provincial planning and budgeting process. In the post 18th Amendment context, which
devolves primary responsibility for implementation of fortification programs to the provincial
level, the NFA with its provincial arms PFAs, provide a critical communications channel to
harmonize provincial policies, regulations, enforcement and other activities.
Response:
 Communicate key role of NFA and PFAs to all relevant stakeholders, including advocacy and
support to PFAs.
 Ensure full participation in NFA of all relevant agencies and sectors.

 Strengthen linkages between NFA and PFAs and among PFAs and provincial line
departments to build coordination for uniformity and harmony of policies and regulations.
 Build capacity of NFA (& PFAs) and develop regular and sustainable annual budgets for NFA.
Maturing Public Policy Environment: Largely In Place

Implementation roles and responsibilities for food fortification in the Post 18th Amendment
environment are evolving and being clarified. Stakeholders agree that the essential role of
federal agencies is to provide policy guidance, technical support and capacity building. In all
provinces nutrition policies specifying fortification as an essential nutrition intervention have
been published. Provincial policy and regulatory portfolio for fortification will be completed in
the near term. While in different phases of completion, advocacy and development of legal and
regulatory instruments is ongoing in the provinces.
49Andrés Mejía Acosta, Jessica Fanzo Fighting Maternal and Child Malnutrition: Analysing the political and institutional
determinants of delivering a national multisectoral response in six countries Institute of Development Studies, 2012
20 25
Response:
 Work to support and complete the provincial policy and regulatory portfolio.
 The NFA should develop a clear National Fortification Strategy and conduct
communications and capacity building to ensure completion and harmonization of
provincial policy that reflects appropriate global best practices.
 Provincial fortification strategies should also be developed taking the overall guidance from
national fortification strategy but incorporating the province specific needs and scenarios
as well as structures in place.
Maturing Regulatory Environment: Largely In Place

Federal government has outlined clear specifications for fortified products (See Table 1):
 Fortification of oil with vitamin A is mandated via National and Provincial Pure Food
Rules 1965, which technically continues to apply to provincial regulations with regular
amendments as required. Recent amendments by PSQCA and Punjab Pure Food Rules
also added Vitamin D as mandatory micronutrient to be added in Oil & Ghee.
 Iodization of salt is mandated via mix of federal legislated mandate and Pure Food
Rules. In addition, provinces are moving ahead with the provincial legislation on
mandatory USI.
 A wheat flour fortification profile including iron, folic acid, zinc and Vitamin B12 that
was finalized by NFA and recommended to all national and provincial regulatory bodies,
has been adopted by PQSCA and is in final stages of adoption by Punjab Food Authority.
While the regulatory instruments are nearing completion (though at different stage in different
provinces), elaboration into clear processes and protocols to enable effective and transparent
enforcement remains a challenge.
Response:
 National Fortification Alliance and participating federal agencies should work in
coordination with PFAs to support and complete the provincial regulatory portfolio to
ensure these incorporate technical best practices and are harmonized amongst the
provinces and regions.
 Wherever possible, integrate fortification roles and responsibilities along with processes,
protocols and budgets into developing capacities of provincial Food Authorities and other
Regulatory Bodies/ Departments.
Taxes and Tariffs and Lowering Industrial Costs of Fortification:

While modest and affordable, passing along the full costs of fortification to the private food
market place remains a challenge. Taxes and duties can significantly increase the scale of this
challenge. Federal government has recently exempted imported vitamin and mineral premixes
(including KIO3, imported fortificant A&D mix for oil fortification or flour fortification premix)
from all import duties and related taxes and service fees lowering the domestic cost of
fortification by ~26 to 40%. However, domestic sale of fortificants, including transactions from
26 21
distributor to food producer remains subject to a 16% General Sales tax (GST) “chargeable on
all locally produced and imported goods…. traded amongst Manufacturing, Import, Service,
Distribution, Wholesale & Retail stage.” 50 Work remains on exemption of taxes and duties on
imported hardware inputs to fortification including of micro-feeders and QA/QC equipment.
Response:
 Develop case to exempt all fortified staple foods protecting populations at risk from
domestic GST and other taxes. Current exemptions include: computer software, poultry
feeds, medicines and unprocessed domestic agricultural produce.
 While it may be difficult to remove GST on consumer or retail sales of flour and oil given the
huge revenue involved at the very least exempting transactions of fortificant along the
supply chain represents a government commitment to fortification and an investment
enabling the market to absorb the remaining cost of fortification.
Government Financial and Program Support via Public Purchases:

