(2023) RANFOSE Final Performance Evaluation Report

This report is made possible by the support of the American People through the United States Agency for International Development (USAID). The contents of this report are the sole responsibility of International Business Initiatives, Corp. (IBI) and Social Impact, Inc. (SI) and do not necessarily reflect the views of USAID or the United States Government. PHOTO CREDIT: DAVID ROCHKIND, USAID RANFOSE FINAL PERFORMANCE EVALUATION REPORT HAITI EVALUATION AND SURVEY SERVICES PLUS (ESS+) December 2023 Task Order #72052122F00001 Under EVAL-ME II IDIQ Contract #7200AA20D00026 USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | ii TABLE OF CONTENTS Table of Contents ..................................................................................................................... ii Acronyms ................................................................................................................................. iii Executive Summary ................................................................................................................ iv Background ................................................................................................................................................... iv Evaluation Purpose and Evaluation Questions ........................................................................................ iv Evaluation Design, Methods, and Limitations .......................................................................................... iv Findings and Conclusions ............................................................................................................................ v Recommendations ...................................................................................................................................... vii Introduction .............................................................................................................................. 1 Evaluation Purpose and Questions ......................................................................................... 2 Evaluation Purpose ...................................................................................................................................... 2 Evaluation Questions .................................................................................................................................. 2 Evaluation Methods and Limitations ...................................................................................... 4 Findings and Conclusions......................................................................................................... 6 EQ 1. Considering the activity’s theory of change, to what extent has the project been effective in improving the availability of adequately fortified foods that are priorities for improving the health of women of reproductive age and children under five? .......................................................... 6 EQ 2. To what extent has the activity’s stakeholder engagement and involvement been effective in accomplishing the rollout of large-scale food fortification (LSFF)? ............................................... 12 EQ 3. To what extent has the activity’s implementation strategy been effective in strengthening the fortified foods supply chain? .............................................................................................................. 16 EQ 4. What has the project done to support or inhibit the sustainability of food fortification? 18 EQ 5. How has RANFOSE evolved and adapted to the political, security, and economic challenges they encountered? .................................................................................................................. 21 Recommendations ................................................................................................................. 22 Continue LSFF Support in Haiti .............................................................................................................. 22 Maintain the Food Fortification Working Group (FFWG) ................................................................. 22 Advocacy at the Highest Political Level ................................................................................................. 22 Premix Availability and Affordability of Fortification ........................................................................... 22 Strengthen Laboratory Facilities ............................................................................................................. 23 Couple Inspections for Enforcements .................................................................................................... 23 Social Audits: An Alternative for Monitoring Compliance of Fortified Foods ................................ 24 Awareness-Raising as the Key to Consumption .................................................................................. 24 Annexes ................................................................................................................................... 25 Annex I: Evaluation Timeline ................................................................................................................... 25 Annex II: Evaluation Scope of Work ...................................................................................................... 26 Annex III: Evaluation Design & Inception Report ................................................................................. 40 Annex IV: Data Collection Tools ............................................................................................................ 68 Annex V: Sources of Information ......................................................................................................... 119 Annex VI: Findings, Conclusions, Recommendations (FCR) Matrix ............................................... 122 Annex VII: Disclosure of Conflicts of Interest.................................................................................... 128 Annex VIII: Evaluation Team Members ................................................................................................ 134 Annex IX: RANFOSE Product mapping outputs ................................................................................ 136 Annex X: Summary of production data (RANFOSE partners and non-partners) ........................ 139 Annex X1: Technical Specifications Published .................................................................................... 140 Annex XII. Assessment on the laboratory capabilities to analyze fortified foods. ....................... 142 USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | iii LIST OF TABLES Table 1: Planned vs Realized KIIs, FGDs, and RIs ........................................................................................... 