ECSA-HC member states have made greater advancements in LSFF – in comparison to SADC -given most ECSA-HC member states have established legislation on food fortification – (Fig 2) – and collected data on a number of parameters which provide information on the status of fortification of food vehicles (i.e., quantity of total production of the food vehicles, proportion of the food vehicles that are centrally processed – ‘fortifiable production’, the percentage of fortifiable foods that are actually fortified, and population coverage of fortified foods) [21].

Notably, Kenya, Uganda, and Tanzania have led the ECSA-HC region in successful LSFF implementation with structured coordination mechanisms, such as annual country-level gatherings and database systems for industry compliance. From 2003–2011, ECSA harmonized fortification standards and monitoring and evaluation at the consumption level with the support of former USAID projects. On the other hand, progress in the SADC countries has been less uniform with variations in legislation, regulations, industry involvement, and laboratory and monitoring capacity to support LSFF. Encouragingly, collaborative efforts with World Food Program (WFP) and United Nations Children’s Fund (UNICEF) aided in developing minimum standards for food fortification within the SADC region. SADC’s annual Food and Nutrition Security Steering Committee has provided a forum to ascertain LSFF progress – with food fortification landscape analyses carried out on wheat and maize flour fortification in Angola, Botswana (+ sorghum), Eswatini (+ edible oil), and Mauritius (wheat flour only) [27].

Coverage of iodized salt is high: Overall, the coverage rate of iodized salt is high among most ECSA-HC and SADC member states, according to data extracted from the GFDx. Most countries have coverage rates of 90% (i.e., South Africa, Eswatini and Zimbabwe, Kenya and Uganda), while few countries showed lower coverage rates, (i.e., 42.5% in Mozambique and 68% in Madagascar). Tanzania and Kenya are the primary manufacturers and exporters of iodized salt to neighboring countries.

Few data are available on oil fortification: GFDx has few data on oil fortification SADC and ECSA-HC countries. The compliance to oil fortification standards varied amongst countries- Malawi (49%), Uganda (60%), and Tanzania (72%). Data indicated that coverage of fortified oil reached half of the population in Tanzania (54%) and Uganda (54%) (Fig 3).

Most wheat flour is centrally produced and fortified, yet consumption is low: The GFDx dashboard revealed nearly all wheat flour is fortified in Malawi and Uganda, and 60%− 86% of flour is fortified in Mozambique, South Africa, Eswatini, Lesotho, Tanzania, and Kenya. However, since most wheat flour is centrally produced by a few large manufacturers, the percentage of the population who consume fortified wheat flour is low (i.e., urban populations only) and few countries have consumption data, except for – Tanzania (33%) and Uganda (9%). Fig 4 shows the compliance and coverage data among countries with data recorded on GFDx.

Compliance of maize flour fortification varies, and coverage is negligible: The compliance rate of maize flour fortification varied widely from < 5% (i.e.,) Zimbabwe to 70–86% in Mozambique and South Africa. Yet, consumption of fortified maize flour is minimal – e.g., 5% in Tanzania (Fig 5). The majority of stakeholders reported that large scale maize flour fortification is limited in several countries due to the predominance of small-scale milling of maize intended for direct consumption by local consumers.

Legislation: Nearly all SADC member states have mandatory legislation on salt fortification as well as legislation on wheat and maize flour fortification (Table 1). Oil and sugar fortification is mandated in Mozambique, Malawi, Tanzania, Zimbabwe, Kenya and only oil in Uganda. In addition, a few countries have standards or implemented voluntary fortification of rice, millet and sorghum fortification.

Mandatory legislation versus voluntary fortification: Stakeholders discussed the value add of mandatory fortification versus voluntary fortification as shown in Box 1. Most stakeholders stressed that the regulatory approach to fortification is a critical determinant of LSFF program coverage, industry compliance, and population-level impact.

Policy environment supportive of LSFF: Most regional stakeholders acknowledged that the SADC and ECSA-HC regions have enabling environments that are supportive of LSFF. Yet prioritization, coordination and implementation of policies can hinder LSFF implementation.

Regional and country experiences demonstrated that lack of alignment and coordination between the government and private sector during the formulation of policies, legislation and regulations is a major barrier to policy uptake and industry compliance. As described below:

On the other hand, since 2005, the Kenya National Fortification Alliance has brought an alliance of health and trade ministries responsible for surveillance and enforcement of the mandatory food fortification standards, cereal millers’ organizations, salt and oil industries, consumer organizations, and development partners – an effective strategy to enhance enforcement and compliance of fortification standards.