Public purchases of fortified commodities – along with quality control of those purchases – can
provide added volume and revenue for producers besides offering incentives to develop
capacity and compliance with quality standards. This includes food security programs,
conditional and non-conditional food transfers, linking cash transfers under social protection
schemes to purchase of fortified food, and other food distributions to qualifying high-risk
populations. There are a number of opportunities in Pakistan including: national programs like
BISP, ZAKAT, Bait-ul-Mal, Social Welfare and a range of local programs implemented by
government agencies, political and welfare parties and private philanthropies (sasti roti, or
cheap bread and sarkari kitchen, or state run kitchen programs).51
Response:
 NFA along with PFAs should develop close coordination with national and provincial
nutrition, social protection and food security programs and advocate targeted public
distributions of fortified foods to high-risk populations include domestically produced
fortified foods in their ‘food baskets.’
2b: Public Policy Environment Barriers
Remaining Clarification of Authority and Coordination in Post 18th Amendment

Environment:
There are continuing reports suggesting that “the administrative structure is still trying to catch
up with devolution.”52 While the task itself may be modest, fortification presents an additional
coordination burden as it requires engagement of stakeholders across bureaucratic silos
spanning federal and provincial government, multiple agencies within government sectors, and
across public and private sector. Some examples for over-lapping mandates and capacities for
food control activity include:
50 Federal Revenue Boardhttp://www.fbr.gov.pk/OfficeHomePage.aspx?view=Office%20Home%20Page&ActionID=39&ArticleID=130

51 Zaidi, S., S. K. Mohmand, Z. Bhutta, and A. M. Acosta. The Political Economy of Undernutrition in Pakistan. DFID-MQSUN: 2013
52 Levinson Engaging Development Partners in Efforts to Reverse Malnutrition Trends in Pakistan IDS Bulletin Volume 44 May
2013 
22
27
 PSQCA has clear mandate to develop product standards while provincial government is
technically free to establish their own rules. PSQCA also has an enforcement function, but
in practice, has limited capacity and tends to focus on registered companies and value-
added products rather than common and staple fortification food vehicles (with the
exception of some retail consumer packs of salt and oil/ghee.
 Ministry of Industry (MOI) annually inspects and registers almost all flour and oil producers
as well as some of the larger salt producers. An integral fortification partner in many
countries, MOI in Pakistan is not fully engaged as a channel to build industry capacity and
to monitor fortification performance.
 District health offices have been integrally involved in salt iodization. The DFID funded Food
Fortification Project (FFP) plans to capitalize on this model of collaboration between project
office and food control authorities at province and district level. However, the longer-term
trend for food control seems to favor Provincial Food Authority undertaking regulatory and
inspection functions. This transition is ongoing and timetables for establishing food
authorities in all provinces are not consistent.
 While MoNHSR&C includes an independent agency to enforce drug safety and quality
(DRAP), there is currently no parallel agency for food quality and safety, as is common in
many countries (like FDA in US). However, such an agency may be proposed and could play
and active role at a future date.
In addition, some reports suggest low provincial “buy-in” for an active federal role within the
context of devolution and provincial autonomy: “The preferred role for the federal platform is
coordination rather than policy steering or monitoring.” 53 However, federal agencies have
important mandates and capacities and other ‘value-added functions’ for food fortification.
Response:
 NFA redouble efforts to communicate division of responsibilities amongst federal and
provincial agencies besides delivering necessary federal inputs under 18th Amendment that
include: overall policy guidance, capacity building and harmonization of policy and
regulatory framework among provinces and regions.
 Food Fortification Project (FFP) will need to balance immediate opportunities to establish
fortification with current partners and capacities on the ground while simultaneously
developing capacity longer term and sustainable environment – which may, but is not yet,
be fully in place.
 NFA should coordinate communications of federal agency members, both individually and
via PFAs, to communicate the value-added of federal agencies to provincial government
counterparts. Consensus documents, possibly intra-governmental MOUs should outline
the optimal roles and responsibilities and commitments of federal and provincial agencies.
Capacity of Provincial Level Food Quality and Safety Functions:

Although provincial governments have long been responsible for service delivery in the health
53
B Zaidi, S., S. K. Mohmand, Z. Bhutta, and A. M. Acosta The Political Economy of Undernutrition in Pakistan. DFID-MQSUN, 2013
28 23
and other social sector programs, they have had little experience with and capacity for strategic
planning and coordination across sectors required for nutrition and fortification.54 For example,
“While the provincial Inter-sectoral Nutrition Strategies have been approved, they do not
provide details on coordination and implementation structures.” 55 Currently, most of the
provinces have placed the coordination structure for these multi-sectoral nutrition strategies in
P&D departments to reinforce cross-sectoral linkages. Fortification represents new area of
activity and therefore, full implementation of regulatory mandates will require a new set of
technical skills including: inspection of producers, sampling of flour, oil and salt, food analysis
to determine levels of fortification both on-site and in government laboratories and reporting
and communication protocols both within government agencies and to private sector
producers. As with all government functions, the foundation of regulatory sustained regulatory
capacity is built on mechanisms to ensure transparency and accountability.
Response:
 NFA along with federal agencies and donors along with and through PFAs, should
communicate national technical guidelines including required technical protocols,
processes and reporting to guide all phases of inspection and enforcement.
 NFA and PFAs along with federal agencies and donors should develop and coordinate
comprehensive program to build capacity of relevant provincial agencies for inspection,
sampling and food analysis as well as reporting, enforcement and communication. These
activities are often best integrated into over-all capacity building for provincial food control
agencies – and development of provincial food authorities.
 Technical guidelines and protocols should recognize both limited capacity and legitimate
competing priorities of provincial food control agencies and personnel. Consequently,
guidelines and capacity building should balance best practices of food science with
feasibility, simplicity and affordability. The objective is to create credible deterrent capacity
to motivate compliance of producers. In general, food control agencies often aim for an
extremely rigorous enforcement regime because for many foods, poor quality may threaten
immediate consumer health and safety, and often generate high levels of negative publicity.
Although mandated by law and critical to public health, failure to comply with fortification
standards does not represent such as an immediate threat to health and safety of
consumers.
Need for reforms to provincial grain policy and subsidy schemes:

As a consequence of current government grain policy including subsidized distribution and
ceiling prices for milled flour, it is virtually impossible to pass along the modest $2-3/MT
incremental cost of flour fortification to traders, wholesalers and to the market place without
the consent and approval of the provincial governments. In the absence of government subsidy
for the premix itself, there is no way to finance this incremental cost – other than the miller
taking on fortification as an expense with no promise of reimbursement or return on
investment. Inability to pass along costs bodes ill for miller compliance with fortification
54 Levinson Engaging Development Partners in Efforts to Reverse Malnutrition Trends in Pakistan IDS Bulletin Volume 44 May
2013 
55
B Zaidi, S., S. K. Mohmand, Z. Bhutta, and A. M. Acosta The Political Economy of Undernutrition in Pakistan. DFID-MQSUN, 2013
24 29
regulations. Currently the Punjab Government has agreed in principle to pass on the
incremental cost of wheat flour fortification to the consumers, although the specific
mechanisms have yet to be clarified.
Response:
 In the short term, NFA and PFAs should support provinces in developing mechanisms to
include cost of fortification in the official ceiling price of flour or develop other short-term
support mechanisms to defray the $2-3/MT cost.
 For long term, NFA and PFAs should participate as a stakeholder in over-all discussions
governing government grain policy to ensure fortification-friendly reform.
3a: Project Environment: Opportunities
Mature, Coordinated and Well-Financed Project Environment:

Currently DFID funded Food Fortification Project (FFP) has secured considerable technical and
financial resources and laid down ambitious objectives to establish and sustain wheat flour and
Oil/ghee fortification programs. Past programs have raised awareness, developed some
capacity, provided experience and lessons learned, and opened channels to most relevant
stakeholders including: federal, provincial and district government, public agencies and private
sector and suppliers and donors as well as academic and research community and consumers.
The USI Project has built capacity throughout industry and government and is currently working
to implement an exit strategy aiming to transfer implementation and financing to domestic
sources. Building on lessons learned in the USI Project, a well-funded Flour and Oil Fortification
Project, FFP is targeting full program scale implementation and sustainably transferring all
financing within 4 to 5 years. Common approaches among wheat flour, oil and salt fortification
Projects include:
 Implementation Approaches
o Coordination, communication and harmonization via multi-sectoral platforms, NFA
and PFA.
o Advocacy, capacity building and other support activities segmented for evolving
roles of federal, provincial and often district government roles.
o Supply side communication and support channels developed for industry both at
individual enterprise level as well as via industry trade associations.
o A ‘learning while doing’ approach where Project staff, which conduct external
quality assurance as they mentor government officers to eventually assume
regulatory functions.
 Project Strategies
o Supply side emphasis focusing industry capacity building, internal quality control
and financial support - including temporary subsidies on fortificant.
o Targeting of external monitoring, regulation and enforcement functions to
provinces and districts where production is concentrated.
30
25
o Developing domestic capacity for import and distribution of fortificants and
premixes to ensure consistent supply, lower costs and develop new business
stakeholders.
 Exit Strategy
o Phased transfer of intensive external monitoring functions led by Project staff to
less intense but credible and affordable monitoring by government.
o Advocacy from the outset aiming to regularize annual public financing for
monitoring and other public oversight activities.
o Revolving fund for industry fortificant purchases, enabling a planned gradual phase
out of subsidies over the project period.
o Facilitating the development of an open market system of import, distribution and
supply of fortificant, which is market driven as included in the DFID funded FFP.
3b: Project Environment: Barriers
History:-Failure of Donor supported Projects to be sustained as National Programs:

There is a well-documented history of failure to scale-up, finance and sustain a range of donor-
driven health and nutrition projects. This includes early salt iodization efforts prior to 2006
along with donor-driven flour fortification efforts supported by WHO/EMRO, GAIN, WFP, MI
and others, which may have achieved their short-term fortified production and other process
objectives but were largely not sustained beyond the project period. While these projects
contributed to higher awareness and built capacity of the government as well as of industry,
this was not sufficient for fortification to continue as donor support was withdrawn.
The current achievement in salt iodization is based on intensive technical and financial inputs
from The MI, WFP and GAIN along with significant efforts by government national, provincial
and district departments and regulatory bodies. Now the MI and WFP are not able to sustain
the level of effort they have put in and are working to implement their exit strategies via
building capacity for government monitoring and supervision, existing well established
revolving fund, domestic distribution of fortificants and other inputs. Exit strategies planned by
FFP (the flour and oil Project) are based on current USI Project approaches.
Response:
 Efforts to build capacity, implement fortification and protect current population at-risk
need to be balanced with consistent advocacy to influence ongoing policy and budget
structures both at the federal and provincial level.
 Technical guidelines and subsequent capacity building efforts should focus on feasible,
affordable and cost efficient protocols - not perfection.
 FFP and other fortification projects should continually update plans and timetables for
transfer of financing – and hold domestic counterparts accountable.
 Donor investments should be benchmarked to domestic uptake of Project activity,
developing regular annual budgeting process for government regulation and enforcement,
26
31
and assuming targeted domestic share of financing.
 Solid and transparent program evaluations with clear evidence of program success and
national impact and benefit should increase likelihood of evolving current Projects into
sustained national programs.
Withdrawal of Subsidies Modeled on USI Program:

Based on the ongoing USI Project exit strategy, the current large scale oil and flour fortification
Project relies on a strategy of gradually phasing-out subsidies – which can be facilitated by
support to a revolving fund for the recurring cost of fortificants, especially for smaller
producers. The USI Project revolving fund, which provides the model for the current DFID-4-5
year FFP, has been evaluated and found to be effective and sustainable under a public-private
monitoring body, NFA. However, iodization was found to decrease significantly during the
period of financial transition (subsidy withdrawal). Moreover, the national cost of premix for
flour fortification, and to a lesser extent oil fortification, will be considerably higher than for salt
iodization. An options analysis of premix distribution in Pakistan is being conducted by GAIN
and will inform the work of all partners. New models for achieving full financial sustainability
may be required, including different strategies reflecting the range of financial capacities from
large to small producers.
Response:
 Ensure key indicators of revolving fund are regularly reported, communicated to
appropriate stakeholders and that NFA continuously provides a platform to discuss results,
develop lessons learned and propose new approaches as needed.
32 27
IV. Strategy Framework: Goals, Objectives, Outcomes, and Outputs
Scope of National Food Fortification Strategy:

Food fortification is a multi-sectoral enterprise requiring participation of multiple government
agencies across food, health, commerce and trade and other departments; private industrial
enterprises and trade associations; academic, health and industrial research institutions; and
media and other visible champions to assist in securing both high level political support as well
as consumer acceptance of fortified products. In Pakistan, this wide-ranging multi-stakeholder
environment is complicated by devolution of most governance and implementation
responsibilities for health and nutrition, food quality and safety and industrial development
activities to the provincial level. With wide discretion allowed to provincial food policy and
regulation, harmonization of province-level activities is particularly important to ensure
awareness and adoption of fortification best practices by provincial governments as well as to
assure implementation is harmonized and supports unencumbered national commerce and
trade in fortified salt, oil and wheat flour.
In the current context, the essential role of federal agencies is to provide policy guidance,
technical support, tax and financing support as well as nation-wide monitoring, surveillance and
communications. The organizational channel for this federal role is the National Fortification
Alliance (NFA) notified and convened by the Ministry of National Health Services, Regulations
& Coordination (MoNHSR&C). NFA membership includes:
 Government Sector including: MoNHSR&C Nutrition and related health programs;

Ministry of Planning, Development & Reforms, Ministry of Science & Technology
including Pakistan Standards & Quality Control Agency; Ministry of Industry; Ministry of
Food Security & Research; Ministry of Finance including Customs department and
Federal Board of Revenue (FBR); representatives of provincial governments including
multi-sectoral Provincial Fortification Alliances.
 Food Industry Sector including: Pakistan Flour Mills Association (PFMA) and 4 provincial
chapters; Pakistan Vanaspati Manufacturer’s Association (PVMA); Salt Processors’
Association and interested individual producers.
 Research and Academic Institutions including: National Institute of Food Science and
Technology (NIFSAT), University of Agriculture, Faisalabad; Nuclear Institute of Food
and Agriculture (NIFA), Peshawar; Department of Human Nutrition, University of
veterinary and Animal Sciences (UVAS), Lahore and others.
 International Partners including donors and NGOs responsible for administration of