5 ACRONYMS BHN Haitian Standards Bureau COA Certificate of Analysis CSO Civil Society Organization CU5 Children Under Five DCQPC Direction for Quality Control and Consumer Protection DEC Development Experience Clearinghouse EQ Evaluation Question ET Evaluation Team FAO United Nations Food and Agricultural Organization FFWG Food Fortification Working Group FGD Focus Group Discussion GAIN Global Alliance for Improved Nutrition GoH Government of Haiti HP Health Practitioner IO International Organization KII Key Informant Interview LSFF Large-Scale Food Fortification MCI Ministry of Commerce and Industry MoA Ministry of Agriculture MoH Ministry of Health MT Metric Ton NGO Non-Governmental Organization PaP Port-au-Prince PNCS Programme National de Cantines Scolaires QA Quality Assurance QC Quality Control RANFOSE Ranfose Abitid Nitrisyon Pou Fè Ogmante Santé RI Rapid Interview SI Social Impact SOW Scope of Work ToT Training of Trainers UNICEF United Nations Children’s Fund USAID United States Agency for International Development USDA United States Department of Agriculture WFP World Food Programme WRA Women of Reproductive Age WTO World Trade Organization Yr Year USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | iv EXECUTIVE SUMMARY BACKGROUND In 2017, the United States Agency for International Development (USAID) launched Ranfose Abitid Nitisyon Pou Fè Ogmante Santé (RANFOSE)—a food fortification project—to reduce some micronutrient deficiencies in Haiti. In collaboration with the Ministry of Health (MoH), Partner of the Americas implemented the project and worked with importers, distributors, and local food producers to fortify wheat flour with iron, folic acid, and other vitamins, as well as vegetable oils with vitamin A and salt with iodine. In 2021, the project received an initial two-year extension until June 2023 and a subsequent extension until January 2024 to allow planned activities to be implemented with the remaining funds. EVALUATION PURPOSE AND EVALUATION QUESTIONS The purpose of the evaluation is to assess progress to date and provide actionable recommendations to inform activity improvements or new approaches and opportunities. USAID, the primary user of this evaluation, may use the results to adjust and adapt its strategy in the Nutrition and Food Fortification program in Haiti. Secondary users include Implementing Partners, the Government of Haiti (GoH), local stakeholders from the private sector, civil society organizations, universities, and international organizations (IOs) in the country. This evaluation responds to the Evaluation Questions (EQ) drafted by USAID in the Scope of Work (SOW) (Annex II), namely: ● EQ1. Considering the activity’s theory of change, to what extent has the project been effective in improving the availability of adequately fortified foods that are priorities for improving the health of women of reproductive age (WRA) and children under five (CU5)?  ● EQ2. To what extent has the activity’s stakeholder engagement and involvement been effective in accomplishing the rollout of large-scale food fortification (LSFF)?  ● EQ3. To what extent has the activity’s implementation strategy been effective in strengthening the fortified foods supply chain?  ● EQ4. What has the project done to support or inhibit the sustainability of food fortification? ● EQ5. How has RANFOSE evolved and adapted to the political, security, and economic challenges it encountered? EVALUATION DESIGN, METHODS, AND LIMITATIONS Following a desk review of available literature, the evaluation used several qualitative methods to capture different perspectives: key informant interviews (KIIs) with stakeholders, participation in the Food Fortification Working Group (FFWG), focus group discussions (FGDs) or individual interviews with health practitioners (HPs), and rapid interviews (RIs) with shopkeepers, customers, and WRA. Some data collected by the evaluation were triangulated against secondary quantitative data from project monitoring data or other existing sources. Data collection lasted five weeks (May 30, 2023, to June 30, 2023) instead of three as planned. FGDs and RIs were carried out in three key departments that RANFOSE facilitated training of trainers (ToT) with HPs, i.e., Port-au-Prince (PaP) and Petion-Ville in the Ouest department, Cap-Haitian in the Nord department, and Jeremie in the Grande Anse department. All KIIs were conducted remotely, reaching 55 percent of planned KIIs, therefore limiting the number of perspectives obtained. Only reaching this percentage of planned KIIs possibly created some bias in the results if those that refused or were unavailable did so because they held a less favorable view of the project or had nothing to say about the project. It should be noted that a separate USAID market analysis of fortified foods comprised conducting interviews with the same USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | v stakeholders at the same time as the evaluation; this may have led to respondent fatigue and may explain the low response rate among KIIs. Three FGDs were held instead of five, and six individual interviews were conducted in lieu of an FGD, meaning 78 percent of planned HP were reached. Again, but to a lesser extent, only reaching this percentage of planned HP limited the range of perspectives obtained, especially in Grand Anse Department, where no HPs were reached. The response rate for Ris was 87 percent. The evaluation faced several challenges, including communication problems, the unavailability of key informants, an earthquake in Jeremie, and floods across the country, which delayed data collection. A thematic analysis of the data was carried out using Dedoose software. While RIs provided a snapshot of population awareness of fortified foods, it did not allow any statistically significant inferences to be made about the population, which would have required a population-based survey applied to a representative sample. FINDINGS AND CONCLUSIONS Below, the evaluation presents high-level findings and associated conclusions for each EQ. The details of the evaluation findings can be found in the body of the report under the findings section. It is important to contextualize these findings as food fortification is not yet mandatory in Haiti. While the Food Fortification Law was passed in 2017, no application texts (regulations)—which form the basis for the enforcement and monitoring of food fortification—have been approved yet. EQ1. Availability. While it is beyond the scope of this evaluation to measure the market share of fortified foods or the adequacy of fortification levels, which are best measured through market analysis, this evaluation found that RANFOSE has increased the availability of fortified wheat flour and oil and contributed to improving the quality of nationally iodized salt and fortified wheat flour on the Haitian market. According to KIIs with key actors in fortification in Haiti, this increase has been influenced by the project’s engagement with, as well as raising awareness to and providing technical support to the private sector, together with the latter’s commitment to fortify or improve their fortification processes, if they were fortifying already. However, the evaluation found that fortified foods are not consistently available in all shops and markets, remote areas, or across all departments, which is often where populations need them the most. It is not clear in what way the project has strengthened the availability of fortified foods for women of reproductive ages and children under five specifically. Awareness-raising and training events targeted different stakeholders and population groups through a variety of mass media campaigns, including WRA and CU5, through HPs and other non- governmental organizations (NGOs) working specifically with these target groups. According to RIs conducted, awareness exists of fortified foods and their benefits. However, RIs provided only a snapshot of the level of awareness in specific areas, whereas a national representative survey would more effectively measure population awareness and consumption behaviors, therefore allowing better targeting of awareness-raising activities (format, locations, and population groups). According to FGDs and RIs, the added cost of fortified foods is a barrier to consumption, in addition to limited availability, mainly due to distribution problems and the internal situation in Haiti. EQ2. Stakeholder Engagement. Both private and public sectors have contributed to advancing large-scale food fortification through their engagement with the project. The MoH, the Ministry of Agriculture (MoA) and the Ministry of Commerce and Industry (MCI) were all listed in the Food Fortification Law as key players in its implementation. All have actively advocated for the approval of the application texts. The MoH collaborated with RANFOSE on the advocacy and behavior change strategy; the MCI, through the Haitian Standards Bureau (BHN), was key to reviewing the USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | vi fortification standards with the project; and the national laboratory under the MoA was involved