Rolling District Study - Food Fortification

Brief - Rolling District Study Phase 2 The Rolling District Study (RDS) is designed to determine the extent to which poor households are benefitting from the improved access and uptake of fortified wheat and oil/ghee, and to generate operational evidence on the impact of programme activities at district level to inform future FFP rollout.

RDS-2 is the second round of the study and was carried out by Abacus Consulting and Gallup Pakistan.

Study Design The RDS is divided into three rounds spread across three consecutive years. The first round of the study, RDS-1, was carried out from February to March 2018 among four “early” districts: Lahore, Rawalpindi, Hafizabad, and Gujranwala. The current study, RDS-2, was conducted from May to April 2019 and covers a follow-up in the early districts and a baseline in four “mid districts” namely Karachi, Peshawar, Rahim Yar Khan and Narowal. The third and final round RDS-3, expected in the year 2020, will serve as an endline assessment for all eight districts.

Figure 1: Three rounds of RDS

RDS 1 Early Districts (Lahore, Rawalpindi, Hafizabad, Gujranwala) - Baseline Feb - March 2018

RDS 2 Early Districts - Follow-up Mid Districts (Karachi, Peshawar, Rahim Yar Khan, Narowal) - Baseline

RDS 3 Early Districts - Endline Mid Districts - Endline Expected TImeline: 2020

May - April 2019

Sampling: The respondent base for RDS-2 survey comprised of 6,607 respondents. The target respondents included Households (4,152), Retail Users (1,221) and Retail Suppliers (1,234).

To determine whether the wheat and oil/ghee products are adequately fortified, 3,342 samples of wheat flour and 201 samples for oil/ghee were collected from the three target segments and tested for fortification status. For wheat flour, a two-tiered process was followed for the testing, with on-site spot testing at the respondent’s premises as first step, conducted at all households reporting buying branded wheat flour, followed by lab testing to measure added iron content in those samples which gave a positive spot test result. For oil, the process was one stage and a target of 25 samples per district were tested.

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Findings Part I: Household Survey Awareness ●

Top-of-mind unprompted awareness about food fortification among respondents was low at 11.2%,

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49.3% of respondents reported that their last purchased wheat flour was fortified, suggesting that familiarity with the general concept, once explained, is higher.

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Of those aware of fortification, wheat flour (26.8%) was the food most widely reported as commonly fortified, whereas ghee and cooking oil were surprisingly mentioned by only 3.2% and 2.8%.

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TV and word of mouth were top cited sources from where respondents reported to get information on food fortification

Consumption of Fortifiable Food Vehicles 

A large majority (95.4%) of respondents in all eight districts indicated using wheat flour to prepare food in their households, while all (100%) respondents use cooking oil and/or ghee to prepare food. This was similar in both rounds.



36.6% of respondents use packaged, branded wheat flour – either commercially branded (14.7%) or branded as “Chakki” flour (24.3%). This packaged flour branded as “Chakki” is reportedly mostly produced by the organised, roller mill sector and is thus regarded as “fortifiable” and covered by the current scope of FFP,



Nearly 58.9% reported using unbranded chakki flour – either getting their own wheat grain ground from the local chakki (37.9%) or buying it from the chakki directly (21.9%).



The more urbanized districts of Karachi, Lahore and Rawalpindi are split nearly evenly between commercial and chakki wheat flour. An outlier is Peshawar, with nearly 86.1% of respondents using commercial wheat flour.



A decline in consumption of unbranded flour was reported from 72.9% in Round 1 to 67.1% in Round-2, whereas a significant increase in commercial “Chakki” brand was witnessed from 27.1% in Round-1 to 32.6% in Round-2.

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Round 2 showed a slightly greater association between use of commercial branded flour belonging to a higher income quintile. However overall, a larger proportion of the population was found to be using commercial branded flour, including commercial “Chakki” brand, compared to the first round. For example, 30% of the lowest income quintile consumes fortifiable wheat flour (12.4% + 17.9%), which is higher than the 25% estimated from Round 1. For the highest income group, this rises to 48.5%.

