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Food Aid Quality Review Phase III:

Quarterly Technical Report No. 7 July 2017-September 2017

This report was produced for the United States Agency for International Development. It was prepared by Tufts University, under the terms of contract AID-OAA-C-16-00020 awarded to the Friedman School of Nutrition Science and Policy.

Tufts Friedman School of

USAID Food Aid Quality Review Phase III July-September 2017

Acronyms AMS Agricultural Marketing Service CMAM Community-based Management of Acute Malnutrition COR Contracts Officer Representative CRG Commodity Reference Guide CSB Corn-Soy Blend CSB+ Corn-Soy Blend Plus CSR Community Status Reports CSWB Corn-Soy-Whey Blend EED Environmental Enteric Disorder FAQR Food Aid Quality Review FAS Foreign Agricultural Service FBFs Fortified Blended Foods FFP Office of Food for Peace (USAID) FSA Farm Service Agency FSN Food Security and Nutrition Network FSQA Food Safety Quality Assurance FVO Fortified Vegetable Oil FY 2017 Fiscal Year 2017 HEB High-Energy Biscuit HFIAS Household Food Insecurity Access Scale HHL Health and Humanitarian Logistics ICN International Congress of Nutrition IFT Institute of Food Technologists LNS Lipid-based Nutrient Supplements IRB Institutional Review Board LRP Local and Regional Procurement LSR Loss Summary Reports MAM Moderate Acute Malnutrition MFFAPP Micronutrient Fortified Food Aid Pilot Project MQ-LNS Medium Quantity Lipid-based Nutrient Supplements MSF Médecins Sans Frontières MT Metric Ton NGO Non-governmental Organization PET Polyethylene Terephthalate PHU Peripheral Health Unit PI Principal Investigator POD Program Operations Division PPB Project Peanut Butter QWICR Quarterly Web-Interfaced Commodity Reporting REFINE Research Engagement on Food Innovation for Nutritional Effectiveness RUSF Ready-to-Use Supplementary Food RUTF Ready-to-Use Therapeutic Food RVA Rapid Visco Analyzer SBCC Social Behavior Change Communication SC+ Super Cereal Plus



SFP Supplementary Feeding Program SNFP Specialized Nutritious Food Product SQ-LNS Small Quantity Lipid-based Nutrient Supplements TOPS Technical and Operational Performance Support Program USAID United States Agency for International Development USDA United States Department of Agriculture UN United Nations UNICEF United Nations Children’s Fund ViM Victory Against Malnutrition WASH Water, Sanitation and Hygiene WBSCM Web-Based Supply Chain Management WFP World Food Programme WHO World Health Organization



Food Aid Quality Review (FAQR) Phase III: Quarterly Technical Report Summary

Summary Covering the fourth quarter of Fiscal Year 2017 (FY 2017), this report documents the progress of FAQR as a whole, highlights new and some preliminary project findings, and outlines actions planned for the coming quarter. The report serves as a vehicle for documenting and communicating the outputs and impact of FAQR Phase III work. The Food Aid Quality Review project’s goal is to establish information systems, tools, data-gathering, and evidence-sharing platforms to support the U.S. Government’s humanitarian agenda. Planned to continue through January 2019, FAQR’s activities and outputs will enable government-wide actions and public-private engagement around food aid to achieve greater cost-effectiveness for decades to come. For a detailed overview of all FAQR activities see Annex I.

EVIDENCE GENERATION: Supporting best practices, FAQR identifies packaging solutions to optimize product integrity and reduce costs along the supply chain and is generating new field-based evidence to support cost-effective use of products. EFFICIENCY GAIN: Across the food aid supply chain, the FAQR is developing tools to support cost-effective product and programming choices to make the best use of taxpayer dollars. INDUSTRY STANDARDS: To enhance food safety and quality standards, FAQR is working with food industry partners on incorporating industry standards into the food aid agenda.



This quarter, the team advanced the FAQR objectives in the following areas:

1. Evidence Generating: 1.1. The team contributed to building evidence on food aid effectiveness through two landscape

scans. The first examines gaps in existing knowledge on how food aid affects nutrition. The second examines research methods used by published and ongoing studies focused on food aid products. The first scan will stimulate conversation among both funders and researchers, by providing insights into what we currently know, and where important empirical blind-spots remain. The second scan will, in turn, point to common methodological challenges in food aid research which help or hinder our understanding of “what works” under what conditions. These reports will feed into improved guidance on study design which will seek to enhance the rigor of future food aid studies, thereby building a stronger evidence base upon which to establish programming and policy decisions.