Standards require adoption at country level: Existing country or regional standards require periodical reviews and updates as some stakeholders discussed that “[standards] need to be informed by science, local practices and the nutritional status of the population.” Standards are legally binding only when the producer claims that the product is fortified. On the other hand, if a country does not have their own standards a regional standard may be adopted. For example, other than for salt iodization. Botswana holds no country standard, and plans to adopt the SADC minimum food fortification standards delineated in its first food fortification strategy [30].

From 2003–2011, ECSA-HC worked with partners on a regional effort to coordinate the implementation of food fortification programs- including the harmonization of standards [21]. ECSA-HC drafted the food fortification guidelines and collaborated closely with the Eastern African Community to bring the guidelines into a regional standardization framework and the adoption of the standards through consensus as “tools of trade.”

Data is sorely needed to inform on LSFF programming. The majority of country, regional, and global stakeholders discussed the importance of having up-to-date data on market reach and consumer coverage to ensure that fortified foods benefit the intended population. Most stakeholders relayed concerns around accuracy and/or availability of country-level LSFF data– stating that” in terms of key challenges, data on consumption, intake, production or market- is really old.... over 10 years old.” At regional and global levels, most stakeholders relayed concerns around accuracy and/or availability of recent country data to inform on LSFF programming. Stakeholders expressed frustration that governments and producers don’t “prioritize it [data] because they are not feeling pressure and nobody’s keeping up with it.”

Data from micronutrient surveys can determine not only the quantity of fortified foods and micronutrients that are consumed, but also the consumption patterns of fortifiable food vehicles in different population strata (i.e., based on gender, age, geographical location, and economic status). In Mozambique, stakeholders noted that the absence of recent data persists despite earlier plans to strengthen surveillance systems through surveys “to improve and monitor trends in the national fortification program’s impact.”

Further, there is a disconnect between methodologies used by industry (i.e., minimum threshold- defined as a set minimum amount of added micronutrients) versus country governments (i.e., use of ranges – defined as minimum to maximum allowable levels of vitamins and minerals added to food products) in sampling the micronutrient content of food – affecting the quality and usefulness of LSFF coverage data.

On the other hand, tools for monitoring fortification production, consumption, and coverage exist, yet require systems in place [31]. Country stakeholders from Mozambique, Ethiopia and Tanzania highlighted the need for monitoring systems to ascertain the level of consumption of fortified foods.

Nearly all stakeholders stressed the need for capacity strengthening for governments, private sector, and regulatory bodies as key to ensuring successful regulatory controls. A global stakeholder emphasized the need for training industries that have not complied with food fortification standards, with a focus on quality control and assurance. Monitoring and evaluation of LSFF programs at country level was perceived to be effective when a collaborative effort between various government ministries and institutions was brokered. For example, Tanzania, has made progress in establishing multiple partnerships to ensure adequate monitoring and availability of household coverage data for LSFF, as described below,

Despite mandatory fortification in most countries, incentivization of the food industry to fortify and comply at scale remains challenging.

Compliance by Industry: In countries with mandatory food fortification, some stakeholders expressed concerns that imported fortified foods are less expensive in comparison to the cost of producing local fortified foods that are compliant at scale. Industry compliance is further hindered by insufficient quality checks at country border points due to limited capacity for inspection and laboratory support for local regulators to ascertain whether imported products meet national fortification standards.

Enforcement by Governments: Even for countries with mandatory legislation for food fortification, some stakeholders reported weak enforcement of standards and regulations due to lack of resources, training, and equipment.

In Eswatini and Lesotho, country stakeholders expressed delays and reduced efforts by government institutions to enforce the relevant legislative actions due to resource constraints. In some member states, e.g., Mozambique, stakeholders relayed that enforcement of monitoring and compliance is donor funded, time-bound and unsustainable in the long-term. Nonetheless, Malawi provides an example of strong enforcement. While about 95% of salt is imported from SADC members states, the Malawi government has adequate regulatory control systems at the border points, which ensures that the unfortified salt is not allowed in the country.

Continuous compliance checks, and enforcement of fortification standards by government authorities is key for long-term success of LSFF programs. Reliable, efficient, and low-cost enforcement systems are needed to avoid an unfair competition of some industries [32]. Government capacities should be improved to not just create regulations, but also to enforce and monitor these regulations. Given there is a dearth of compliance data in the GFDx, countries need to budget for monitoring fortification levels in food samples against the standards.

