Macro-level interventions: C
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Macro-level interventions studies at ANH2020


Session recording:

ANH2020: Macro-level interventions C


Speakers and presentations:

  • Session chair: Mohammad Jahangir Alam, Bangladesh Agricultural University 

  • Hugo De Groote | Nilupa Gunaratna, International Maize and Wheat Improvement Centre (CIMMYT)
    @NilupaGunaratna @CIMMYT
    Measuring consumer acceptance of instant fortified millet products using affective tests and auctions in Dakar, Senegal
    Presentation | Slides

  • Martin Mwale, University of Stellenbosch
    The complementary effects of farm input subsidies and good health care quality on child nutrition in Malawi
    Presentation | Slides

  • Shruthi Cyriac, Emory University
    @shruthicyriac @emoryuniversity
    Understanding the drivers of high coverage and low utilization of double fortified salt in Uttar Pradesh, India: Insights from a mixed methods study
    Presentation | Slides


Measuring consumer acceptance of instant fortified millet products using affective tests and auctions in Dakar, Senegal

Hugo De Groote1

Bernard Munyua1

Djibril Traore2

John R. N. Taylor3

Mario Ferruzzi4

Cheikh Ndiayeb Isiguzoro O. Onyeoziri3

Bruce R. Hamaker5

1International Maize and Wheat Improvement Centre (CIMMYT)
2Institut de Technologie Alimentaire
3University of Pretoria
4North Carolina State University
5Purdue University


The emergence of small-scale affordable extruders creates new opportunities for food processors in Africa, in particular formulation of nutritionally enhanced products, fortification with micro-nutrients and an opportunity for small enterprises to enter the market. Before producing new extruded products, however, consumer interest needs to be assessed.


In this study, 296 randomly selected consumers (men and women) participated, all from Dakar, Senegal. They tasted and evaluated porridge from instant and fortified pearl millet flour, produced using a mini extrusion cooker, in comparison to plain conventional sifted pearl millet. The evaluation was for all major sensory characteristics: appearance, aroma, taste texture, as well as overall. The major product traits under evaluation were instant versus conventionally cooked cereal, sifted vs whole cereal and fortification from a commercial premix vs food-to-food fortification. Participants received a show-up fee of 7000 FCFA. They were asked some socioeconomic questions, followed by affective tests with cooked products to determine consumers’ acceptance, and finally participated in the economic experiment to determine their willingness to pay (WTP) for the packed finished products (flours). To estimate the effect of information on the content of the products on WTP, the auctions were conducted either with or without that information.


The results of the affective tests indicate that consumers were able to distinguish whole flour porridge and porridges fortified with commercial premix or food-to-food fortification from conventional porridge. However, consumers did not distinguish between instant and conventional flour. Further, none of the new products scored better than the conventional product on sensory characteristics. The experimental auctions showed no differences in WTP for the different traits without information. However, analysis with pooled data showed a strong information effect on WTP for different traits. The WTP for food-to-food fortification changed from a 63% discount without information to a 47% premium with information. WTP for instant trait was not significantly different from that of conventional products, either with or without information, indicating that the cost of extrusion is an important consideration for this population. With information, further, consumers were only willing to buy whole four at a discount of 14%. The cost benefit analysis for extrusion showed that it is the costs of ingredients used and not the cost of extrusion that have the largest effect on the expected retail price of instant products. While food-to-food fortification was highly appreciated, its cost of production was substantially higher than the premium in WTP.


Consumers did not distinguish between instant and conventional flours, so there is an opportunity for ready-to-eat instant cereals. Further, with proper information, consumers were willing to pay a premium for nutritional enhancement and compromise on instant and whole pearl millet products. There is a market for extruded fortified products especially where consumers are informed on their benefits. However, food-to-food fortification was more expensive than WTP for the trait. Therefore the amounts of food-to-food fortification need to be balanced with the costs, likely in combination with premix to produce acceptable products within the acceptable retail price for low-income groups.


De Groote, H., S. W. Kariuki, D. Traore, J. R. Taylor, M. G. Ferruzzi, and B. R. Hamaker. 2018. Measuring consumers' interest in instant fortified pearl millet products: A field experiment in Touba, Senegal. Journal of the Science of Food and Agriculture 98 (6): 2320-2331.
De Groote H., C. Narrod, S. Kimenju, C. Bett, R. Scott, M. Tiongco and Z. Gitonga. 2016. Measuring rural consumers’ willingness to pay for quality labels using experimental auctions: the case of aflatoxin free maize in Kenya. Agricultural Economics 47 (2016) 33-45. DOI: 10.1111/agec.12207.
De Groote H., N. S. Gunaratna, J. O. Ouma, A. Wondimu, C. K. Chege, and K. Tomlins. 2014. Consumer acceptance of quality protein maize (QPM) in East Africa. Journal of the Science of Food and Agriculture 94:3201-3212
De Groote, H., Chege, C.K., Tomlins, K., Gunaratna, N.S., 2014. Combining experimental auctions with a modified home-use test to assess rural consumers’ acceptance of quality protein maize, a biofortified crop. Food Quality and Preference 38, 1-13.