from the start but has been out of operation since 2021. The project further engaged stakeholders from industries, civil society organizations, universities, and international and non-governmental organizations. It carried out advocacy and capacity-building initiatives with the public and private sectors, as well as civil society actors. These activities have maintained motivation levels and strengthened collaborations within and between the private and public sectors to improve the legal environment. According to most stakeholders interviewed, the lack of approved regulations is a major barrier to private sector engagement in fortification, which subsequently limits the effective rollout of LSFF. RANFOSE has influenced the legislative environment in the country by collaboratively reviewing and supporting the approval standards provided by WFP for fortified foods, which are voluntary, as well as the development of the application texts and continued advocacy for their approval to make fortification mandatory. The three key ministries identified by the Food Fortification Law (MoH, MCI and MoA) have independently and collaboratively advocated for its approvals, as has USAID. The lack of approval to date is out of RANFOSE’s control, but advocacy must persist if the application texts are to be approved and guarantee mandatory food fortification. Only then will the country have the legal framework to implement monitoring and enforcement. In the absence of approved regulations for fortification, which form the basis for enforcement, alternative solutions have not been found; there is no enforcement of food fortification to date despite the Food Fortification Law being approved in 2017. Since the MoH has been doing food safety inspections with salt producers, the food safety inspections could be extended to food fortification inspections, thereby strengthening enforcement. The inaccessibility of the national laboratory, in addition to the lack of regulations, hinders the GoH’s ability to monitor fortified foods. The equipment donated by the project to the laboratory could not be installed and remains unutilized. Industries received testing kits from RANFOSE and are reportedly using these to monitor fortification levels. Until the national laboratory is operational again, other laboratories could have been strengthened to conduct sample testing to monitor quality control (QC) of fortified foods. EQ3. Supply Chains. Industries identified several factors that negatively impact their production and the supply chain, such as a) the unfair competition resulting from those factories not fortifying, who are able to make higher profits than those fortifying given the added cost of fortification; b) smuggled products flooding the market; c) the exorbitant customs tariffs which apply to premix and fortification equipment; and d) poor quality and limited raw material availability. Those who are fortifying do so voluntarily because they want to contribute to the population’s health and because they can sustain the added cost of fortification. All project partner importers and producers reported implementing Quality Assurance (QA) and QC procedures to control the production or importation of fortified foods, thanks to RANFOSE’s training and technical assistance. Incentives for industries are needed to ensure that the cost of fortification does not render fortified products too costly to produce and, therefore, unaffordable for the population, especially for vulnerable populations in hard-to-reach areas. EQ4. Sustainability. The sustainability of LSFF in Haiti cannot be guaranteed until the application texts are approved, resulting in mandatory fortification and enforcement. Some strong foundations for the implementation of LSFF have been laid by RANFOSE through the creation of multi- stakeholder networks, which are said to be beneficial to all stakeholders involved in the FFWG. However, LSFF takes time and requires persistence, especially in a challenging socio-political context USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | vii such as Haiti. Many key informants report that financial and technical support from IOs to the GoH to consolidate LSFF should continue and thereby build on the foundations that have been laid. EQ5. RANFOSE Adaptability. The operating environment in Haiti entails a great number of significant challenges: the deteriorating national infrastructure, widespread and severe insecurity, national hyperinflation, and the COVID-19 pandemic are major factors that have limited the ability of RANFOSE to deliver a full rollout of LSFF. To overcome the challenges, RANFOSE developed and adopted alternative strategies to continue advocacy, awareness raising, stakeholder engagement, and capacity development. RECOMMENDATIONS Key Priority. USAID should continue supporting LSFF in Haiti to capitalize on the achievements made by RANFOSE and to contribute to improving the nutritional intake of a population that greatly needs it. Food Fortification Working Group. The FFWG should be structured through a steering committee where sensitive matters can be discussed and solutions can be proposed. Include an advisory committee. Advocacy. The FFWG should advocate at the Inter-Ministerial Human Rights Committee, which is presided over by the Prime Minister, for the approval of the application texts (regulations), application of enforcement by GOH, and any other important matters related to fortified food that arise in the future. Premix and Affordability of Fortification. The FFWG should advocate to the GoH to implement measures to facilitate imports of premix, such as tax exemptions for purchases of premix, equipment (feeders and reagents), and supplies for i-checks used in QA/QC, and to provide technical assistance to develop the technical criteria needed to implement these measures. Strengthen Industry Production Process. USAID should strengthen the overall capacities of factories in food safety and food fortification so that they can comply with potential client requirements, such as organizations distributing fortified foods through government or other food aid programs. Food Fortification Cost Analysis. USAID should carry out a cost analysis of fortification in Haiti and use that information as an advocacy tool for the food industry and GoH, showing that food fortification’s impact on price is not as high as previously thought and that the industry can still have revenue. Updating the Application Texts. Based on the standards approved by BHN, the FFWG should review the application texts to ensure that there are no contradictions between them and address any issues identified before they are approved. E.g.: consider the addition of vitamin B12 to wheat flour. QC/QA Activities. While it is still ongoing, RANFOSE should analyze the data from industry reports and present a report periodically to the FFWG to discuss results and implement actions to improve the process. Consider praising the actions of those factories complying with the Food Fortification Law. Laboratory Facilities. USAID should map laboratories around the country and assess their capacity to find an alternative laboratory to provide testing services Enforcement. Food fortification inspections should be coupled with other inspections carried out by the MoH, MCI, and MoA to optimize available resources. While there is improvement in USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | viii laboratory capabilities, inspections should focus on verifying the QA/QC practices of the factories, with an equivalent approach for imported foods. “Social Audits.” While enforcement is being established in the country, USAID could support consumer associations or consumer organizations to carry out “social audits”: purchasing fortified food samples at retail stores around the country and sending them to a laboratory to determine compliance. Awareness-Raising Activities. USAID should continue raising awareness of fortified foods, especially in remote and hard-to-reach areas where