current oil, flour and salt fortification Projects: DFID, AusAID, WFP, UNICEF, WHO, MI,
GAIN, FFP.
The NFA opens multiple channels for communication and collaboration including: national-
international, federal-provincial, intra-government agencies, and public-private sector. These
functions are critical to ensure effective and harmonized provincial policies, regulation and
enforcement. While some concerns and ambiguities remain regarding the optimal federal role
28 33
to support fortification, consultations among federal and provincial governments will address
these issues and, where required, make appropriate changes in institutional structures.
Federal agencies have important mandates, capacities, efficiencies of scale and other ‘value-
added’ contributions to make, including providing national capacity for:
 Product standards consistent with global best practice and national context.
 Harmonization of standards and protocols to achieve efficiencies of scale and to ensure

open trade and commerce.
 Expert federal technical and support agencies offering food science capacities,
laboratory services, industrial development, monitoring and other expertise.
 Tax and Tariff Policy along with customs services for imported inputs to fortification.
 National statistics and monitoring agencies to document national scope of external

quality assurance, distribution and impact of fortified products.
 National media communications and public education to marshal political will and to
inform consumers via national broadcast and other channels.
 Platform for capacity building, information sharing and collaboration to enhance
provincial policy, planning and implementation.
This federal ‘value added’ should be fully developed and communicated from NFA and its
member federal agencies to PFAs, provincial governments and appropriate provincial agencies.
National Food Fortification Strategy
Goals:
 Create enabling national environment for sustained salt, wheat flour and oil
fortification programs implemented by private sector and public agencies and
departments within various provinces.
Objective:
 Support ongoing USI, flour and oil fortification Projects to achieve their 5-Year policy
regulatory, coverage, quality and financial sustainability objectives including:
o 90% national coverage of iodized salt
o 70% national coverage of fortified oil and ghee
o 50% national coverage of fortified wheat flour
Outcomes:
1. Enabling Public Policy & Regulatory Environment Established
2. Provinces with Capacity for Food Control Inspection and Enforcement
3. Food Industry Aware, Equipped and Trained for Implementation
4. Available Supply of Affordable High Quality Fortificants and Other Inputs
5. National Surveillance, Monitoring & Evaluation Systems in Place
6. Options Developed for Populations who cannot Access Fortified Flour, Oil and Salt
34
29
7. Strengthening NFA/Functioning Platform for Multi Sectoral Advocacy, Communications
& Public Education
Outcome 1: Enabling Public Policy & Regulatory Environment Established

Outputs:
 Review and develop standards for imported fortificants and other inputs.
 Review and promulgate normative documents including product fortification standards.
 Support to provincial governments to establish mandatory legal mechanisms for
fortification and advocacy for harmonization across provinces.
 Develop national technical dossier (Fortification Manual) including regulatory protocols,
inspection guidelines, sampling and analytical methods and other guidance for inspection
and enforcement.
 Facilitate/Coordinate provincial dialogue on reforming grain policy and subsidies and other
policies that may present barrier to sustaining and expanding fortification.
 Sustain and expand tax and tariff exemptions and other federal financial incentives for
fortified products as appropriate.
 Advocate purchase and distribution of fortified foods to national food security and social
protection programs, including purchases by relief agencies for import.
Outcome 2: Provinces with Capacity for Food Control Inspection and Enforcement
Outputs:
 Support federal technical agencies to fully achieve their potential role in building capacity,
monitoring and program support of provincial agencies.
 Support efforts of fortification Projects, donors and federal agencies to build technical,
analytical and enforcement capacity of provincial food control agencies.
 Ensure capacity of national food laboratories (at PSQCA, PCSIR) to harmonize and augment
provincial food laboratory analysis.56
 Coordinate advocacy from federal level agencies and other stakeholders to provincial
government aiming to standardize and integrate fortification into over-all food control
structure, activities and annual budgets.
 Undertake special research and development to support and inform challenges to ongoing
salt, flour and oil fortification Projects.
Outcome 3: Food Industry: Aware, Equipped and Trained for Implementation