1.2. New evidence is being generated in Sierra Leone through FAQR’s research on the nature of “recovery from MAM.” Looking beyond anthropometric indicators and thresholds, this sub-study applies complementary measures of neurocognitive function. Using eye-tracking techniques as well as conventional neuropsychological assessment techniques, the study assesses children’s cognitive development as a parameter which could reflect “full” recovery beyond physical growth. The eye-tracking tests developed in this study may also provide a quick, objective and fully-automated system for monitoring neurocognitive function and recovery in children in food aid programs. Results will contribute to the base of knowledge related to the quality of recovery and may redefine our ability to treat child malnutrition and prevent long-term negative effects.

2. Industry Standards:

2.1. The FAQR team further advanced the objective of promoting industry standards through an evaluation of the USAID/FFP Program Operations Division (POD) Food Safety and Quality Feedback Loop and Questionnaire1. The latter is used in reporting food aid commodity incidents. The results revealed that there would be large efficiency gains if the feedback system provided real time incident reporting, and if it stored data to allow for a monitoring of trends. Any system must be widely accepted, mandatory and useful to all parties. If improvements are made, these will contribute to an improvement in process quality for food aid products and packaging.

Upcoming Activities in Fiscal Year 2018, Quarter 1, October-December 2017: In the coming quarter, FAQR is prioritizing completing some key deliverables and promoting FAQR work in an international arena.

1. The FAQR team will be hosting two symposia at the 2017 International Congress of Nutrition (ICN): a. Food Aid Research: Update on Food Aid for Preventing and Treating Undernutrition and b. Addressing Child Malnutrition: Newer Measures to Advance Prevention and Treatment Outcomes. Both symposia support

1The feedback loop gives stakeholders an idea of who should be involved in troubleshooting incidents, while the questionnaire can help narrow the focus to when and why an incident might have occurred.



achievement of the FAQR’s objectives: the first will share advances and challenges in food aid research, informing new paradigms of food aid products and programs, and clarifying remaining questions in the field of food aid. The second symposium will promote the discussion of advances and challenges in research on the frontier of child malnutrition, inform new approaches to food-based solutions and measures of success, share current and planned research, remaining questions and the way forward.

2. FAQR is developing a product supply chain optimization model and tool based on the current operations of the USAID/FFP supply chain. The FAQR team will share the tool with FFP which will promote more effective decision-making in the procurement process. At the same time, ongoing supply chain optimization work will focus on identifying choke points across the system and will estimate the magnitude of efficiency gains if the bottlenecks could be resolved through better advance planning.

3. A key component of the FAQR research ongoing in Sierra Leone is the assessment of a food aid-focused Social Behavior Change Communication (SBCC) campaign. During this coming quarter, the roll-out of the SBCC component will be completed. This will include the integration of counseling cards focused on the key messages surrounding food aid preparation and use. The FAQR team is fully documenting and testing the process they have used to develop this campaign since one of the main recommendations for effective supplementary feeding programs is to prioritize messaging and behavior change surrounding food aid interventions. FAQR plans to develop a framework for best practices and systems for integrating SBCC. FAQR Reports and Manuscripts Published in Quarter 4 of 2017

1. “Programme News: Tufts University-based Food Aid Quality Review activities.” UNSCN News 42—A Spotlight on the Nutrition Decade, July 2017. p. 144.2

2. Preparation and presentation of corn-soy blend for moderately malnourished children in Malawi. Field Exchange 55, July 2017. p. 26. www.ennonline.net/fex/55/csbmalawi3, Rogers, B.L., Webb, P., Boiteau, J., Langlois, B.K., Maganga, G., Walton, S.M. and Suri, D.

3. EffectivedeliveryofsocialandbehaviorchangecommunicationthroughaCareGroupmodelinasupplementaryfeedingprogram. Journal of Health, Population and Nutrition, 36, 34. http://doi.org/10.1186/s41043-017-0111-34, Wilner, L., Suri, D. J., Langlois, B. K., Walton, S. M. & Rogers, B. L. (2017).

2 https://www.unscn.org/uploads/web/news/UNSCN-News42-with-Programme-News.pdf 3 http://www.ennonline.net/fex/55/csbmalawi 4https://foodaidquality.org/effective-delivery-social-and-behavior-change-communication-through-care-group-model-supplementary



II. Key Activities for the Period July 1- September 30, 2017 The activities listed below are selected to showcase some of the major accomplishments over the quarter. All work streams have ongoing activities.

A. Commodity Management System 1. Food Aid Commodity Fact Sheets � FAQR created 25 updated and new USAID Food Aid Product Fact Sheets to be more in line with industry standards for food product information sheets. Each Fact Sheet is designed to be easy to read and provide information on: product description, programming uses, preparation and applications, along with a Profile of Key Nutrients table (i.e., nutrient values over 20% of daily value [DV] for 2000 calorie adult diets). The new Fact Sheets include graphics and photographs of the raw product and primary packaging. The fact sheets provide links to product specifications for more detailed information for ordering and procurement. Once approved, the Product Fact Sheets will be posted on the USAID/FFP website and replace those currently posted.