the population is most vulnerable to malnutrition. Awareness raising must be coupled with the availability of fortified foods. USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | 1 INTRODUCTION In 2017, the United States Agency for International Development (USAID) launched Ranfose Abitid Nitrisyon Pou Fè Ogmante Santé (RANFOSE)—a food fortification project—to reduce some micronutrient deficiencies in Haiti. In collaboration with the Ministry of Health (MoH), Partner of the Americas implemented the project and worked with importers, distributors, and local food producers to fortify wheat flour with iron, folic acid and other vitamins, as well as vegetable oils with vitamin A and salt with iodine. RANFOSE also supported the implementation of food fortification legislation by providing technical assistance to the Government of Haiti (GoH) to create a legislative and regulatory environment supporting the production and importation of fortified foods. In 2021, the project received a two- year extension to January 2024. The project aimed to contribute to long-term health and economic benefits for the Haitian people, including the decreased prevalence of micronutrient deficiencies and related micronutrient deficiency disorders (e.g., anemia), increased nutritional resilience against future food security shocks, decreased morbidity and mortality via improved disease immunity, and increased economic productivity and growth. In addition, the project was to ensure that strong channels of communication and participation among the public sector, private sector, and civil society remain open in support of the nutrition strategy and its operationalization. Lastly, RANFOSE aimed to strengthen the national strategy for fortification and improve quality control (QC) for locally sourced or imported fortified food products. RANFOSE aligned with both a) the Plan Stratégique de Nutrition 2013-2018 of the GoH’s MoH, which focuses on the prevention of malnutrition, and b) USAID’s Multi-Sectoral Nutrition Strategy (2014– 2025), which seeks to decrease chronic malnutrition through the increased availability of and access to high-quality nutrition-specific services and commodities, increased political will and resources for nutrition programs, and strengthened engagement with the private sector to improve nutrition. 2 | RANFOSE FINAL PERFORMANCE EVALUATION REPORT USAID.GOV EVALUATION PURPOSE AND QUESTIONS EVALUATION PURPOSE The main purpose of this evaluation is to assess progress to date and provide actionable recommendations to inform activity improvements or new approaches and opportunities. As the primary user of this evaluation, USAID may use the results to adjust and adapt its implementation strategy in Nutrition and Food Fortification in Haiti. Secondary users include the Implementing Partners, GoH, MoH, and local stakeholders such as producers, importers, sellers in markets, consumers, as well as local universities, and major international organizations (IOs), such as UNICEF (United Nations Children’s Fund), Food and Agriculture Organization (FAO), World Food Programme (WFP), and Iodine Global Network. EVALUATION QUESTIONS This performance evaluation aims to answer the evaluation questions (EQs) drafted by USAID (see Annex II). For each EQ, USAID has requested that the Evaluation Team (ET) consider the project performance in relation to specific aspects. These are as follows: EQ1. Considering the activity’s theory of change, to what extent has the project been effective in improving the availability of adequately fortified foods that are priorities for improving the health of women of reproductive age (WRA) and children under five (CU5)? a. Identify specific areas in which RANFOSE’s input has improved the availability of fortified foods, particularly for WRA and CU5. b. Consider key factors that facilitate or inhibit the availability of fortified foods, particularly among WRA and CU5. c. Highlight the relevancy and effect of the advocacy campaigns with consumers and the factors affecting consumers’ awareness and consumption of fortified foods. EQ2. To what extent has the activity’s stakeholder engagement and involvement been effective in accomplishing the rollout of large-scale food fortification? a. Identify where RANFOSE’s engagement with leadership in different areas (e.g., private sector; GoH) has proven to be instrumental in improving availability. b. Assess the project’s accomplishments and influence on the local Food Fortification Alliance, the national standards, and legislative environment about fortified foods. For instance, consider the performance of the GoH in the areas of: 1) regulation; 2) enforcement (at factories, importation sites, and markets); and 3) the monitoring of fortified samples. c. Determine what—if anything—were the limiting factors or what RANFOSE could have done better to support the development and implementation of the national standards. EQ3. To what extent has the activity’s implementation strategy been effective in strengthening the fortified foods supply chain? a. Consider what factors and activities affected food fortification production and value/supply chain stakeholders (production centers, importers, distributors, markets and retailers, regulatory agencies, etc.). b. Capture business performance and practices as well as price and perceived affordability of fortified wheat flour and edible oil/ghee, how the project influences the premix and micro feeder market, and the technical challenges and lessons learned in strengthening the fortification compliance of the current food fortification programs (wheat flour, oil, and salt—including use of iodized salt in bouillon cubes). USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | 3 EQ4. What has the project done to support or inhibit the sustainability of food fortification? a. Identify nutrition-related barriers and opportunities for sustainability. b. Consider synergy with other USAID projects, factors affecting public and private sector engagement, the regulatory and socio-political environment, and other factors that are likely to support or inhibit the sustainability of food fortification. Consider if there were opportunities and stakeholders that RANFOSE had hoped to use that did not materialize, and document why they were not possible. c. Explore emerging opportunities and alternative options for monitoring compliance of food fortification beyond reliance on the GoH. EQ5. How has RANFOSE evolved and adapted to the political, security, and economic challenges it encountered? a. Explore how the environment has affected the project’s ability to deliver from when it was awarded to what it is doing now. Document the lessons learned to avoid reinventing the wheel in the future. 4 | RANFOSE FINAL PERFORMANCE EVALUATION REPORT USAID.GOV EVALUATION METHODS AND LIMITATIONS The evaluation adopts Social Impact’s (SI) Evaluation, Quality, Understanding and Impact (EQUI) approach, ensuring quality checks are applied at each stage of the evaluation process. Based on the nature of the evaluation objectives and following the desk review, the ET chose a qualitative approach to data collection, to be triangulated against secondary data from project monitoring data or other existing sources, where possible. Please refer to Annex I for the evaluation timeline, Annex III for the Evaluation Design and Inception Report—including full details of the evaluation design and ethical clearances obtained—and Annex IV for the full list of data collection tools used. Methods. The ET used various methods to capture different perspectives: Key Informant Interviews (KIIs) with stakeholders, Food Group Discussions (FGDs) or individual interviews when FGDs were not possible with Health Practitioners (HPs), Rapid Interviews (RIs) with shop owners and managers, customers and WRA, as well as an observation of and participation in a Food Fortification Working Group (FFWG) meeting—instead of holding a planned FGD with FFWG members. The sampling was purposeful, with locations