Outputs:
 Collaborate with salt, flour and oil Projects to develop training programs and materials.
 Advocate to federal industrial development agencies to define optimum fortification role
including investments in industry modernization and market development.
 Build capacity of relevant industry and trade associations to communicate program
messages and provide other fortification related services.
 Undertake special market and industry research to address obstacles and inform ongoing
salt, flour and oil fortification Projects.
56
As reference labs, back-up labs or other support functions
30 35
Outcome 4: Available Supply of Affordable High Quality Fortificants and Other Inputs
Outputs:
 Develop capacity of private companies or public-private partnerships for sustained and
cost-efficient and possibly centralized import, distribution and finance of fortificants to
producers.
 Explore feasibility57, and if deemed cost-effective and sustainable, develop opportunities
for domestic private sector to manufacture, mix, repackage or otherwise add value to
fortificants and other inputs to fortification.
 Develop capacity of private companies or public-private partnerships for sustained
equipment maintenance and/or replacement of fortification hardware.
Outcome 5: National Surveillance, Monitoring & Evaluation Systems in Place

Outputs:
 Coordinate national technical institutions in developing comprehensive approach to
national level surveillance and monitoring of health, nutrition, industrial and other
fortification program indicators.
o Coordinate with agencies regulating food industry and commerce to compile
database on volumes fortified commodities produced; import, sales and
distribution of fortificant mix; and other relevant trade and commerce indicators.
o Compile provincial food control and inspection data to create national database
documenting national compliance and quality of fortified products.
o Coordinate with relevant federal statistical agencies to include fortification
program indicators in surveys such as NNS, DHS, MICS, HIES or other routine or
special national data gathering exercises.
o Support establishing National Birth Defect registry to track Spina Bifida,
anencephaly and other birth defects to monitor impact of folic acid fortification.
o As needed, mobilize resources and capacity to conduct national surveys on relevant
biochemical and other nutrition and health impact indicators.
 Support monitoring and evaluation conducted by salt, oil and flour fortification Projects.
 Convene periodic national and inter-provincial reviews aiming to develop and disseminate
comprehensive monitoring national data, share provincial experiences and lessons learned,
and recommend ways to address obstacles and improve provincial implementation.
Outcome 6: Options for Populations who cannot Access Fortified Flour, Oil and Salt
Outputs:
 Develop research opportunities to address special needs of rural, poor and high-risk
consumers who cannot regularly access fortified foods. Options include:
o Consider new fortification food vehicles including rice, iron-iodine-fortified salt.
o Develop commercial markets for RUSF and/or fortified complementary foods.
o Support for development and potential scale-up of bio-fortified crops.
o Develop public and/or commercial potential of Multiple Micronutrient Powders.
57
Business development studies for fortification support industries including premix and fortificant production, procurement
and/or distribution; manufacturing and maintenance of dosifiers and other process equipment.
36 31
o Coordinate with public health agency to target pharmaceutical supplementation
and nutrition education to areas where fortified products and not distributed.
o While national scale-up may not be possible, assess potential feasibility for chakki
fortification in specific markets and consider piloting chakki flour fortification to
assess feasibility and possibilities of scale up.
Outcome 7: Strengthening NFA: Platform for Multi Sectoral Advocacy, Communications

and Public Education
Outputs:
 Provide opportunities for implementing stakeholders to review program experience, share
knowledge and lessons learned.
 Coordination of advocacy to Finance Ministry and other agencies for inclusion of
fortification related activities in regular annual budget process.
 Coordination and facilitation of resource mobilization targeting international donors.
 As required, develop national level communications including:
o Advocacy to provincial political and business leaders;
o Mass public education via national media and other channels when appropriate and
cost-efficient;
o Other activities that may be more effective or affordable when implemented from
federal level.
 Advocacy to MoNHSR&C to develop regular sustained domestic financing for NFA to
support appropriate mix of dedicated NFA staff and empowered focal points within
appropriate agencies with accountability to the NFA. A parallel process of advocacy should
be conducted to secure support and financing of PFAs by Provincial governments.
32 37
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Ministry Logo, WFP Logo, NFA Logo

