Mandana Arabi, MD, PhD, and Luz Maria De-Regil, Unit Head, Multisectoral Action in Food Systems, World Health Organization.

With the UN Food Systems Summit and Nutrition for Growth both on the horizon, this year offers an unprecedented opportunity to harmonize global policy commitments, financing and programmatic scale-up across nutrition, global health and food systems. While the impact of COVID-19 continues to be devastating on its own, the ongoing and reverberating impacts on nutrition are growing, pushing at least a 100 million people into states of hunger and food insecurity over the last 16 months.

Large-scale food fortification (LSFF) offers an opportunity for effective and catalytic programming that moves from incremental change to change at scale making population level impacts to achieve global targets and eradicate malnutrition. It is a powerful, evidenced-based and cost-effective tool that when optimally delivered can accelerate progress and improve health outcomes at scale – but challenges remain in harnessing LSFF effectively.

On June 10, 2021, Nutrition International and the Accelerated Reduction Effort on Anaemia Community of Practice (AREA CoP) hosted a dialogue on harnessing LSFF as a game-changing solution to transform food systems and tackle malnutrition at scale. The dialogue focused on closing the gaps in fortification global governance and accountability to improve program quality, performance and coordination, and accelerate the implementation and scale up of LSFF. This virtual event was held as part of the World Health Organization’s Health Talks contributing to the Food Systems Summit 2021 Dialogues.

“The challenges we’re facing are huge and we need to work at scale. But at the same time, we need to be very precise about which data we use for which purpose.” – Stineke Oenema, UN Nutrition

Panelists in the discussion from across UN agencies, key donors and existing fortification alliances clarified that global governance remains one of the largest hurdles in effectively coordinating LSFF activities, and the lack of an articulated global accountability framework for LSFF has left programs and initiatives operating incongruently. Moreover, the ‘unfinished business’ of fortification at country and regional levels means that significant gaps exist in implementation of effective programs. Some of these gaps include missing fortification legislation, inadequate fortification standards, ineffective enforcement of mandates and policies, capacity gaps and inconsistent data and reporting capacities and mandates. “The challenges we’re facing are huge and we need to work at scale. But at the same time, we need to be very precise about which data we use for which purpose,” was a critical point raised by Stineke Oenema, UN Nutrition.

Defining governance within the global context is a key priority, with the aim of situating LSFF within the global nutrition context, while at the same time outlining a framework for implementation and normative work for fortification. However, defining specific roles for actors and carving out accountabilities at the global level remains a challenge. Panelists noted the critical importance of the role of country-led governance frameworks to ensure the long-term sustainability of program implementation. “There needs to be a joint effort that is strategic, structured and country-led to raise the bar on governance for fortification,” shared Andreas Bluethner, Bill & Melinda Gates Foundation. A similar lens can be applied to accountability frameworks and their impact on sustainability, with the priority being on country-led accountability within a larger global framework.

At the global level, panelists noted that the design and data gap were barriers that were holding back progress in building effective LSFF programs as well as setting clear data standards for program implementation. “With better data we can reassess if standards are accurate. Are we fortifying the right staples and condiments with the right nutrients so that we can optimize impact?” was an important question raised by Shawn Baker, USAID. Gaps in design and accurate data at the outset can lead to programs that don’t effectively address malnutrition within a country.

“There needs to be a joint effort that is strategic, structured and country-led to raise the bar on governance for fortification.”                       – Andreas Bluethner, Bill & Melinda Gates Foundation

Levelling up ambitions for LSFF and harnessing those ambitions to effectively target malnutrition at scale for improved health and economic outcomes is possible – with the right combination of data, accountability, and the harmonization of local, regional and global frameworks.

By bridging the gaps in challenges faced at the local level with challenges faced at the global level, UN agencies, implementers and donors can work together to ensure programs are optimally designed to effectively target nutrition needs in a population and that they are built with long-term sustainability driven by country-level ownership. Co-creation is enabling and empowering at the local level to get to accountability and governance frameworks and build the capacity that is needed for effective implementation.

This is a critical year for nutrition and our collective action (or inaction) will echo its impact for years to come. We have an opportunity. But we don’t yet have a clear diagnosis of the situation. We need to have a roadmap outlining our intentions and to respect the roles of different partners working at country level. We also need an advocacy plan to know where we can commit as a community and to get a clear idea of the gap we can aspire to close.

It is our hope that by positioning the importance of this issue, as we build towards the upcoming global events, we can continue to engage in informed discussions to pave the way for meaningful concrete actions that prevent malnutrition before it starts.