A Framework for Evidence-Based Decision Making in Large-Scale Food Fortification Programs

Abstract

Abstract Objectives The use of evidence on program performance and potential for impact for decision making in food fortification programs is limited and often done in isolation from other micronutrient interventions. We present a framework for fortification stakeholders responsible for making program recommendations and decisions to facilitate and document evidence-based decision making. Methods First, we reviewed the literature to define the key decision makers and decisions necessary for effective fortification program design and delivery, informed by a clear impact pathway. Then we classified decisions by domain, identified data sources and criteria for their assessment, and adapted the GRADE Evidence to Decision framework to summarize the results. Finally, we considered how the framework would apply to different country programs to test its utility. Results Policymakers, particularly government ministries, and the food producers themselves are the most important decision makers in a fortification program, while technical support agencies, donor agencies, and the research community play important roles in translating data and evidence into contextualized recommendations that meet the needs of different decision makers. The main fortification decision types were classified into five domains across the impact pathway: 1) program design (need, food vehicle(s)); 2) program delivery (compliance, quality, coverage); 3) program impact (nutrient intake and status); 4) overlapping micronutrient interventions and/or under-served populations; and 5) decisions to continue or stop programs. Important criteria for the assessment of each decision type included priority, benefits/risks, equity, acceptability, and feasibility among others. Country examples illustrated the importance of coordinating decision-making in the context of overlapping micronutrient interventions to ensure continued safety and impact over time. Conclusions This framework is a practical tool to enable evidence-based decision making by fortification stakeholders. Using evidence in a systematic and transparent way can enable more effective program design, delivery, and ultimately health impacts. Funding Sources Bill & Melinda Gates Foundation.