National Fortification Alliance

Dr. Baseer Achakzai

Ministry of National Health Services, Regulations & Coordination (MoNHSR&C) acknowledges

Ministry of National Health Services, Regulations & Coordination (MoNHSR&C) acknowledges

NFA: National Fortification Alliance

Food fortification is a multi-sectoral enterprise requiring participation of multiple government

Human and Economic Impact of Vitamin and Mineral Deficiencies in Pakistan:

 While documentation is available for decades of fortification, most recently, a national

 Consumption is widespread and sufficient to deliver significant nutrition protection to

hemoglobin concentrations in women and children1–5. Am J Clin Nutr 2015:101(1):210-7.

Market and Industry Environment:

Public Policy and Regulatory Environment:

18 National Nutrition Survey Report, Government of Pakistan 2001

2. Wheat Flour Fortification with Multiple Vitamins and Minerals

Market and Industry Environment:

Public Policy and Regulatory Environment:

The full spectrum of provincial mandates, necessary in decentralized post-18th Amendment

 Establishing updated federal standards, provincial legislative mandates, regulatory

29McKee, D, Pakistan What Flour Milling Profile World Grain, 2013

3. Oil Fortification with Vitamin A and D

Market and Industry Environment:

Public Policy and Regulatory Environment:

 Lower coverage of less affluent and rural

Public Policy Environment: Opportunities Public Policy Environment Barriers

 Remaining Clarification of Roles and Responsibilities

Project Environment: Opportunities Project Environment: Barriers

 Mature, Coordinated and Well-Financed  Possible failure to Sustain Projects as National

1a: Market and Industrial Environment: Opportunities

Projections for Nutrition Protection, Coverage and Cost

Geographic Concentration of the Relevant Industries:

38 Authors calculations based on parameters from Table above.

Contributions of Past Programs to Industry Awareness and Capacity:

1b: Market and Industrial Environment: Barriers

Fortification reach into less affluent and rural households:

 Advocacy to develop and/or sustain a more comprehensive portfolio of interventions to

Industry Capacity and Focus on Grain Trading as Opposed to Milling:

Reports of Consumer Resistance:

National and Provincial Fortification Alliances:

 Ensure full participation in NFA of all relevant agencies and sectors.

Maturing Public Policy Environment: Largely In Place

Maturing Regulatory Environment: Largely In Place

Taxes and Tariffs and Lowering Industrial Costs of Fortification:

Government Financial and Program Support via Public Purchases:

2b: Public Policy Environment Barriers

Remaining Clarification of Authority and Coordination in Post 18th Amendment

50 Federal Revenue Boardhttp://www.fbr.gov.pk/OfficeHomePage.aspx?view=Office%20Home%20Page&ActionID=39&ArticleID=130

Capacity of Provincial Level Food Quality and Safety Functions:

Need for reforms to provincial grain policy and subsidy schemes:

3a: Project Environment: Opportunities

Mature, Coordinated and Well-Financed Project Environment:

3b: Project Environment: Barriers

History:-Failure of Donor supported Projects to be sustained as National Programs:

Withdrawal of Subsidies Modeled on USI Program:

Scope of National Food Fortification Strategy:

 Government Sector including: MoNHSR&C Nutrition and related health programs;

 International Partners including donors and NGOs responsible for administration of

 Harmonization of standards and protocols to achieve efficiencies of scale and to ensure

 National statistics and monitoring agencies to document national scope of external

National Food Fortification Strategy

Outcome 1: Enabling Public Policy & Regulatory Environment Established

Outcome 3: Food Industry: Aware, Equipped and Trained for Implementation

Outcome 5: National Surveillance, Monitoring & Evaluation Systems in Place