Written and edited by Corrina Vali and Nikita Patel

Executive summary

Fortify Health is an EA-aligned non-profit that was founded in 2017, which is when we last posted on the EA forum. As we turn four years old this week, we have been reflecting on some of the organisation’s major lessons that might interest others starting up new organisations. In this post, we cover the three major lessons Fortify Health has learned about systems change over our four-year lifespan:

• Lesson 1: Identify and address the key pain points that are preventing systems or policy change from happening or sustaining. Sometimes the pain point is a lack of policy advocacy and sometimes it is not.
• Lesson 2: Build a team of local domain experts early in the start-up process to bridge the gap between high-level data and ground reality
• Lesson 3: Become the expert at solving a particular pain point to gain credibility and create leverage for future advocacy work.

We break each lesson down into three sections: 1) the challenge we faced; 2) how Fortify Health responded to the challenge, and; 3) how early stage NGOs can use our learnings in a range of contexts. Finally, if you’re interested in supporting Fortify Health, we provide some ways to contribute to our work at the end of this post.

Introduction

Fortify Health is a non-profit working in India to reduce the incidence of anaemia, and prevent the downstream consequences of this condition at population scale. India has a high prevalence of anaemia, with 63% of children and 48% of women suffering from anaemia. 

Fortify Health currently addresses this problem by setting up and expanding wheat flour fortification in the open market and in government safety net programmes (SNPs). We focus on the states of Maharashtra, Madhya Pradesh and West Bengal, where we’ve identified the burden of disease, the gap, potential for scale, and program feasibility as high. Fortify Health has been evaluated by GiveWell in 2018 and 2019, and has received two GiveWell incubation grants totalling approximately $1.3 million. 

Through our open market work, we aim to increase the availability of fortified wheat flour in our target geographies. We do this by providing financial and technical support to wheat flour mills so that they are able to fortify all their flour.  Our government partnerships focus on partnering with SNPs that provide wheat at subsidized prices to vulnerable populations at scale. We have recently received approval to partner with the Tribal Development Department of Maharashtra to conduct a pilot for one of their flagship SNPs reaching vulnerable school children with fortified wheat flour. The department is eager to scale up the program across the state if the pilot is successful, and we are now actively looking to fill a $225,000 funding gap to see the pilot forward.  

Over the past four years of building on these approaches, we have been able to observe and better understand the areas, information or decisions that have hampered or furthered our growth. We include some of these lessons in the next sections.

Lesson 1: Identify and address the key pain points that are preventing systems or policy change from happening or sustaining. Sometimes the pain point is a lack of policy advocacy and sometimes it is not. 

The challenge

When it comes to achieving impact at scale, high level policy advocacy is considered one of the most effective ways to solve a large problem. However, sometimes an organization needs to create the environment to make policy change feasible before prioritizing advocacy. Even when policies are changed in a top-down manner, they may not be enforced due to lack of awareness, buy-in or capacity at the ground level. Unfortunately, this is the case in many countries that have mandated fortification, where the ground reality is that fortification is not done at all or not done well.  Fortification, including wheat flour fortification, is a stated policy priority of the government of India. However, this has not translated into incentives for wheat flour millers to implement fortification in their mills. In addition, the government has limited capacity to enforce quality assurance and quality control standards for fortification. Therefore, industry buy-in is crucial for any fortification mandate to be effective in a context where enforcement capacity is limited. There is a lack of such industry buy-in for fortification among wheat millers in India because of: 

• Low market incentives: Mills lack market-driven incentives to fortify because consumer awareness of the benefits of consuming fortified staples is low.   
• High industry fragmentation: The wheat milling industry is highly fragmented with small-scale service mills (chakkis), centralized wholewheat flour mills and large roller flour mills. Consensus over fortification has been lacking because these different types of mills are not organised under an umbrella association or institution.   
• Lacking industry innovation: The milling industry in India is rich in experience but has little room for risk in adopting innovations. This makes millers skeptical of experimenting with fortification, especially if they have heard of product quality issues that other mills have experienced. 