Product Fact Sheets: Fortified Milled Rice and Ready-to-use Supplementary Food (RUSF):



B. Food Aid Packaging The team drafted an interim report on packaging for Fortified Vegetable Oil including findings related to main packaging challenges and recommendations to address them. Implementing partner representatives, both in the U.S. and in the field, were interviewed to discuss packaging-related challenges. The team had discussions with food aid suppliers, packaging suppliers and transporters to identify opportunities for improvement. Data on losses were collected from the Quarterly Web-Interfaced Commodity Reporting (QWICR) system, in which implementing partners are required to submit Commodity Status Reports (CSR) and Loss Summary Reports (LSR) quarterly, to attempt to quantify losses and identify areas where most losses occur. A literature review was conducted to gain technical knowledge regarding the performance of available oil packaging technologies. Recommendations were drafted to highlight the most promising options and suggest additional testing which should be performed to confirm their suitability for use in the food aid supply chain. Finally, the consequences of switching to these options and the adjustments which would be needed to accommodate them were highlighted.



The main challenges identified in the report are: a) leakage of the cans; b) use of two different types of cans5; and c) quality losses prior to consumption. Several packaging options were identified to address one or several of these challenges, including: 1) current cans with crimped-in closures; 2) standard number 10 cans with crimped-in closures; 3) one-quart cans with crimped-in closures; 4) 32-ounce opaque polyethylene terephthalate (PET) bottles; and 5) 35-pounds jugs or jugs-in-box. A tentative protocol was developed to further test these technologies and ensure that they are suitable for use in food aid programs. A full report of findings and recommendations will be available pending USAID approval.

C. Food Aid Safety and Quality Systems

1. Food Safety Quality Assurance (FSQA) Feedback Loop Assessment The FAQR team is reviewing the USAID/FFP Program Operations Division (POD) Food Safety and Quality Feedback Loop and Questionnaire6 used in reporting food aid commodity incidents in order to have a more useful and streamlined tool. The team interviewed commodity management, supply chain and food safety experts within USAID/FFP and in the larger stakeholder community to gather information on how they have used this feedback loop and questionnaire. The team also consulted with stakeholders familiar with the WFP food incident oversight system, the Web-Based Supply Chain Management (WBSCM) Complaint System7 used by USDA domestically, and the Quarterly Web Interfaced Commodity Reporting (QWICR) System8 used by USAID Implementing Partners to analyze and review the existing tools. Based on FAQR’s review of current tools and stakeholder reviews, preliminary recommendations to improve the FSQA Feedback Loop System include developing and implementing a feedback system that: 1) captures incident feedback in real time throughout the supply chain, especially the “last mile,” with immediate feedback reaching USAID and suppliers, and; 2) stores and saves data, to identify trends and create an institutional memory of food aid product incidents and how they were addressed. A more widely-used, effective feedback system that produces and stores data will allow food aid stakeholders to prioritize incidents and determine the costs/benefits of product improvements. This will lead to a continuous improvement process for food aid products and packaging. These recommendations could be achieved through USAID adopting the WBSCM Complaint System. In the meantime, USAID/FFP could make QWICR Complaint Reports required instead of recommended, in order to have more accurate (although not aggregated) quarterly information on FSQA incidents.

5 Having two different types of cans creates significant logistical challenges in warehouses. The two types, which have different dimensions, cannot be stacked together resulting in a waste of warehouse space. 6The feedback loop gives stakeholders an idea of who should be involved in troubleshooting incidents while the questionnaire can help narrow down the focus to when and why an incident might have occurred.7The Web-Based Supply Chain Management (WBSCM) system is an integrated, Internet-based commodity acquisition, distribution, and tracking system used by USDA [Food and Nutrition Service (FNS), Farm Service Agency (FSA), Agriculture Marketing Service (AMS), and Foreign Agricultural Service (FAS)] and USAID.8QWICR is a web-based system that USAID/FFP cooperating partners use to submit quarterly commodity reports for claims tracking, processing and payment.



D. Cost-Effectiveness

1. Decision Support Tool The team continued to develop the FAQR Decision Support Tool as a web-based interactive interface. The tool aims to help policymakers and food aid program officers to make more informed decisions on cost-effectiveness (cost per impact) in nutrition programming of specialized food aid products. The team gathered initial feedback on a beta version from USAID and other partners. For images of the FAQR Decision Support Tool Interface see Annex5. The team received a great deal of positive feedback on the usability of the tool. Suggestions were given on a range of modifications and additions to the tool features. The updated interface has completely addressed some of the feedback received including having region-specific international freight cost and auto-resizing windows. The team is currently working to address additional comments such as having an export function as well as including in-land transport, shipping and handling cost, and relapse rates.