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Figure 2: Type of wheat flour used by households by income

12.4% 17.9%

14.5%

19.5%

20.5%

22.6%

26.4%

22.7%

25.7%

25.2%

27.1%

18.1%

28.2%

29.3%

32.5%

24,000-28,000

28,000-34,000

>34,000

26.0%

16.5% 19.6% 52.8%

< 20,000

39.2% 20,000-24,000

Household Monthly Income in PKR Grind own grains at Chakki Buy Chakki brand flour from market

Buy unbranded Atta from Chakki Buy commercial brand flour from market

Brands 

The top three (overall) wheat flour brands used by households were Punjab, Super Fine and Special. For oil, the top brands were Sufi, Dalda and Kiran.

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Wheat and oil/ghee brands enjoy high brand loyalty - a large majority (89.3%) of respondents reported not having switched their wheat brand in the last year and 82.4% for oil/ghee.

Consumption patterns of wheat-based foods ●

The estimated annual per capita consumption of wheat flour is 96.4 kg and of oil/ghee, it is 17 kg, which does not vary noticeably by income group. These estimates do not include consumption through other ready-to-eat products bought directly from the market or food consumed outside the home, and are comparable with results from the GAIN Study 1 which found per capita consumption of flour for Punjab to be 101 kg per annum.

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A study of consumption of wheat flour-based products was added in Round 2 which asked about 6 common wheat-based foods and where these were made/sourced – whether from home or market

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The study established that sliced bread, khatai/biscuit and rusk are generally sourced from the market, indicating that wheat flour consumption by households is being supplemented by these ready-to-eat products, which are, for the most part, made with commercial branded (and thus fortifiable) flour. This pattern was fairly even across income quintiles, although the lowest income group was less likely to consume sliced bread, khatai/biscuit and rusk. (Figure 3)

Figure 3: (Selected) food items consumed by households in the past 24 Hours by income 1 Source: Punjab Large-scale Wheat Flour Fortification Project - Punjab, Pakistan Wheat & Wheat Flour & Fortification Supply Chain Study’, September 2014, Global Alliance for Improved Nutrition (GAIN)

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17.1% 21.3%

17.3% 23.0%

7.1%

10.0%

28.3%

30.5%

30.8%

70.4%

68.9%

64.9%

68.5%

75.4%

81.1%

86.2%

86.6%

80.4%

< 20,000

20,000-24,000

24,000-28,000

28,000-34,000

> 34,000

6.6%

6.8%

16.4% 16.4% 26.3%

4.9%

12.3% 8.5% 19.9% 63.4%

Kulcha/ Naan/ Roti Sliced Bread

Paratha Rusk

17.7% 25.4%

Khatai/ Biscuit Halwa

Intra-household consumption patterns



Differences in the consumption pattern among household members were observed. Around 80% of households reported that the respondent herself and an adult male at home had eaten kulcha/naan/roti in the last 24 hours, but only 60.5% reported this for the child under 5. On the other hand, adolescent girls were reported to have had paratha the most times (59.5%), compared to 48.1% of men, with children under 5 having had it the least times (40%). However, some foods were given more to young children than to other family members including khatai/biscuit (consumed by a child in 46.5% of households, rusk (15.4%) and sliced bread (12.8%), the highest among all family members analyzed for these foods. (Table 1 and Table 2))

Table 1: Incidence of consumption of selected food items by household members in last 24 hours REPONDENT (WRA)

ADOLESCENT GIRL

CHILD UNDER 5

MALE ADULT

Total

Urban

Rural

Total

Urban

Rural

Total

Urban

Rural

Total

Urban

Rural

Kulcha/ Naan/Roti

80.3 %

80.0%

80.8%

74.7%

73.4%

76.2%

60.5%

59.6%

61.7%

81.3%

81.5%

81.0%

Sliced Bread

9.4%

13.1%

4.1%

10.1%

14.0%

5.0%

12.8%

16.4%

7.9%

5.4%

7.1%

3.1%

Khatai/Biscui t

12.4 %

14.8%

8.8%

20.0%

27.2%

10.8%

46.5%

51.5%

39.9%

5.2%

5.9%

4.1%

Rusk

8.6%

10.1%

6.5%

7.5%

8.5%

6.3%

15.4%

16.4%

14.2%

4.5%

5.2%

3.4%

Halwa

5.5%

6.7%

3.7%

4.1%

6.3%

1.3%

3.8%

4.8%

2.3%

3.6%

4.8%

2.1%

Paratha

54.9 %

58.0%

50.5%

59.5%

62.6%

55.5%

40.0%

41.8%

37.6%

48.1%

50.8%

44.3%

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Total

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

A comparison of average consumption of six wheat flour-based products by household members is provided in the table 2, keeping the adult male as the control variable.