The complementary effects of farm input subsidies and good health care quality on child nutrition in Malawi

Martin Mwale1

1The University of Stellenbosch, South Africa


Child nutrition is one of the important indicators of household health benefiting from farm input subsidy programmes. The subsidies boost farm productivity-increasing food availability. Furthermore, revenue from crop sales allows farmers to afford good quality health care and nutritious food supplements. Despite these benefits, nutrition has received inadequate attention in the farm input subsidy programmes evaluations. The only evidence on the subject (Harou, 2018; Kalamba, 2013) indicates that the subsidies improve short-term but not long-term child nutrition. Therefore, this paper investigates whether good healthcare quality can complement farm input subsidy vouchers to unravel the missing improvement in long-term child nutrition.


The study estimates both homogenous and heterogeneous relationships between child nutrition and the programmes (Farm Input Subsidy Programme-FISP, Focusses Antenatal Care Programme-FANC and Community Based Under-five Nutrition Programme). We capture child-nutrition by height for age z-scores, the subsidy program by, a specific fertilizer voucher, and a generic farm input coupon. We include good quality health care by a variable that captures whether the closest health facility encourages pregnant women to meet a minimum of four prenatal visits (FANC) and another variable capturing whether or not an under-five child participates in any community-based nutrition programme. The analysis uses the 2010-2013 Malawi Integrated Household Panel Survey data. We employ an instrumental variable technique-the binary endogenous regressor Lewbel (2018) that generates internal instruments by exploiting the heteroscedasticity in the data. This method removes estimates bias even in cases of scarce valid traditional external instruments. We use the Lewbel to counter the potential endogeneity in our results caused by non-random selection of subjects into the subsidy and the health care quality programmes.


We find that the Malawi Farm Input Subsidy Programme positively and significantly relates to long-run child nutrition only when complemented with good maternal health care quality, in utero. Disaggregation by age of the child reveals that only children under the age 3 benefit much from this complementary relationship through increased mothers’ exposure to FANC during the prenatal period. This might be the result of mothers’ nutrition improving birthweight for the children, which puts them (under 3’s)on a favourable growth path. Nevertheless, these mothers’ nutrition investment only remains sustained beyond the age of three conditional on the child participating in a nutrition-enhancing program. This suggests that input subsidies relieve a liquidity constraint to child nutrition, but that this merely arises when continuous complementary health interventions are in place throughout early childhood.


The study found that a farm input subsidy voucher combined with good health care quality relates to improved long-term child nutrition. The voucher sustains the in-utero nutrition investment beyond 3 years only with further participation in a nutrition program. Therefore, to improve child nutrition policy has to adopt a holistic approach that complements the subsidies with improved maternal health care quality to provide a big push to initial investment in child nutrition. To sustain this investment beyond infancy, policy needs to increase the availability of nutrition participation programs in early childhood to eradicate the child malnutrition problem from both ends.


Harou, A.P., Liu, Y., Barrett, C.B. & You, L. 2017. Variable returns to fertilizer use and the geography of poverty: Experimental and simulation evidence from Malawi. Journal of African Economies. 26(3):342–371.

Kalamba, R. 2013. Input subsidies and their effect on cropland allocation, agricultural productivity, and child nutrition: Evidence from Malawi.Ph.D. Thesis.

Lewbel, A. 2012. Using heteroscedasticity to identify and estimate mismeasured and endogenous regressor models. Journal of Business and Economic Statistics. 30(1):67–80.

Lewbel, A. 2018. Identification and estimation using heteroscedasticity without instruments: The binary endogenous regressor case. Economics Letters. 165:10–12.