E. Field Research 1. Burkina Faso Prevention of MAM and Stunting Study9 FAQR presented preliminary results from the Burkina Faso Prevention study to USAID/FFP representatives on August 10, 2017 in Washington, D.C. The Burkina Faso study tests the effectiveness and cost-effectiveness of four supplementary foods (Corn-Soy-Whey Blend [CSWB] prepared with FVO, Ready-to-Use Supplementary Food [RUSF], SC+ and CSB+ prepared with FVO) in the prevention of MAM and stunting in normal programmatic settings. The team shared preliminary effectiveness results, describing the relative effectiveness of the four foods in preventing stunting and wasting in children 6-23 months in Burkina Faso and preliminary cost-effectiveness results describing which of the four foods appears to be most cost-effective at preventing cases of stunting and wasting in children. Results still pending include more robust analyses of the above, as well as assessment of factors (determinants) that contribute to relative effectiveness. Once final, these results will be critical in determining which products can prevent malnutrition at best value. 2. Sierra Leone Treatment of MAM Study10 This quarter, the neurocognitive function sub-study began as part of the Sierra Leone treatment study. This sub-study examines neurocognitive function and recovery in children with MAM and evaluates the effects of different supplementary foods on neurocognitive function in children. The Neurocognitive Sub-Study Consultant visited Pujehun, Sierra Leone between July 27 and August 11, 2017 to transport study equipment to the site, make final adjustments to the pilot study procedures together with Neurocognitive Research Assistant and Field Research

9 http://foodaidquality.org/focus/field-research 10 http://foodaidquality.org/focus/field-research



Manager, and to recruit and train a local study assistant on the use of the eye-tracking technologies and other testing methods. During the visit, the Neurocognitive Consultant and Research Assistant finalized study procedures, acquired remaining study equipment from local sources, conducted a two-day training and evaluation for three local assistants for the use of the study technologies and selected one of the trained assistants to start as a research aide for the study. The Neurocognitive Sub-Study began with a pilot phase in August 2017. The pilot phase will include 32 children with MAM and 32 well-nourished controls. All participants will be tested by eye-tracking and conventional neuropsychological tests upon enrollment to the study (i.e., baseline) and again in up to four weekly follow-up assessments to monitor changes in neurocognitive status over time. The purpose of the pilot study is to examine the feasibility, measurement properties and utility of the study procedures at the sites and with different age groups, and to obtain preliminary data on the differences in performance between MAM children and well-nourished controls. Data from the pilot study will be used to inform the design and sample size for the principal Neurocognitive Sub-Study which compares the effects of the four supplementary foods on children’s neurocognitive function. The Neurocognitive Sub-Study and its results could have significant implications for our abilities to treat early childhood malnutrition and prevent its long-term negative effects. The eye-tracking tests developed in this study may provide a quick, easy, objective and a fully-automated system for monitoring neurocognitive function and recovery in children with MAM in food aid programs.

F. Knowledge Management

1. REFINE Landscape, Methodology and Research Gaps Scan FAQR completed drafts of two landscape scans. The first examines what research gaps in the existing knowledge base of food aid for nutrition are being addressed by recently published and ongoing studies. These gaps, identified through expert consultation and a literature review, include many issues around new food product acceptability, adherence (consumption) by food aid beneficiaries, composition of products, efficacy, effectiveness and cost-effectiveness, innovations relating to product formulation or preparation, and programmatic innovations. Eighty-one studies published between January 2011 and March 2017, as well as 29 ongoing clinical trials, were identified using REFINE search criteria and were assessed in relation to their contribution to filling information gaps on these topics. The analysis reveals that many gaps are being addressed, some more comprehensively than others, while other gaps have yet to be filled:

• Effectiveness of products and programmatic innovations have received significant attention in recent years. Considering the ongoing development of new formulations and interventions, this kind of research remains useful to food aid decision-making and will continue to be important.



• Product efficiency, usually in clinical settings, remains mostly unexplored. This is largely because most “new” products represent modifications of existing foods and because donors tend to need information quickly from community- and home-based programs in the field.

• Rigorous evidence on acceptability, adherence and use of products remains weak.

• The relative cost-effectiveness of products and programs remains a huge gap in knowledge. Although several recent publications and ongoing trials do investigate these topics, much more is needed to better inform conclusions on cost-effective comparisons.