Table 2: Relative consumption of household members

Kulcha/ Naan/Roti

Sliced Bread

Khatai/ Biscuit

Rusk

Halwa

Paratha

Respondent Herself

82%

170%

219%

175%

121%

93%

Adolescent Girl

61%

167%

362%

168%

89%

87%

Child Under 5

22%

132%

781%

221%

60%

33%

Adult Male

100%

100%

100%

100%

100%

100%

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These results show that the contribution of the ready-to-eat wheat-based products is more significant for children under 5 than for other age groups, and so the fact these products are very likely to be made with fortifiable wheat flour is welcome. However, it is of concern for the future disease burden from non-communicable diseases that very young children are eating khatai/biscuits at a frequency approaching that of kulcha/nan/roti (46.5% versus 60.5%).

Likewise, the fact that almost 60% of adolescent girls consumed paratha in the last 24 hours is of concern for rapidly rising levels of overweight and obesity, which are especially affecting women in Pakistan.

Product Testing ●

It was found that labels on about a third of wheat flour packages (33.5%) provided for inspection had some mention of the product being fortified, either in writing or logo.

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Disappointingly, however, only 2 out of 3,342 wheat flour samples (virtually 0%) tested across eight districts were validated as adequately fortified, with 45 yielding ambiguous results. This was a decline from the first Round when 13% of wheat flour samples were adequately fortified.

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It is interesting that 49.3% respondents thought their last purchased wheat flour was fortified (even though testing established it was not), while 42.1% could not tell.

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A decline in the ratio of Ghee/cooking oil samples being fortified was also observed, from 100% in Round-1 to 91.1% in Round-2. 82.1% of the tested 201 samples were found to be adequately fortified with Vitamin A.

Price Perception and Sensitivity 

The average cost of wheat flour per capita per annum is PKR 3,359 while for oil/ghee it is PKR 2,805.



The majority (69.6% for wheat, 77% for oil) of households thought that fortified wheat flour and oil/ghee were more expensive than unfortified products.

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

Importantly, a majority of consumers demonstrated a low level of price sensitivity. 85.2% of consumers would buy fortified wheat flour if the price differential was PKR 0.50 per kg higher than the unfortified alternative (equating to PKR 10 for a 20 kg bag) and 78.5% of households would purchase if the cost was higher by PKR 1 per kg. For early districts, the price sensitivity of customers decreased for both wheat and oil/ghee from Round 1 to Round 2.

Attitude and Perceptions ●

Across all 8 districts, the responses indicate a generally positive attitude towards food fortification across all income segments: 75% of households find the idea of food fortification plausible, and 81.3% think that food fortification has major health benefits.

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However, only 57.5% of the households indicated that fortified foods were easily available, 76% expected the taste of fortified foods to be different than unfortified foods and 71.7% thought the appearance could be different.

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Nearly 80% of all respondents stated that they would switch to fortified foods if available in the market alongside their unfortified alternatives, with 61.6% indicating a strong preference.

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A significant improvement in attitude and perception regarding fortified foods was witnessed in the early districts over the year. There was a deterioration, however, in the perception that information on fortification was easily available.

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Resistors, defined as those who said they deliberately bought unfortified wheat flour or oil, are no more than 2-3% of the entire sample.

Part II: Retail User Survey ●

Retail Users, i.e. those businesses (nan shops, bakeries etc.) which procure large volumes of wheat flour with which they manufacture ready-to-eat products, were added in Round 2 to provide information on this source of products.

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Unlike the households category, chakkis are not a major direct source of wheat flour amongst Retail Users, even in the major production districts, with unbranded flour used by just 10.8%. This may be because they need to purchase regularly in bulk quantities and need a reliable source.

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About 243 brands were reported by Retail Users in addition to unbranded wheat flour.

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A majority of Retail Users consumed fine flour (53.9%), a relatively finer version of wheat flour which is whiter in colour. This was followed by atta (26.7%), a slight courser and browner variety normally used for roti. Maida or refined flour, which is generally used for making samosas, bread, Khatai/biscuits etc. was reported in use by the fewest respondents (19.4%),

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Around 65.8% of the respondents considered fortified wheat flour to be priced higher than unfortified. About 74.8% of Retail Users indicated their willingness to purchase fortified wheat flour even at a cost higher by PKR 1 per kg than the unfortified alternative. While a relatively low level of price sensitivity was seen, they were slightly more price sensitive than households.