How Fortify Health responded to the challenge

Fortify Health works to facilitate wheat industry buy-in for fortification in the long term by demonstrating to mills and government stakeholders the ease, cost-effectiveness and health impact of fortification through pilots. We remove industry barriers by:

1. Absorbing fortification costs: We partner with medium and large centralized mills to absorb all the additional costs of fortification by providing equipment, premix and technical assistance for free. This reduces millers’ reluctance to start fortification if they are risk-averse or do not want to experiment with value addition (product enhancement through a change in its manufacturing processes or in its delivery to consumers, such that consumers find it more valuable) on their own. We also highlight success stories of partner mills that have successfully launched and sustained fortified wheat flour products in the market, which builds industry confidence.
2. Offering monitoring and evaluation support: We support mills in setting up Quality Assurance/Quality Control systems, providing information about fortification standards and conducting quantitative iron tests ourselves. This helps mills implement clear QA/QC systems for fortification and ensure high levels of product quality.
3. Saturating major wheat milling clusters: We focus on expanding fortification within clusters (districts that have a high density of wheat flour mills) across our target states in India with our fortification program. As mills launch fortified wheat flour in the market and find consumers accepting their product, they are less skeptical of fortification.  This builds industry buy-in for fortification and could be very useful for policy advocacy in the future
4. Facilitating research and development (R&D) to improve quality control: We aim to improve the efficiency and ease of fortification in local operational set ups. Potential R&D solutions include low cost automated microdosing equipment that can work within Indian mills and Management Information Systems that can integrate the different aspects of fortification quality assurance and control.
5. Supporting other fortification advocacy and consumer awareness organizations with evidence from our programs such as product quality studies, consumer acceptability reports, case studies from our government partnerships, as well as a potential impact assessment in the long term.

How this translates to other contexts  

Before designing an intervention to address a certain problem, new organizations should spend time understanding the key pain points, (specific challenges preventing effective resolution of the problem) around the intervention, especially from local experts. They should map out the different stakeholders connected to the issue they are trying to address, what their incentives are and what their bargaining power is.  This will help new organizations to identify the largest pain points they could effectively resolve to enable high impact. 

For example, if an organization is aiming to reduce the negative health outcomes caused by alcohol consumption at the population scale, its stakeholder map could include alcohol manufacturers, consumers, the hospitality and tourism industry, regulatory agencies, the treasury department, the public health department and so on. As you can imagine, each stakeholder has a different set of incentives and bargaining power. For example, the treasury department and the public health department may face opposing incentives, wherein taxation on the sales of alcohol boost the revenue of the treasury department but lead to poor health outcomes that increase the costs borne by the public health department. At the same time, the treasury department may have higher bargaining power over the public health department. This pain point could potentially be reduced by funding the creation of a research group based at a reputed university in the country in partnership with the treasury department, with a goal of assessing the purely monetary costs incurred and income generated through various potential alcohol regulation policies. 

There could be other pain points such as the difficulty in changing consumer preferences, the high dependence of the country’s hospitality and tourism industry on alcohol sales, etc. The organization should identify and rank various pain points and corresponding solutions for the system in which the problem is based before choosing the most effective solution.   Some resources to help new organizations or teams think about a problem from a systems lens are the Impact Gaps Canvas, the Iceberg Model, and Tools for Systems Thinkers.

Lesson 2: Build a team of local domain experts early in the start-up process to bridge the gap between high-level data and ground reality 

The challenge

High level metadata and studies can miss important nuances of the ground reality. This could be due to problems related to the representativeness of the sample selected or the veracity of the data collected. For example, the World Bank’s Ease of Doing Business index measures a variety of metrics such as the ease of getting credit, the ease of starting a business and the ease of enforcing contracts. However, the index’s ranking of India depends only on data collected from Mumbai and Delhi, where business facilities are much more sophisticated than in most of India.  If a new organization were to use this index to identify which country would be the most feasible to launch a rural development intervention in, the organization would be disappointed by the ground reality. Most new organisations will face this challenge of bridging the gap between their idea/theory and practical reality in the initial years.