In terms of geographic coverage of research, most work has focused on food aid in sub-Saharan Africa, though ongoing trials are increasing engagement with Asian contexts. Rural areas receive most interventions and studies, leaving our understanding of food aid programming in urban contexts underdeveloped. Few studies examine product or programmatic effectiveness in any emergency settings; most focus on development programs or non-emergency settings where studies can be more easily conducted. Overall, this knowledge gap review aims to stimulate conversation among both funders and researchers, and provide insight into key areas of exploration for future studies. The second landscape scan examines the methodologies of published and ongoing food aid product studies. Although there are many studies that deal with food aid effectiveness, the quality of existing evidence is mixed due to issues related to study design and various sources of bias. Therefore, this scan reviews the study designs and methods used in ongoing research and articles on food aid for nutrition published in peer-reviewed academic journals from January 2011 to March 2017. Using REFINE search criteria, 71 publications and 29 ongoing clinical trials were included in the review. Overall, this analysis revealed that there is no consistent methodology used to study food aid products and interventions. Given the wide range of products and programs available, this is not surprising. However, this diversity presents several challenges to both researchers and policymakers. The diverse study designs, interventions, inclusion criteria and outcomes used by both published and ongoing studies present a challenge to those who would assess these studies for inclusions the study designs do not produce comparable results, and make the evidence vulnerable to bias. The results of this scan will be used to call attention to common methodological choices and challenges in food aid research, highlight options to improve the quality of evidence provided and thus enhance studies’ viability for inclusion in systematic reviews and meta-analyses, and inform FAQR’s forthcoming research protocol guidance document, a Phase III deliverable.



III. Plans for the Coming Quarter (October-December 2017): The matrix below highlights some of the key planned activities for the coming quarter:

A. Food Matrices

a. Finalize recommendations for future research based on literature review/landscape analysis on current food matrices and gaps in data.

b. Finalize report on food matrices and nutrient bioavailability based on discussions from the roundtable hosted as a pre-meeting during the Institute of Food Technologists (IFT) annual meeting in 2017.

c. Create protocols for measuring viscosity of porridges using Bostwick testing of fortified blended foods (FBFs) being used in field research studies, conduct testing and analyze results. A more scientific test using Rapid Visco Analyzer (RVA) will be conducted to further support the findings from Bostwick tests.

B. Food Aid Basket

a. Food Basket with Existing Commodities: i. Host a feedback workshop on the results of the qualitative assessment of which

food aid products are used and how and how well they meet program needs.

b. New Products, Technologies and Formulations, and Deployment of New Specialized Products:

i. Create an application and an evaluation rubric for new products. ii. Run the MFFAPP products through the application and evaluation rubric. This will:

1) serveas a “method demonstration” of the application and approval process; and 2) determine which MFFAPP products FAQR will recommend to be included in the list of available foods.

iii. Start to identify a “short-list” of potential food aid suppliers: identify characteristics of potential suppliers; identify U.S. suppliers that meet those characteristics; and then have a discussion with suppliers to gauge their interest.

C. Commodity Management System

a. Commodity Reference Guide (CRG) Fact Sheets: i. Develop a strategy via report and presentation for regular updating of the

Commodity Reference Guide (CRG) and propose a mechanism internal to FFP.



D. Food Aid Packaging Solutions

a. Finalize the interim report on FVO packaging; select the packaging options which should be further tested; and finalize testing protocols.

b. Complete the analysis of the data on losses collected from QWICR.c. Update and finalize the protocol for testing the use of biodegradable food aid packaging film

in the field.

E. Food Aid Safety and Quality Systems

a. Supply Chain Oversight: i. Complete a limited review of analytical tools framing data analytics work and the

Supply Chain decision tool. ii. Analyze in-country supply chains for Ethiopia. iii. Develop an Excel-based decision support tool from the mathematical model of

supply chain optimization. iv. Develop a data report detailing the current FFP supply chain procurement phase

and recommendations to improve the supply chain.

b. Food Safety and Quality Assurance Feedback Loop: Finalize Feedback Loop Assessment and Recommendations:

i. Draft USAID/USDA FSQA Data Map table and QWICR and WBSCM systems assessments.

ii. Research Open Data Kit systems as a potential way to create a mobile app survey to aggregate data on Last Mile FSQA incidents.

F. Cost-Effectiveness

a. Cost-Effectiveness in Response to Emergencies: i. Complete a limited review of analytical tools framing data analytics work and the

Supply Chain decision tool. ii. Analyze emergency response operations after receiving data on sudden onset

emergency response.

b. Cost-Effectiveness Tools: Decision Support Tool: i. Continue to develop the Decision Support Tool through web-interface

programming (R Shiny), literature review and team consultation. ii. Develop demonstration papers of the tool with case scenarios.

c. Cost Methodology: i. Collect and categorize cost data for the Sierra Leone MAM Treatment Study. ii. Continue to work on cost-effectiveness data analysis for Burkina Faso Prevention

Study.

G. Field Research



a. Burkina Faso Prevention Study: i. Conduct data analysis. ii. Plan for results disseminations in the United States and Burkina Faso. iii. Prepare documents for qualitative data analysis (translations).

b. Sierra Leone MAM Treatment Study: i. Continue distributing foods for study and enrolling participants. ii. Continue collecting data for main study and body composition, and EED sub-

studies. iii. Finalize design of SBCC program’s counseling cards and implement training

modules for community health workers. iv. Continue implementation of the Pilot-phase of data collection for the

neurocognitive sub-study.