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Labels on about a third of all packages (33.5%) had some mention of fortification, either in writing or logo, with a number of packages indicating in writing that the wheat flour in them was fortified 2.

Karachi’s packages had the highest proportion of fortification labeling (59.7%), followed by Gujranwala (46.1%)

2 Note: None of the 807 samples tested were verified as fortified.

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Most respondents (68.6%) indicated that they had never heard or seen any promotion about fortified wheat flour or related products, much like the households, yet about 60.2% respondents indicated that their purchase decision could be moderately or strongly influenced by the promotions they saw or heard.

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62.5% of Retail Users reported that they were using fortified wheat flour at their outlet, with almost a third (29.9%) saying they did not know and 7.6% stating they were using unfortified flour. This confirms findings from the household survey of a confusing picture in which purchasers may think they are using fortified flour, not being entirely clear about the meaning and potentially being misled by product labelling.

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Only about a fifth of the 7.6% reporting buying unfortified flour (1.7% overall) reported they were doing so because they did not want fortified flour and who may be considered resistors.

iii. Retail Supplier Survey Awareness ●

The highest overall first mention against ‘Food Fortification’ by Retail Suppliers, was Wheat Flour (33.2%), followed by Roti (15%). Ghee was mentioned by 4% and Cooking Oil by 3.3% of the Retail Suppliers.

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For Early Districts, the first mentions of Flour grew from 20.7% to 41% in Round-2; whereas, Ghee, however, lost its standing significantly from 23.7% in Round-1 to 6.2% in Round-2

Availability ●

A total of 243 brands of wheat flour were reported to be in stock at the Retail Suppliers surveyed across the eight districts. Wheat flour in loose form was available at 423 (54%) retail outlets out of the 780 having wheat flour in stock. Rates ranged from PKR 32 to PKR 57 per kg.

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For Early Districts, the top three wheat flour brands in stock in Round 1 (Punjab, Classic, Islamabad) were also the top three in the second round, albeit with a different ranking.

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The top three oil brands in stock were Sufi, Dalda, Shaan for both rounds.

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A total of 111 different brands of Ghee were identified in stock with the Retail Suppliers interviewed across the eight districts in Round-2. Ghee was also available in loose form at 10% of retailers having Ghee/cooking oil in store at the time.

Price Perception and Sensitivity ●

Retail suppliers considered customers to be more price sensitive towards both wheat flour and ghee/cooking than indicated by households.

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There was an increase in the perceived price sensitivity in the Early Districts from Round 1 to Round 2, which contradicts the decline observed in the price sensitivity of the households.

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Conclusions and Recommendations ●

Projections of which groups are likely to benefit from fortification remain completely theoretical unless and until the “fortifiable” products become “fortified” products. The dismal results of wheat flour testing indicate a need to step up efforts by the milling industry and to establish universal and mandatory legislation for wheat flour to ensure a level playing field for all mills.

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The decline in adequately fortified samples for oil/ghee calls for a need to strengthen the implementation of the mandatory legislation for the fortification of oil/ghee.

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The positive attitude and perceptions toward fortification, and low price sensitivity, indicate an acceptance of the concept and healthy latent demand for fortified products. The supply side needs to be pushed so availability is no longer a challenge.

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Advocacy and communications activities should be prioritised to raise awareness and demand for fortified products with the population, and to encourage the milling industry to proceed with fortification.

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The issue of misleading packaging which suggests that products are fortified when they are in fact not, needs to be urgently addressed. FFP should undertake awareness raising to ensure greater accountability to consumers. Provincial regulatory bodies and consumer protection agencies need to undertake checks to ensure claims made on the packaging are valid. This is very important to maintain the credibility of fortification logos.

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While the percentage of consumers/retailers who actively avoid fortified food is small, the “resistors” pose a risk of rumors/disinformation and opposition to the programme. FFP’s media and communications activities should include a preemptive crisis communication plan/strategy.

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As the supply of fortified wheat flour grows, the final round of RDS needs to track whether income groups benefit equally or whether some higher income markets move faster than others, and ensure promotional efforts are targeted to mitigate any discrepancy across markets.