Understanding the drivers of high coverage and low utilization of double fortified salt in Uttar Pradesh, India: Insights from a mixed methods study

Shruthi Cyriac1

Mduduzi N.N. Mbuya2

Regine Haardörfer1

Amy Webb-Girard1

Usha Ramakrishnan1

Reynaldo Martorell1

Lynnette M Neufeld2

1Emory University

2Global Alliance for Improved Nutrition


Anemia affects 58% children (6-59 months) and 53% women (15-49 years) in India. Iron deficiency is a major causal factor; corrective efforts provide iron supplements and/or fortified cereals to offset low dietary iron intakes. Building on the success of universal salt iodization, a new program by the state government in Uttar Pradesh leverages the network of fair price shops (that provide subsidized rations to registered households) under India’s public distribution system (PDS), to sell subsidized double fortified salt (DFS) – salt with iron and iodine. If implemented effectively at scale, DFS can make a substantial contribution to reduce iron deficiency.


In five of the 10 DFS intervention districts, we applied mixed methods to assess implementation fidelity, coverage and utilization of the DFS, and examined pathways through which utilization occurred. We conducted 23 in-depth interviews with caregivers to understand DFS utilization and associated reasons for use, partial use or non-use. We conducted interviews in the local language, transcribed them verbatim and translated them to English. Transcripts were reviewed, memoed and coded in MAXQDA using a priori codes based on research objectives and inductive codes. Data were analyzed thematically. Using a stratified random sampling approach, we conducted surveys in urban and rural clusters with 1202 PDS cardholder households. Surveys queried sociodemographic characteristics, housing conditions, assets, food security, PDS access, DFS purchase and utilization, quality of PDS commodities, and types of salt present in the kitchen. We created wealth quintiles using principal components analysis for household assets. We dichotomized households as high/low income with households in the lowest two quintiles forming the low-income category. We conducted path analysis to test a theorized model where household income levels influenced DFS adherence, and assessed all direct and indirect pathways. We adjusted all analysis for survey weights, and the final path model indicated a good fit.


Reported coverage was high, with 89% survey respondents having seen/heard of DFS, 80% having purchased it at least once, and 75% typically purchasing DFS with PDS rations. Yet, only 28% indicated complete DFS adherence and only 20% were aware of its health benefits. DFS stock was present in 64% households – modest DFS coverage was plausibly due to several shopkeepers bundling DFS sales with more desirable, subsidized PDS rations. 60% considered DFS quality poor, only 44% rural and 26% urban households used DFS in at least some foods. Several DFS users noted changes in taste and food color, “our curry turns dark in color. Even our utensils become black and the taste is different…”. Path analysis revealed higher odds of complete DFS adherence for low-income households (aOR:1.10, p<0.0001), households that access the PDS (aOR: 1.28, p<0.001) and households with respondents aware of DFS benefits (aOR: 1.16, p<0.001). Households with lower income were more likely to be in a rural area (aOR:1.25, p<0.001) and moderately/severely food-insecure (aOR:1.40, p<0.001). The indirect path effects indicated higher odds of DFS adherence for both rural (aOR: 1.03, p<0.001) and food-insecure households (aOR: 1.02, p<0.001) as they were more likely to access the PDS regularly.


DFS coverage was high but regular use low, especially in urban areas. DFS in the PDS might be subsidized, but promotions are still required to make it desirable and overcome barriers to use. Poor awareness is a key barrier to DFS adherence; the program’s communication strategy needs strengthening. Rural areas had better adherence. While it is reassuring that lower income households are more likely to use DFS, iron deficiency and anemia are not restricted only to rural poor. PDS subsidies alone will not ensure program success. Implementation constraints hamper DFS program’s potential, but concurrent corrective actions can help improve it.


Coates, J., Swindale, A., Bilinsky, P. (2007). Household Food Insecurity Access Scale (HFIAS) for Measurement f Household Food Access: Indicator Guide (v. 3). from FHI 360/Food and Nutrition Technical Assistance Project (FANTA), Washington.D.C
International Institute for Population Sciences (IIPS), I. (2017). National Family Health Survey (NFHS-4) 2015-16. Retrieved from Mumbai, India

Mannar, M. G. V. R., J.K. , 2018. Double Fortified Salt in India: Coverage, Efficacy and Way Forward. Indian Journal of Communtiy Health 30(April).
Nguyen, P. H., Menon, P., Keithly, S. C., Kim, S. S., Hajeebhoy, N., Tran, L. M., Rawat, R., 2014. Program impact pathway analysis of a social franchise model shows potential to improve infant and young child feeding practices in Vietnam. J Nutr, 144(10), 1627-1636. doi:10.3945/jn.114.194464
Petry, N., Olofin, I., Hurrell, R. F., Boy, E., Wirth, J. P., Moursi, M., Rohner, F., 2016. The Proportion of Anemia Associated with Iron Deficiency in Low, Medium, and High Human Development Index Countries: A Systematic Analysis of National Surveys. Nutrients, 8(11). Retrieved from

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