H. Interagency Communications and Harmonization

a. U.S. Interagency: i. Outline report on institutionalization options.

b. U.S.-Global Interagency (Harmonization) i. Ongoing support of International Inter-Agency Working Group.

I. Knowledge Sharing

a. International Congress of Nutrition (ICN) 2017: i. Host two symposia and present four posters based on FAQR research. ii. Prepare proceedings from each symposium and submit each to a peer-reviewed

journal.

b. FAQR “Scorecard Report” Handouts: i. Distribute completed handouts.

c. Evidence Summit: i. Finalize concept notes for Evidence Summit. ii. Determine Evidence Summit date and venue. iii. Form logistics and program committees to facilitate event planning.

d. REFINE: i. Disseminate quarterly REFINE resource updates. ii. Finalize Research Gap and Methodology Analyses. iii. Begin REFINE website promotion campaign.



Annex 1. Overview of the Food Aid Quality Review (FAQR) Phase III Activities For more information on FAQR Phase III, please visit the FAQR website11. I. Background The Food Aid Quality Review (FAQR) provides the United States Agency for International Development’s (USAID) Office of Food for Peace (FFP) and its partners with actionable recommendations on ways to improve nutrition among vulnerable people for whom the direct distribution of food aid can make a significant impact. FAQR Phase I recommendations were published in Delivering Improved Nutrition: Recommendations for Changes to U.S. Food Aid Products and Programs12. That report led to FAQR Phase II’s focus on reformulating Fortified Blended Foods, the inclusion of lipid-based products in FFP’s commodity list and testing new products under field conditions. A full summary of FAQR Phase II accomplishments is highlighted in the Food Aid Quality Review Phase II Closeout Report13. FAQR III14 focuses on generating links between research on food product formulation and recommendations on cost-effective programming and policy-level action among national and multilateral institutions engaged in food assistance. Tufts is working closely with several domestic and international collaborators, including USAID, United States Department of Agriculture (USDA) and United Nations (UN) partners, all of whom are committed to strengthening the evidence base for use of specialized food products for targeted nutrition goals. The work of FAQR III is framed under three major topics related to food aid: 1) Products, 2) Programming, and 3) Processes. Products With a view to making actionable recommendations to USAID, Tufts is examining a number of priority mission-critical issues, such as how food matrices (“the nutrient and non-nutrient components of foods and their molecular relationship to each other”15) affect bioavailability of nutrients and digestibility of products; the potential for thermal/non-thermal processing technologies to improve food matrices; potential roles for existing products that are rarely used today, as well as new products (which may include fortificant powders) and novel packaging technologies to improve resistance to infestation, shelf life and efficiency of handling; dual-use products for emergency response; and completion of the data collection, analysis and reporting on field studies which assess the effectiveness and cost-effectiveness of various newly-formulated food products.

11 http://foodaidquality.org 12 pdf.usaid.gov/pdf_docs/pnadz842.pdf 13 pdf.usaid.gov/pdf_docs/PA00M9B8.pdf 14 Contract awarded to Tufts University’s Friedman School of Nutrition Science and Policy for the period covering Feb. 1, 2016 to Jan. 31, 2019 with two option years.15Source: United States Department of Agriculture: National Agricultural Library (https://agclass.nal.usda.gov)



Programming One important focus of FAQR field research and statistical modeling is on the cost-effectiveness of various products used in operational settings. This includes strategy development for pre-positioned specialized nutritious products, guidance on options for their use, elaboration of a strategy for responding to food needs in the initial stages of a sudden onset emergency and dissemination of cost calculation tools. FAQR is generating improved technical guidance, sharing details on research protocols used in testing new food aid products in the field and making further progress in harmonizing product specifications among food aid donors. Processes FAQR III provides recommendations to USAID on institutional and industry processes for capacity building, including the institutionalization and strengthening of interagency technical collaborations, mechanisms to ensure greater policy, and product harmonization domestically and internationally. This provides recommendations for enhanced supply chain oversight, establishes stronger and more user-friendly quality assurance feedback loops, and promotes food safety and quality standards which can also be applied to local and regional food procurement. FAQR III organizes its activities into the following work streams: Food Matrices Food Aid Basket Commodity Management System Food Aid Packaging Solutions Food Aid Safety and Quality Systems Cost-Effectiveness Field Research Interagency Communications and Harmonization Knowledge Sharing Overview of Work Stream Activities

A. Food Matrices Activities related to:

1) Examining the evidence on how the composition and structure of food products influence the bioavailability, absorption and physiological utilization of nutrients.

2) Exploring innovations in thermal and non-thermal food processing, including: perspectives on food functionality (quality control), nutrient content and bioavailability, palatability, and digestibility.

Contributions of these activities will be:

• Understanding the effect of consuming food aid products on the health outcomes of beneficiaries.

• Recommendations for how to design better food products which can carry energy and nutrients more effectively.

• Achieving more favorable cost-benefit ratio in programming.