Fortify Health has faced this challenge while navigating India’s flour milling industry. Some industries, such as wheat milling, are tight knit and based on personal connections. This means it is difficult to understand the true challenges of wheat flour fortification without having worked in the sector or having strong connections in the industry. One challenge we faced was in finding out and analysing the average monthly production of wholewheat flour by mills. Initially, we assumed that installed capacity for wholewheat flour production, which was a metric available in milling databases, would be close to the average production of wholewheat flour in mills. During our first onboarding visits, millers would also state the mill’s installed capacity rather than average production due to a lack of trust in external partners. However, as we started working within partner mills, we realised that average production in medium sized mills is 65% to 75% of their installed capacity. This difference is crucial for our cost effectiveness calculations because it affects the total volume of wholewheat flour we are able to fortify per dollar spent. In addition, we found that certain fortification standards or guidelines could not be directly applied in real-world milling contexts. For example, most mills face a shortage of technically trained Quality Assurance/Quality Control staff, which makes it difficult for them to monitor fortification levels to a high standard, without providing additional training and incurring associated costs. 
 

How Fortify Health responded to the challenge 

Fortify Health conducted expert interviews with organizations working on fortification in Indian mills and government schemes during our first scoping visit to India in January 2018. The experts we spoke to included managers and leaders from organizations such as the Global Alliance for Improved Nutrition, PATH, World Food Programme, Food Fortification Resource Centre, Food Fortification Initiative, and Nutrition International. This gave us a fair idea of the impressive work that was already being done in India and put into perspective implementation challenges that nonprofits were facing in sustaining wheat flour fortification in government programs and industry. For example, certain pilots in collaboration with government programs had shut down due to product quality issues such as excessive moisture content in the flour or the darkening of flour as a result of the use of iron sources other than NaFeEDTA. This is one of the reasons we developed a focus on technical assistance, and on implementing the fortification process well, before pushing for scale. 

Secondly, we transitioned from obtaining the services of technical consultants to hiring domain experts to be a part of our team full time. In the first two years of Fortify Health’s existence, our team was primarily composed of generalists with a background in public health and NGO work. While the team was committed to Fortify Health’s mission, we found that our progress in signing mill partnerships and launching fortification was slow. In January 2020, we hired our first team member from the milling sector, who is now our Program Manager. By May 2021 our team of mill technologists expanded to 6 people, who cultivate and manage relationships with millers and handhold them through the fortification process. This has helped us to sign partnerships with more and larger mills and to accelerate the launch of fortification in existing partner mills. Despite the COVID-19 pandemic, we have signed 9 new mill partnerships between June 2020 and August 2021, compared to 4 mill partnerships between December 2018 and December 2019 pre-COVID. Similarly, since September 2020, Fortify Health has hired team members who have previously worked within state governments or have extensive experience with local government, to lead our government partnerships work. This has improved our understanding of the functioning of different levels of government. It has also helped us research, design and push for approvals from government departments more smoothly. We believe that this was a significant factor in our recently receiving approval to partner with the Tribal Development Department of Maharashtra, which is a major step forward for our organizational impact, and increases our potential to work with larger government schemes later down the line. 

Finally, Fortify Health has built relationships with and received advice from various milling and fortification experts from organizations such as Nutrition International, Food Fortification Initiative (FFI) and Project Healthy Children, some of whom are even part of our advisory board (such as FFI’s Laura Rowe, who is Fortify Health’s Chief Advisor).  In 2020, we also signed a partnership with the Central Food Technological Research Institute (CFTRI), India’s premier food and milling technology institute.  These connections and partnerships have deepened our industry network, helped us understand the milling industry and accelerated progress with larger mills. We have found that investing time and funds in forging partnerships with well-reputed institutions such as CFTRI, that can effectively influence our target audience, that is, millers, has been well worth it. 