selected based on the departments in which the project facilitated the training of trainers (ToT) to HPs to disseminate the benefits of fortified foods among their colleagues and the wider population. The three selected departments were the Ouest (Port-au- Prince [PaP] and Petion-Ville), Nord (Cap-Haitian) and Grande Anse (Jeremie) departments. Data Collection. , an ESS+ subcontractor, and the ET collectively carried out data collection. organized a five-day training for enumerators and the supervisor (May 24 to 29, 2023), including a day of piloting, and carried out field visits for RIs and FGDs, which started immediately after the training and continued for two weeks. then began outreach and scheduling for KIIs. Data collection ended on June 30, 2023, having lasted five weeks instead of three as planned. teams conducted FGDs and individual interviews and RIs in person in the three departments and carried out both remote and face-to-face KIIs. In Grand Anse, the few HPs that were reachable (six) were not available to attend an FGD; therefore, remote individual interviews were carried out with those who were available. All FGDs and RIs were carried out face-to-face either in health centers (FGD and RIs with WRA) or in shops (RIs with shopkeepers and customers), except one FGD in the Ouest, which took place in a private space as the sampled health center did not authorize the evaluation to conduct activities on the premises. In the Nord, HPs were either not reachable or unwilling to participate, meaning no HP was interviewed in the Nord. The ET carried out remote KIIs, with the assistance of two note-takers from ESS+ and performed data quality checks on the data collected by . The ET checked both the original transcripts (French or Kreyòl) and the English translated versions provided by , in addition to translating their own KII transcripts. Data Analysis. A thematic analysis of the data was done in Dedoose software, using a hybrid approach of both deductive and inductive methods for coding the data. Before analysis, a codebook was prepared based on the EQs. During analysis, new codes were generated as required. The coded data was extracted from Dedoose and analyzed to allow themes and sub-themes pertinent to each EQ to emerge. Interactions between themes and sub-themes were analyzed to produce findings. Several analytical working sessions were held by the ET to triangulate the findings, draw conclusions, and produce recommendations. Data was disaggregated by department and respondent type wherever it was helpful to do so. Limitations. The political insecurity in Haiti limited the team’s mobility and geographic reach during data collection. Moreover, during the initial weeks of data collection, an earthquake in Jeremie and severe floods in Haiti (start of June) delayed teams from collecting RI and FGD data, given health 6 | RANFOSE FINAL PERFORMANCE EVALUATION REPORT USAID.GOV FINDINGS AND CONCLUSIONS EQ 1. CONSIDERING THE ACTIVITY’S THEORY OF CHANGE, TO WHAT EXTENT HAS THE PROJECT BEEN EFFECTIVE IN IMPROVING THE AVAILABILITY OF ADEQUATELY FORTIFIED FOODS THAT ARE PRIORITIES FOR IMPROVING THE HEALTH OF WOMEN OF REPRODUCTIVE AGE AND CHILDREN UNDER FIVE? PROJECT EFFECTIVENESS IN IMPROVING THE AVAILABILITY OF FORTIFIED FOODS The evaluation finds that RANFOSE has been effective in improving the availability of fortified foods in Haiti. One of the first initiatives undertaken by the project was the mapping of fortified products and associated stakeholders in 2018 and again in 2022; this initiative enabled the identification of a) industries already engaged in food fortification; b) the fortified products available on the market; and c) potential industries to approach to join food fortification efforts (see Annex IX for the RANFOSE mapping outputs). The project advocated the importance of food fortification to these industries and obtained the commitment of some industries that were already fortifying to strengthen their fortification practices (wheat flour [two] and salt [one]) as well as recruiting new industries and importers to begin fortifying (e.g., oil [two], importer [one] and wheat flour [one]). Later in 2018, the project supported partner industries with site visits and observations of the factories’ fortification capacities to provide technical recommendations for reaching adequate fortification levels. While providing this technical support to industries, the project collaboratively reviewed the fortification standards (see Annex XI for the final version of the technical specifications) with the Haitian Standards Bureau (BHN) and industries to ensure the adequacy of fortification. Producers also received rapid test kits to verify the adequacy of vitamin A levels in oil and iron levels in wheat flour. AVAILABILITY OF FORTIFIED WHEAT FLOUR, OIL, AND SALT It is beyond the scope of this evaluation to assess the availability of fortified foods on the market. However, according to the data collected by this evaluation, by 2020, the project had partnered with three wheat flour mills, three oil bottlers, and one salt producer to fortify to recommended levels. Wheat Flour One of the three wheat mill partners unfortunately ceased operations following a violent attack in October 2022, consequently reducing the availability of fortified wheat flour on the market. According to secondary data, there is a wheat mill that recently began fortifying and produces approximately 30,000 metric tons per year (MT/Yr). However, the evaluation has no information on the specifications used. Collectively, the two remaining wheat mills that partnered with RANFOSE produce 95,000 MT/Yr of fortified wheat flour (equivalent to 129,960 MT/Yr of wheat). 1 The quantity of fortified wheat flour produced by these two factories alone represents nearly one-third of the total wheat flour and wheat products obtained from imported wheat grain into Haiti (405,000 MT/Yr). 2,3 Wheat flour and wheat products (including pasta and other wheat products) are imported from the Dominican Republic and other countries (Turkey, Peru, Egypt, Argentina, European Union). 4 It is 1 Considering wheat grain imports were around 210,000MT, the flour yield from wheat grain being about 70-75%, therefore, that amount of wheat would yield 152,250 MT of wheat flour. 2 USDA & GAIN “Grain And Feed Annual”, Haiti 2022, https://www.fas.usda.gov/data/haiti-grain-and-feed-annual-4 3 Food and Agriculture Organization (FAO). Food Balance Sheets (2010- ). https://www.fao.org/faostat/en/#data/FBS/report 4 USDA & GAIN “Grain And Feed Annual”, Haiti 2022, https://www.fas.usda.gov/data/haiti-grain-and-feed-annual-4 USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | 7 estimated that illegal imports of wheat flour and wheat products comprise between 100,000 to 120,000 MT/Yr. 5 Oil Haiti imports 100 percent of the vegetable oil on the market. Palm is the most widely consumed oil (about 80 percent) followed by soybean oil (13 percent). 6 It is mainly imported from Indonesia and Malaysia, with some from the Dominican Republic. 