B. Food Aid Basket The “food aid basket” refers to the list of Title II products available for programming. Activities related to the Food Aid Basket include:

1) Enhancing the food basket with existing commodities; 2) Assessing new products for inclusion in the food basket; 3) Exploring dual-use products for emergency response; 4) Developing a strategy to introduce new or modified specialized products; 5) Providing food and ration technical guidance; 6) Facilitating the institutionalization of an expert-driven periodic review of nutrition evidence; and 7) Planning to conduct accelerated shelf life trials for fortified rice and high-energy biscuits.


• Modernizing the range of food aid products used in projects and programs administered by USAID/FFP will lead to more efficient, effective and cost-effective programming.

• Key policy goals this work stream addresses:

o Food aid products are consistent with current research and prevailing expert opinion of what works in nutrition-focused interventions.

o Available food aid products allow for various food baskets which are sufficient and appropriate to their programming contexts.

o Sudden onset emergencies are responded to with appropriate, cost-effective food aid.

C. Commodity Management System Activities related to:

1) Updating and streamlining the USAID/FFP commodities resources portal; 2) Developing and modernizing commodity reference guide fact sheets; and 3) Harmonizing specifications and templates for food aid commodities.


• Enhance real-time information access through the USAID/FFP Commodities Resource Portal, including modernized commodity fact sheets;

• Raise the profile of the U.S. food aid basket and better present commodity information to stakeholders;



• Harmonize food aid products among agencies (USAID, USDA, WFP, United Nations Children’s Fund [UNICEF], MSF) to make them interchangeable in programing and accepted by multiple agencies and programmers; and

• Create specifications that apply to U.S. and non-U.S. sourced products which are in line with industry practice standards and created with stakeholder input.

D. Food Aid Packaging Solutions Activities related to:

1) Exploring the potential for improved food aid packaging.

Contribution of these activities will be:

• Identification of alternative packaging materials, sizes and forms will reduce breakage, improve resistance to insect and rodent infestation, and optimize transport and handling, thus reducing product losses and leading to cost savings.

E. Food Aid Safety and Quality Systems Activities related to:

1) Reviewing supply chain oversight; 2) Assessment of the existing food safety and quality feedback loop; and 3) Quality assurance for local and regional procurement (LRP).


• USAID will have new data-driven, decision-aid tools which can quantify the impact of decisions for procuring and distributing food aid locally, regionally and/or globally.

• An improved supply chain positively affects the number of beneficiaries reached, total amount of commodities sent, lead times, total cost of the program and integrity of products once they reach the end user.

• Stronger and more user-friendly quality assurance feedback loops promote food safety and quality standards which can also be applied to local and regional food procurement.

• The system identifies incidents and provides information upstream on issues detected after arrival in a country through the “last mile,” creating an institutional memory of food aid product incidents and how they were addressed.

• Recommendations are in place for ensuring the food safety and quality of LRP products, including that they follow U.S. food aid product specifications.

F. Cost-Effectiveness Activities related to:

1) Developing a strategy for assessing cost-effectiveness of new modalities of response to emergencies;



2) Developing a decision-support tool for food aid programs; and 3) Developing the costing methodology and cost-effectiveness analysis plan for ongoing field studies.


• Evidence on cost and the cost-effectiveness of using specialized food aid products will contribute to decision-making around better designed and implemented food aid policy and programming.

• Building capacity within USAID and USDA for considering products not just based on price per ton of a food but based on both cost and effectiveness of an intervention will contribute to more cost-effective programming.

G. Field Research Activities include:

1) Malawi feasibility study assessing the effectiveness and cost-effectiveness of changes in Corn-Soy-Whey Blend (CSWB) oil ration quantity, packaging and Social and Behavior Change Communication (SBCC) messaging focused on increasing the amount of oil added to CSWB porridge prepared by caregivers;

2) Burkina Faso Study comparing the effectiveness and cost-effectiveness of four supplementary foods for prevention of stunting and moderate acute malnutrition (MAM);

3) Sierra Leone study comparing the effectiveness and cost-effectiveness of four supplementary foods for treatment of MAM; and

4) Development of guidance and examples to inform future research protocols intended to assess the effectiveness and cost-effectiveness of foods, rations, and programming approaches related to preventing and treating malnutrition.


• The study results will guide decisions about what commodities to use in supplementary feeding programs.

• Results will answer questions related to effectiveness, cost-effectiveness and determinants of recovery/optimal growth (drivers of relapse, sustained recovery, body mass, cognitive development, linear growth) as well as provide contextual information about sharing and use of the rations.

• The studies will address programming innovations including the role of SBCC, “last mile” concerns and the true cost of interventions in emergency/non-emergency settings.

H. Interagency Communications and Harmonization Activities related to:

1) Interagency consultations (U.S.-focused and U.S.-Global) toward greater harmonization around products, processes and programming; and institutionalization of interagency communication and collaboration mechanisms.




