A case study on the scaling-up of double fortified salt through the public distribution system of a food security program in Uttar Pradesh, India: experiences, challenges, and achievements

Abstract

# Background Iron deficiency anemia (IDA) exerts an enormous public health burden in low-income countries, primarily affecting women and children. Double fortified salt (DFS) -- salt fortified with Iodine and Iron -- has the potential to prevent and correct iron deficiencies. Major challenges relate to the implementation and scaling-up of the production, distribution, and promotion of DFS. # Methods A pilot project for scaling up DFS through integration with the public distribution system (PDS) -- a federal food security program in India -- was implemented for a one-year period. One of the objectives was to test the scale-up model, critically evaluate its scalability, and assess drivers and spaces for the scale-up. Using the case study methodology, we reviewed program records, monitoring data, and key informant interviews with stakeholders. "Scalability considerations" and "drivers and spaces" framework from scale-up literature were used for synthesizing findings. # Results The PDS provided a readily available and expansive platform for DFS distribution, accelerating scale-up. Bundling DFS with other subsidized commodities increased the purchase of DFS, but not necessarily ensured utilization. Low demand due to lack of consumer awareness; consumer preference to the specific physical appearance of salt as a quality indication (premix particles in DFS perceived as impurities); slight discoloration of some food items, were main demand-side factors presenting a challenge to optimal scale-up. Inadequate state government resources for subsidizing DFS, lack of financial incentives to PDS shopkeepers for additional work, were significant supply-side challenges. The approach, however, provided for innovative financing (especially from the private sector) for investments in scaling-up nutrition interventions through multi-sectoral partnerships, while serving the interests of individual sectors. # Conclusion Introducing DFS in food security schemes with extensive outreach can accelerate the scaling-up of fortification interventions. Contextual factors critical to scaling-up, from both the supply and demand side, should be identified and addressed before and during scaling-up.