7 There was no locally fortified palm oil before RANFOSE began; the project approached and obtained the engagement of two oil bottlers to start fortifying the oil they bottle and one importer to import fortified oil. It is not clear what share of the market is held by illegally imported oil, which reportedly remains the biggest competitor to fortified oil. Thanks to the increased availability of fortified oil on the Haitian market, WFP now reports being able to source fortified oil and wheat flour locally for their school feeding programs, which they couldn’t before RANFOSE. Salt The only salt producer to iodize salt in the country has a market share of 3 to 5 percent, produces 2,500 MT/Yr of salt, and supplies both industries and the retail market. RANFOSE worked with this producer to improve the iodization process, thereby improving the adequacy of fortified salt for the Haitian market. Despite this low reported market share, according to the population and HPs interviewed, salt is the most readily available fortified food, possibly resulting from the technical support brought by UNICEF to salt iodization over the years. Based on documents reviewed, either from RANFOSE or international reports, 2,8 as well as data collected by the evaluation, information about the coverage of fortified wheat flour, oil, and salt in the country is sometimes contradictory and is not based on actual data from sampling and chemical analysis of products. However, most respondents report that availability is restricted to select shops in urban areas, with limited or no availability in markets, rural areas, and departments with low accessibility. Even though RANFOSE is a policy project and therefore not directly targeting specific areas or population groups, the ET found that the project has made concerted efforts to raise awareness among WRA and mothers of CU5 (vulnerable groups targeted through the Nutrition Strategic Plan for Haiti) 9 on the benefits of fortified foods by training HPs and partnering with civil society organizations (CSO) and nongovernmental organizations (NGOs) that work directly with these target groups. AVAILABILITY OF OTHER FORTIFIED FOODS Although the law on food fortification is limited to specific products, there are other fortified products on the market, such as butter, margarine, mamba, peanut butter, and cereals. However, it is not clear what specifications are being used in these products. Moreover, according to both public and private sector actors, the widespread benefits of fortification could be strengthened by fortifying other products on the market, such as rice, pasta, and maize, which are widely consumed by the Haitian population. 5 USDA & GAIN “Grain And Feed Annual”, Haiti 2023, https://www.fas.usda.gov/data/haiti-grain-and-feed-annual-4 6 Food and Agriculture Organization (FAO). Food Balance Sheets (2010- ). https://www.fao.org/faostat/en/#data/FBS/report 7 Malaysian Palm Oil Council. https://mpoc.org.my/palm-oil-market-chain-in-haiti/ 8 Food and Agriculture Organization (FAO). Food Balance Sheets (2010- ). https://www.fao.org/faostat/en/#data/FBS/report 9 Ministère de la Santé Publique et de la Population.Unité de Coordination de Programme National D’alimentation et de Nutrition UCPNANU. Plan Stratégique de Nutrition 2013-2018. 2013. 8 | RANFOSE FINAL PERFORMANCE EVALUATION REPORT USAID.GOV FACTORS THAT FACILITATE OR INHIBIT THE AVAILABILITY OF FORTIFIED FOODS Among the key factors facilitating the availability of food fortification in Haiti are the motivation of industries to fortify foods and the demand for these products, with the latter increasing as awareness of the benefits of fortified foods grows, according to a variety of respondents. However, these two aspects alone are stalled by difficulties associated with the availability of raw materials, the legislative and operational environment, economic instabilities, and product identification, all of which hamper the availability of fortified foods. KIIs collectively suggested the following key factors inhibit the availability of fortified foods. “The micronutrients have to be cleared at exorbitant prices. They sometimes impose slips with false amounts on us and we cannot rectify it, we just have to give in. These factors push me to sell our products at a price that allows me to stay in the market and be able to order more products.” – KII Industry “Sometimes we spend six months without reaching some areas because of insecurity.” – KII Industry Raw Materials The private sector has the will to fortify foods but is discouraged by the high customs tariffs that sometimes apply to premix imports into Haiti, which are not standardized. On the other hand, the Food Fortification Law states that the GoH will subsidize the premix, 10 but this has not been implemented yet. Haiti does not produce wheat or oil but relies on imports to satisfy domestic demand 11 and, therefore, suffers the associated customs tariffs. With the additional cost of the premix and equipment related to fortification, which are also imported, production prices go up even further. Legislative Environment The evaluation finds that the lack of approved application texts is a key limitation to increasing the availability of fortified foods, as well as to ensuring the compliance of the ones already being fortified. It inhibits oil producers that are still not engaged from fortifying and discourages wheat flour producers from continuing to do so. Some industries refuse to fortify because of the absence of the application texts, while others refuse or are discouraged from continuing fortifying because there are non-compliant, sometimes illegal wheat flour and oil products entering Haiti that are more competitive. Controls and enforcement are lacking, making fortification unattractive to some industries. Operating Environment The operating environment is highly unstable, and the availability of fortified foods is highly volatile. Insecurity, bad roads, fuel scarcities, corruption, and COVID-19 hinder the production and distribution of fortified foods. At the production level, it creates irregularities in raw material supply, inhibiting the constant availability of fortified foods. At the distribution level, areas like Plateau Central and Bas Artibonite, where gangs operate, have difficulties receiving supplies. Some companies interviewed distribute fortified foods to St. Mark’s via boats. This situation inhibits the availability of fortified foods for the population outside the metropolitan area or in remote areas. 10 Food Fortification Law. 2017. Le Moniteur. Journal Officiel de la Republique D'Haiti. 172 Année. Special No. 6 11 USDA & GAIN “Grain and Feed Annual” Haiti 2022, https://www.fas.usda.gov/data/haiti-grain-and-feed- annual-4 USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | 9 "Tariffs reach 40–45 percent of Cost, Insurance, and Freight (CIFs). In the end, it's the consumer who pays. Given living conditions, if this continues, I may stop fortifying." – FFWG Economic Pressures Food fortification incurs a cost that affects a) producers, who can’t always afford the raw materials and equipment for fortification; b) importers, for whom customs tariffs are high; and c) consumers, who can’t afford fortified foods, especially in a context of inflation. Lack of Entry Barriers According to KII respondents, smuggled imports (fortified and unfortified) compete with fortified foods as they are often cheaper but reportedly not adequately fortified or pose food safety issues. Smuggling cases are common in Bas Artibonite, Plateau centrale, Nord, and near the border. In the North, according to respondents, some smuggled oil is said to be made from recycled oil and not fortified, and some wheat flour is said to be expired, both of which come from the Dominican Republic. Unfortunately, the United States Department of Agriculture (USDA) expects that in the short- and medium-term, illegal trade of wheat products across the Haiti–Dominican Republic border will continue. 