How this translates to other contexts 

New organizations that aim to create a lasting impact in foreign countries or new industries need to dive deeper than global data/indices to understand the ground reality of any issue before choosing an intervention. New organizations could start by:

1. Speaking to and ideally visiting local domain experts early on to get initial feedback on their intervention idea or possibly co-designing an intervention with them. The additional benefit of doing this is it helps new organizations to quickly build authentic relationships and local networks in their domain of work.
2. Hiring local domain experts in decision-making roles early in the start-up process, and finding effective incentives to encourage these domain experts to join and remain in your team.
3. Creating an advisory board with senior industry experts and building partnerships with local institutions.

Lesson 3: Become the expert at solving a particular pain point to gain credibility and create leverage for future advocacy work. 

The challenge 

In some cases, if a brand new organisation without strong networks or a robust track record starts out doing only policy advocacy, it runs the risk of not being taken seriously. This is especially true when the policy change proposed by the organization would invite strong opposition from stakeholders. Some governments are also skeptical of new (often external) organizations conducting advocacy without much insight into the day-to-day realities of the issue they are trying to solve. In our case, while wheat flour fortification is a stated policy priority of the central government’s anaemia reduction program, the idea faces opposition from:

• certain sections of the civil society that prefer dietary diversification over fortification
• decentralized small service mills (chakkis) and packers of wholewheat flour who fear that mandatory fortification would lead to market capture by large mills
• medium and large sized millers who are reluctant to implement fortification at scale due to the fear of changes in product quality

Moreover some government officials, who agree with fortification in principle, are waiting to see some momentum in its implementation in order to invest their time and resources in advocating for scaling it up. In this situation, the central and state governments require assistance in designing the rollout of mandatory fortification and getting buy-in from various stakeholders.

How Fortify Health responded to the challenge 

Fortify Health has chosen the strategy of becoming a technical expert in wheat flour fortification. This means we have initially chosen to work with mills to facilitate the smooth launch and sustenance of cost-effective fortification. Through our direct implementation work, we are gaining experience in setting up and maintaining fortification at a high standard. We are also building relationships with mills, retail brands, premix suppliers, equipment vendors, labs, technical specialists, and food regulators. This domain expertise and network could help us to become the go-to organisation for technical support and industry stakeholder management. It has already become much easier for us to speak to policymakers in the past six months, as our 11 mill partnerships reflect a ground-level presence that the government is looking for. Our increasing domain expertise will help us to provide useful inputs to state governments, and advocacy partners in the future.

As we mentioned above, Fortify Health has just received approval to partner with the Tribal Development Department of Maharashtra, which has the mandate to ensure the welfare and development of some of the state’s most marginalised “tribal” (indigenous) communities. Through this partnership, Fortify Health will support the TDD to transition from the provision of wheat grains to the provision of fortified wheat flour to around 22,000 tribal children studying in its residential schools next year, scaling to 192,000 when rolled out in the following years. As the technical partner, Fortify Health will assist the TDD to develop fortification SOPs for the supply chain, strengthen monitoring systems and sensitize relevant stakeholders. Fortify Health will also offer its mill partnership program to the mills tendered by the TDD. We hope to build our technical expertise and networks within government safety net programs through this pilot, which could legitimize future advocacy for the provision of fortified wheat flour across all of these programs in the state. 

Fortify Health regularly builds and shares insights from our implementation work that could be used by NGOs, mills and policymakers to improve the wheat flour fortification ecosystem in India. 