Challenges with consumer awareness and trust are thought to negatively impact consumption of fortified foods, according to stakeholder interview data.

Most country stakeholders noted long-term advocacy and integration of iodine awareness in the education system increased the acceptance of iodized salt among communities, especially in ECSA-HC. However, aside from universal salt iodization (USI), the “knowledge of large-scale food fortification among the general public in the region is too low” and higher price differential of some fortified food products may pose an affordability challenge for consumers. Both regional and country stakeholders stressed that most consumers are not aware of “what fortification is” despite the presence of fortification logo on the product.

Despite fortified foods being indistinguishable from their unfortified counterparts in terms of taste and texture, some stakeholders emphasized the importance of continuous SBC to ensure consumers understand the health benefits of fortified foods versus unfortified foods. Several regional and country stakeholders relayed that some consumers had suspicions of what was added to fortified foods, and “had to put a lot of public awareness for them to understand” noting the need for continuous public education as relayed below.

Country stakeholders from Botswana, Tanzania, Malawi, Eswatini and Ethiopia described the need to specifically raise community awareness around LSFF, to strengthen capacity of governments and industry and “to be deliberate in strengthening the relationship between industry and governments.” From country stakeholders’ perspectives, implementing changes around awareness creation and increasing advocacy for fortification “can be used to improve the [knowledge of] nutritional content [of the diet], and people will see the needs [and value of fortified foods]” which can help create appreciation for fortified foods at both country and regional levels.

In addition, targeted SBC is needed to broaden industry’s understanding of the broader public health population-wide impacts of LSFF. According to regional stakeholders, some large-scale food producers advertise the health benefits of their fortified products, indicating a readiness to align -profit making with the broader public health advantages of LSFF. To enhance engagement with the private sector, some stakeholders suggested increasing awareness among private sector actors on the health benefits of LSFF – demonstrating how even small additions of nutrients can significantly contribute to improved health outcomes.

All stakeholders underscored the importance of active engagement with the private sector (i.e., millers and food manufacturing industries) across the entire LSFF value chain. While the private sector is primarily motivated by profit, a return on investment for their involvement can be an incentive for covering the cost of fortification. Since the private sector’s motivation often stems from market advantages and brand competitiveness, a multi-sectoral approach incorporating both the private and public sectors is necessary to ensure that LSFF programs are sustainable and effective. Most stakeholders expressed that the private sector often do not allocate time and resources to participate in collaborative LSFF initiatives unless their participation is sponsored. High costs associated with compliance fees and necessary infrastructure investments bore by the industry is a barrier to participation.

Most global, regional and country stakeholders highlighted the need for incentives, such as transferring fortification costs into the product price, and public recognition programs to reward companies for their contributions to public health. Some global stakeholders recommended implementing annual recognition of compliant brands to encourage consumer trust and industry compliance. As expressed by a global stakeholder the mutual benefits of public-private partnerships are “where the private sector can benefit from increased competitiveness and market share, while [simultaneously meeting] public health goals through improving the nutritional quality of widely consumed foods.” Some country stakeholders highlighted a critical need for governments’ intervention to create conducive policies and incentives for the private sector. Government mandates on fortification should be supported by policies that facilitate implementation. Without such measures, industries may question the feasibility and necessity of compliance.

Small and medium producers often view fortification as an added financial burden, especially in country contexts with limited government support. Most stakeholders described the operational and regulatory challenges of integration of small-scale millers into LSFF programs. Limited technical capacity, and high compliance burden necessitate tailored approaches from those applied to large-scale millers. Stakeholders emphasized that targeted capacity strengthening, incentives and revision of regulatory frameworks are essential tools for engagement of small-scale millers. Moreover, the additional efforts needed to ensure products by small-scale millers meet fortification standards have high-cost implications to both the government and industry, often leading to sub-optimal implementation of LSFF programs (see Box 2).

Countries’ advocacy for inclusion of fortificants in the list of essential medicines allow for tax waivers or reductions. According to several country stakeholders from Botswana and Kenya, LSFF is “a cost-effective intervention with minimal additional costs.” Yet, on the other hand, some country budgets do not allocate funding for the implementation of fortification strategies, which affects sustainability. Some country stakeholders proposed that free trade within the region may be a key opportunity to improve food fortification implementation across the region.