Introducing double fortified salt in social safety net programmes in Madhya Pradesh and Gujarat in India: Success factors, challenges and lessons learned.

Double fortified salt (DFS; with iron and iodine) was introduced in social safety net programmes (SSNPs) in Madhya Pradesh (MP) and Gujarat states in 2018. Nutrition International (NI) provided critical support for the intervention. An impact evaluation in MP found high DFS uptake, exceeding 90%. Conduct a process evaluation of the DFS programmes in MP and Gujarat states to identify success factors, challenges, and recommend considerations for scale-up. Twenty-eight qualitative interviews were conducted with NI staff, national and state level government officials, and DFS producers in 2022. Enabling environmental factors included national-level support for food fortification, consensus that anaemia was essential to address, and institutional trust in NI for technical assistance. In programme implementation, the primary challenges were reports of black specks in DFS and the darkening of food cooked with DFS. NI supported the government in improving handling practices, ensuring a regular and stable supply, introducing quality monitoring efforts and launching targeted behaviour change communication (BCC) campaigns regarding the value of DFS. Long-term implementation of the programmes is a weak point, as DFS production is more expensive than iodised salt, there is no existing market outside of institutional demand, and BCC must be long-term, high-quality, and requires resourcing for continued high uptake among SSNP beneficiaries. Strong government buy-in and technical support along the supply chain to address quality issues and beneficiary acceptance were key factors for the successful introduction of DFS. Comparative studies of DFS programmes should be conducted to improve confidence in the success factors that lead to high DFS uptake.