How this translates to other contexts 

• Before deciding to focus on policy advocacy, new organisations should consider why their intervention/aim hasn’t already been successfully made a policy. Then, they should consider addressing some of those bottlenecks and becoming troubleshooting experts for those. Resolving an important bottleneck will not only give the new organisation the credibility it needs, but also make it appreciate the nuances of the issue it is trying to solve.
• As the organization gains domain expertise and crucial partnerships, it should think very carefully about how it wants to start advocacy work and how it wants to scale it up to achieve its end goal. With time and good execution, the organisation will be able to push for incremental changes and build its reputation. As the momentum towards the desired policy change builds, the organisation will have the clout required to push for the change as well as the ground-level experience to enable policy implementation by the government, industry or other relevant stakeholders.
• For example, imagine that your goal is to advocate for the government to improve access to clean drinking water in rural India through the installation of chlorine dispensers next to commonly used water sources, at scale. As a new organization, you could start by developing domain expertise. You could conduct pilots in partnership with rural NGOs to create local evidence for your intervention. Or, if the evidence is already robust, your organisation could become a training institute assisting local partners with project design, sourcing chlorine dispensers, budgeting, testing and behaviour change communication. As you gain experience and credibility, you could decide to advocate first for low hanging fruits such as:

1. the inclusion of this solution in the training modules for mid-level officials from the Ministry of Water Resources.
2. presentation of this solution to senior bureaucrats at a state/national level development conference conducted by the government in partnership with a reputed university
3. the inclusion of chlorine dispensers under the list of “essential goods and services”, thus making them eligible for lower goods and services taxes. 
   
   With small wins such as these over the next few years, your organisation could become the go-to chlorine dispenser technical expert. When there is a window of opportunity during a budget plenary session of the Ministry of Water Resources or the Ministry of Rural Development, and you are invited to speak as the “clean water expert”, your organisation could push for your end goal - the installation of one chlorine dispenser next to every common water source in each rural district of that state. This way, your organisation could not only contribute towards a change in legislation, but also ensure that the system has the capacity to implement the proposed solution effectively.  This sort of legitimacy could also be gained by establishing institutional partnerships with well-reputed and influential institutions that are already experts at resolving an important systemic pain point. In this case, there would be no need to start an independent organisation duplicating the existing and effective efforts of another institution. The value add or expertise of the new organisation could be its ability to manage influential stakeholders and develop consensus.

• Whichever strategy the new organisation chooses out of the two outlined above, its value add beyond advocacy will give it an added advantage during its policy advocacy work.
   

Opportunities to contribute

While we’re here, we thought we’d share some upcoming opportunities for anyone interested in contributing to Fortify Health’s impact:

1. Support us in filling our funding gap

We are currently looking to fill a $270,000 funding gap to facilitate the initial stage of our pilot in collaboration with the Tribal Development Department, Maharashtra. This year we will expand the program to Amravati Division, which will reach 27,016 children across 83 schools with fortified wheat flour. We consider this a high-leverage opportunity that would not take place without any third-party funding. We are seeking interim funds for this pilot separately from our GiveWell funds, as our next evaluation by GiveWell will likely be finalised in mid-2022, and the pilot will launch over the coming few months. We will be approaching GiveWell for funding for the full scale-up of the program. Please contact us at corrina[at]fortifyhealth[dot]global and nikita[at]fortifyhealth[dot]global if you are interested in supporting us with funding.
 

2. Apply to work with us as an Associate Director of Operations 

We are hiring an Associate Director of Operations to oversee Fortify Health’s operations work. The ideal candidate will be based in India or the UK, be a quick learner, and ideally have experience in supply chains, logistics or finance. Location can be a little flexible across Europe and Asia in exceptional circumstances.
 

3. Attend our events to learn more about our work and scale-up

We share our upcoming public events on our social media; we’re speaking at an event hosted by EA Denmark on 6th October 2021 at 4pm BST. We’ll be sharing more details about this and other future events on Fortify Health’s Facebook, LinkedIn and Instagram profiles. 

Additional resources to learn about systems change through charity entrepreneurship:

• Charity Entrepreneurship Handbook
• What’s your endgame? 
• Systems Change - Big or Small?
• Philanthropy University’s free Advocacy course
• Communities of Practice: Systems Innovation and Complexity Weekend
• Santa Fe Institute