12 Identification KII and FGD respondents agree that a logo is needed for consumers to identify fortified products, as stated in the 2017 Haiti Food Fortification Law. Currently, the population must read labels— requiring literacy—or recognize the fortified brands. While most stakeholders believe the logo to be a very good initiative as it will allow easy identification of fortified foods and serve as a quality certification, some producers worry about the added cost of adding a label to their packaging. To date, a logo has been developed and agreed collaboratively with GoH and industries and is with the MoH, waiting for the approval of the application texts. RELEVANCE AND EFFECTIVENESS OF THE ADVOCACY CAMPAIGNS The project developed an advocacy strategy and behavior change activities in collaboration with the MoH’s National Nutrition Program. However, campaign effectiveness would be best measured through a representative survey at the population level. Awareness-raising activities included: ● Fairs and events to celebrate World Health Day, Vitamin A Day, Agriculture and Labor Day Fair, and others. ● Training and events to promote fortified foods to industries, universities, schools (via the Programme National de Cantines Scolaires [PNCS]), and local authorities. ● Training on iodized salt to over 400 street vendors to promote iodized salt use in cooking. ● ToT to over 200 HPs (nurses and health agents) with USAID Health program. ● Communication materials developed collaboratively with the Directorate of Health Promotion and Environmental Protection. ● Hiring of a Communication firm to manage the communication campaign. ● The launching of mass media campaigns with local and national coverage through television adverts and radio spots at peak viewing times, posters and brochures, Facebook, Instagram, and online platforms that disseminate the benefits of fortified foods for pregnant and lactating women, children, and youth. ● Interviews with project representatives on local PaP radio and television to talk about the benefits of fortified foods. ● The publishing of various press and academic articles on fortified foods. 12 USDA & GAIN “Grain and Feed Annual” Haiti 2022, https://www.fas.usda.gov/data/haiti-grain-and-feed-annual-4 10 | RANFOSE FINAL PERFORMANCE EVALUATION REPORT USAID.GOV ● The launch of a radio jingle contest with the National Nutrition Program with sponsorship from three industry partners. While the project aimed to equip the HPs to replicate the training, they were not provided with sufficient knowledge, tools, resources, or the authorizations required to do so, thereby reducing their effectiveness. HPs say that training sessions should have lasted longer and that they should have been equipped with material and financial support to facilitate further dissemination. Moreover, they were not provided with any instruction or authorization from their internal structures to replicate the training, suggesting that the project did not coordinate the activity with the health structures. All HPs interviewed report promoting fortified foods to colleagues and community members, including WRA, in the scope of their work but only a few replicated the training to colleagues, as planned by the project. In addition to RANFOSE’s awareness-raising activities, the promotion of fortified foods is being done by the MoH and health centers, UNICEF, NGOs, and mothers clubs led by HPs that reach WRA and women with CU5. RANFOSE engaged with many of these organizations, many of whom participated in the FFWG. RI respondents report having heard about fortified foods from a variety of sources: schools, hospitals, radio (most common) and television, churches, posters, women’s groups, friends, and word of mouth (less commonly reported). RANFOSE targeted schools through its collaboration with the National School Feeding Program (PNCS). According to respondents, RANFOSE was the only project to launch a radio and TV campaign on fortified foods. Radio is reportedly more effective than television. Fairs and promotion events are considered highly effective and have led to increased sales, according to industries. The Facebook and Instagram pages, which have over 5,000 followers, received low reactions to posts. KII respondents report that Facebook is a good medium for reaching young people and urban populations, although there is no evidence to suggest that RANFOSE reached either of these population groups specifically. Campaigns are not likely to have reached rural and remote areas, according to respondents, and some HPs had concerns about the format of the media campaign, saying the television and radio campaigns were too short, used the wrong platforms, or were not "catchy" enough. Only a few industries reported an increase in sales but did not quantify the increase. FACTORS THAT AFFECT CONSUMER AWARENESS AND CONSUMPTION OF FORTIFIED FOODS Awareness RIs with customers, shopkeepers, and WRA show that awareness levels are higher in Grand Anse and higher among WRA—who seek care in hospital during pregnancy—except in Ouest where awareness levels are generally low across all the sampled population. Those who report knowing about fortified foods could also list their benefits, which confirms their knowledge goes beyond only having heard the term and suggests there is awareness of the benefits of fortified foods. Given that only RANFOSE promoted fortified foods through radios and schools, it appears awareness raising has been effective through these media, whereas awareness obtained from hospitals could have resulted from other interventions rather than RANFOSE’s ToT activity. Most RI respondents said they have no concerns about fortified foods. Among those who did express a concern, the main issues were cost, the fact that the oil curdles, that iodized salt tastes too salty, and that the foods might lose their beneficial properties if not stored properly. Such "RANFOSE has contributed, educated and trained local consumers and manufacturers. But it's unfinished business." – KII Industry USAID.GOV RANFOSE FINAL PERFORMANCE EVALUATION REPORT | 11 concerns can mostly be overcome through better information dissemination on specific issues. Key informants emphasize the need for increased awareness raising at the community level to drive demand and, therefore, production. Consumption There are no reliable figures on fortified food consumption levels in the population. One key factor that prevents the population from consuming fortified foods is a lack of awareness. According to FGD and KII respondents, given that the Haitian markets are filled with smuggled or illegal products (fortified and unfortified), awareness becomes key to influencing the population to choose fortified products over unfortified ones. When awareness exists, the biggest hurdle to consumption is cost, followed by irregular supply and scarce availability of fortified foods on the market, especially in rural areas. According to KII and FGD respondents, the availability and consumption of smuggled products are still common, primarily because of their cheaper price, regardless of fortification levels and quality (e.g., recycled oil or expired wheat flour). The existence of cheaper products on the market is a barrier to the consumption of fortified foods. Salt seems to be the most cited fortified food purchased by respondents in the population, either locally produced fortified salt or imported fortified salt, although many also listed buying wheat flour and oil. CONCLUSION Thanks to the advocacy and the technical support provided, and despite challenges such as the lack of raw materials, the legislative and operational environment, and economic instability, RANFOSE has improved the availability of fortified wheat flour and oil nationally by increasing the number of producers and importers fortifying in the country and by building capacities to fortify adequately. Although fortified salt was already on the market before RANFOSE, the project improved the adequacy of fortified salt through technical support to the only salt factory fortifying but did not extend salt iodization to other factories. Given the additional effort and cost of fortifying for the private sector, obtaining the commitment of industries to fortify despite the lack of regulations is a significant achievement in improving the availability of fortified foods. Despite clear improvements in the availability of fortified foods, in the absence of a national market analysis, the ET could not provide a reliable estimate of the availability or adequacy of fortified products in the Haitian market. Efforts remain to be made to improve the availability, and therefore consumption, of fortified foods nationally, especially in markets, in rural areas, and in departments with low availability, particularly given that these are areas that comprise high proportions of vulnerable populations who are most in need of the health benefits brought by fortified foods. The evaluation finds that the ToT of HPs was a good strategy for raising awareness in the population, especially in WRA and mothers of CU5, but it was not sufficiently supported to reach its intended potential. Better collaboration with health structures and more support and follow-up from RANFOSE would have undoubtedly increased ToT effectiveness significantly. It is not clear what the mass media campaign’s overall reach was, but from the small and unrepresentative RI sample, radio appears to be the most effective media, and hospitals and schools the most effective locations. Furthermore, it is said by diverse KII and FGD respondents that a logo would not only ease product identification for consumers but would also represent a quality seal for producers that are fortifying adequately. A logo could, therefore, promote consumption for the population that will a) easily find the product and b) have confidence in its quality. [... middle sections omitted for long document ...] 