Unpacking the 'Business Model' for Fortification Initiatives in Low- and Middle-Income Countries: Stakeholder Identified Drivers of Success and Constraints to Progress.

Initiatives to tackle micronutrient deficiencies (MNDs) in low-and middle-income countries (LMICs) have increased steadily in recent years. Commodities such as staple foods (e.g., cereals) and condiments (e.g., salt) have been targeted as 'vehicles' for industrial fortification through numerous projects and initiatives. However, mixed experiences with delivery, coverage and sustainability have been found. Using an online survey of 71 key stakeholders (from 35 countries) consisting of the public/private sector, academia and civil society, this study sought to unpack the 'business model' for fortification initiatives to identify the key drivers of success and constraints faced by stakeholders in LMICs. Bivariate analysis was conducted to identify factors associated with the coverage of the target market and the perceived success and sustainability of fortification initiatives. We identified four key factors contributing to the success of fortification initiatives. The first involves the size of the firm. Large firms had a significantly higher ( < 0.05) self-sustaining index (perceived level of sustainability of the fortification initiative) than smaller sized firms. In addition, a higher perceived success score ( < 0.05) was associated with non-targeted initiatives compared to those specifically targeted at a certain cohort of the population, further illustrating the benefits of producing at scale. Secondly, a significant relationship was found between whether standards were enacted and the coverage of the target market by the project/firm ( < 0.05).). The third key factor relates to the ability to source adequate testing for the fortified produce in-house. A positive correlation was found for post-mix in-factory testing and the self-sustaining index ( < 0.05). Finally, delays to importation and high charges were cited as key constraints to the use of premix. We argue therefore that a successful 'business model' for industrial fortification initiatives invariably consist of: (i) the involvement of larger sized firms that have the advantage of benefiting from economies of scale; (ii) the availability and application of agreed standards by the producer; (iii) high quality assurance/compliance monitoring (including post-mix testing where relevant), and; (iv) the ability to procure premix in a timely/cost-effective manner. These criteria are likely to be important factors that contribute to the success of fortification initiatives in LMICs.