139 | RANFOSE FINAL PERFORMANCE EVALUATION REPORT USAID.GOV ANNEX X: SUMMARY OF PRODUCTION DATA (RANFOSE PARTNERS AND NON-PARTNERS) Food product Production (2022) Wheat flour (3 wheat mills) 95,000 MT/year (129,960 MT/year of wheat) Oil and derivatives (3 oil producers/importers) 124,000 MT/year Salt (1 salt fortification factory) 2000-2500 MT/year 140 | RANFOSE FINAL PERFORMANCE EVALUATION REPORT USAID.GOV ANNEX X1: TECHNICAL SPECIFICATIONS PUBLISHED The nutrient content in fortified foods included in the specifications is presented below. These specifications were used as reference to develop the wheat flour and table salt standards approved by BHN. Table X. Summary of the nutrient fortification levels established in the specifications. Food Nutrient Chemical form Nutrient content Salt Iodine Potassium iodate 40 ± 10 mg/kg (33.7 to 67.5) Oil Vitamin A Not specified 50,000 UI/kg Wheat flour Iron Zinc Thiamin Riboflavin Niacin Folate Sodium iron EDTA Zinc oxide Thiamin mononitrate Riboflavin Nicotinamide Folic acid 30 mg/kg 60 mg/kg 5.4 mg/kg 3.6 mg/kg 40 mg/kg 1.5 mg/kg An analysis of the technical specifications adapted by RANFOSE to fortify wheat flour and palm oil is presented below. Technical specifications for iodized salt: ●Iodine units are ppm/kg. The correct expression is mg/kg or only ppm. ●In section 4.1 the iodine content required in salt is expressed as iodate, not iodine. The tolerance interval indicated (± 10) is not coherent with the limits indicated in section 7, expressed as iodine (33.7 to 66.5) ●Review of appropriate expression of required content is needed prior approval of the regulation (technical texts). [1] The list of potassium iodate in the specification does not include the actual suppliers of this compound listed in GAIN’s premix facility website. [2] Technical specifications for the manufacture of fortified refined bleached deodorized - palm olein-. ●Vitamin A content indicated (50000UI/kg oil) but the chemical source for vitamin A is not indicated. ●It is not clear if retinyl palmitate will be used or other. ●There is not a tolerance interval for vitamin A which is important to include for enforcement purposes, especially considering the decrease of vitamin A during shelf life due to environment and packaging effects. [3] Technical specifications for the manufacture of wheat flour. ●A link to a list of certified suppliers is included. ●It indicates that a certificate of analysis must be included along with the premix purchase. ●Storage instructions for premix are included. The same information should be included in the other specifications since the same QA principles apply. ●Table 1 (Section 4.2.1) describes the vitamin and minerals content in flour, as well as the chemical form. A “permitted variation” value is indicated, but no interval is included. A 141 | RANFOSE FINAL PERFORMANCE EVALUATION REPORT USAID.GOV GAIN Mission recommended addition of vitamin B12 [4] but it was not included in the formulation as part of the adaptation of the specifications by RANFOSE. [1]Technical Specifications for iodized salt. Partners of the Americas-GAIN. [2]Gain’s premix facility website. [3]Technical specifications for the manufacture of fortified refined bleached deodorized -palm olein-. Partners of the Americas-GAIN. [4]Mansour M. Mission GAIN en Haïti Visite au projet RANFÒSE 4 – 13 Avril, 2018. 54 p. 142 | RANFOSE FINAL PERFORMANCE EVALUATION REPORT USAID.GOV ANNEX XII. ASSESSMENT ON THE LABORATORY CAPABILITIES TO ANALYZE FORTIFIED FOODS. On March, 2018 an evaluation on the laboratory capabilities of the Tamarinier Laboratory was carried out by the implementing partner. The report 22 presented several recommendations, but it was not specific about the equipment that the laboratory had at the time of the assessment that could be used to implement test to determine specific nutrients added to fortified foods in Haiti. It recommended to supply equipment to implement mycotoxins tests and reagents and supplies to carry out heavy metals tests, in addition to training the personnel on tests for fortified foods. The laboratory received a High-Performance Liquid Chromatographer (HPLC) to determine vitamin A in oil, but it has not been possible to install it due to the current situation in Haiti and the laboratory is currently closed. The HPLC is a sophisticated equipment that would allow the laboratory to determine vitamin A accurately for monitoring purposes provided that it is operated under proper laboratory environment conditions (temperature, relative humidity, electric installation), reagents are supplied and resources for annual maintenance are allocated to guarantee proper functioning. Since it is uncertain when the Tamarinier laboratory will restart activities, it is recommended to identify other laboratories that have the capability to implement the test for fortified foods. In addition to common glassware used in physicochemical tests, specific capabilities are described below: 1. Iodine in salt. The test to determine iodine is simple and only requires an analytical balance and a burette, in addition to other common glassware used in the laboratory. 2. Iron in wheat flour Any laboratory equipped with an analytical balance, furnance, fume hood and a UV/VIS spectrophotometer can implement the colorimetric test for iron. If the laboratory already has an Atomic Absorption Spectrometer (AAS), it can implement both the iron and zinc tests, considering that the specifications require fortification with zinc. However, the tests using AAS are more expensive than the colorimetric test for iron and it is only recommended if zinc is being added. 3. Vitamin A in oil Vitamin A testing with HPLC in oil is accurate, but more expensive than other options, as well as time consuming. Any laboratory with a UV spectrophotometer could implement the "Quantitative Spectrophotometer Method to Determine Vitamin A in Oil" described in the ECSA Manuals 23. The disadvantage of this option is that an irradiation chamber should be built to carry out the test and standardize the irradiation conditions to obtain accurate results, but the costs are cheaper than with HPLC. The other option is to carry out vitamin A tests using the I-Check, which the project has already provided to the oil bottlers. Quantitative results would be obtained also, no purchase of sophisticated equipment would be required and it does not need additional equipment in a laboratory, except for basic glassware and chemical waste management. It is recommended to identify a laboratory willing to implement the test and analyze the samples they receive. 22 Partners of the Americas/GAIN. Rapport d’évaluation du Laboratoire de Vétérinaire et de Contrôle de Qualité des Aliments de Tamarinier (LVCQAT) Mars 2018 23 East, Central and Southern African Health Community. Manual of Laboratory Methods for Fortified Foods (vitamin A, riboflavin, iron and iodine). PART II Determination of vitamin A in sugar and oil. 143 | RANFOSE FINAL PERFORMANCE EVALUATION REPORT USAID.GOV United States Agency for International Development 1300 Pennsylvania Ave, NW Washington DC 20004