• Discuss and promote agreement around international standards in the formulation, production, and use of food aid products drawing from both normative and scientific guidance is imperative to the success of the food aid agenda.

• Propose mechanism(s) to institutionalize U.S. and U.S.-Global interagency consultations and communication.

• Facilitate generation of institutional knowledge toward continued improvements to food aid products, processes and programs.

I. Knowledge Sharing Activities include:

1) FAQR “Scorecard Report;” 2) Evidence Sharing; 3) Research Engagement on Food Innovation for Nutritional Effectiveness (REFINE)—

http://www.refinenutrition.org; and 4) FAQR communications.


• Ensuring that evidence generated by FAQR and other research is accessible to stakeholders, promoting evidence-based policy-making and practice within the food aid agenda.

• Disseminating emerging evidence relevant to food aid; highlighting ongoing knowledge gaps and study priorities to help improve operational practice and promote evidence-based policy-making and a focus for future research investments.



Annex 2. Meetings and Events during the Period July 1, 2017 to September 30, 2017

Select meetings include the following:

• Co-PI Monitoring Visit to Sierra Leone (July 9-22, 2017) The Co-PI (Principal Investigator) visited the Sierra Leone Treatment Study for a monitoring visit. The trip’s objective was to monitor and evaluate the quality of data collection for the main study and the environmental enteric dysfunction and body composition sub-studies. Over the course of two weeks, the Co-PI visited two different main study clinics, observed sample collection for both sub-studies, oversaw surveys for three different in-depth interviews, met with study personnel, observed food storage and maintenance, and briefed key government stakeholders on the study’s progress.

• TOPS Knowledge Sharing Meeting (July 19-20, 2017)

The FAQR team held a session at the TOPS Knowledge Sharing Meeting entitled, “What to Consider when Programming Food Aid Products: Operational Research findings from the Food Aid Quality Review (FAQR) Project.” The session provided over 80 participants with key findings from the FAQR field research studies on the following themes of: (a) diversion of food aid products (sharing, giving away or selling); (b) behaviors surrounding food aid products in the household; and (c) messages and education on beneficiary uses of food aid products. Findings within each of the thematic areas included: (A) Diversion of food aid products (sharing, giving away or selling):

o Reported sharing was 54% in the Malawi field study and 61% in the Burkina Faso field study. Sharing was most commonly with other young children in the household.

o In Burkina Faso, there was no reported selling of the ration and low reports of giving the ration away.

o In Malawi, qualitative data highlights that others commonly ask for the ration. (B) Behaviors surrounding food aid products in the household:

o In the Malawi field study, FAQR observed that porridge was mostly prepared 1 to 2 times per day and was most often prepared by mothers.

o In Malawi, porridge was observed to be consumed 1 to 2 times per day and was consumed fresh 93% of the time.

o In Burkina Faso, FAQR found that 8% of children ate the CSB flour raw. o In Malawi, mothers described food hygiene as a part of the porridge preparation

process. (C) Messages and education on beneficiary use of food aid products:

o FAQR conducted formative research to provide information on the setting and understand current behaviors when developed social behavior change communication (SBCC) messaging as context was found to be important in SBCC message development.

Key presentation messages emphasized that food aid programming efforts should be focused toward beneficiary adherence in order to achieve intended impact. Programs should



consider within-household sharing when determining ration amounts and challenges to proper preparation, consumption and use of the product should be well-understood when designing programs. In addition, effectiveness of specialized food aid products requires context-specific social behavior change communication which involves formative work and strong understanding of the local environment. Following the presentation of results, participants had a chance to discuss the findings and how the results related to their own experiences in food aid programming plus efforts to increase effectiveness and cost-effectiveness in programming. Important points raised during the discussion included that food aid sharing is common and inevitable, and is not always a bad thing. However, more data is needed to provide evidence to donors that sharing is common and that program adjustments to address the reality of sharing are necessary. Participants were surprised that the FAQR research did not find any selling. Participants reported that selling and appearance of food aid products in the market is common, but it may be context specific. Participants also noted that all of the FAQR field studies are in “development” settings; it will be critical to understand these key aspects of food aid programming in the context for an emergency setting where practices will likely be different. Finally, there was emphasis in discussion on the importance of SBCC messaging coupled with distribution and the need for a longer-term focus on social behavior change rather than just on food aid. Participants also identified future research areas based on the findings presented and discussion which included:

o Data to explore associations between level of food insecurity and sharing; o Food aid needs and specialized products for school-aged children; o Longitudinal data on effectiveness of food aid products; o How to program food aid to address the double-burden; and o Identification of the good practices and costs associated with the different channels

of SBCC messaging.

In addition to the FAQR session, the Cost Specialist hosted a lunchtime discussion on the Decision Support Tool to receive feedback on the beta version of the tool from food aid program staff.

• Neurocognitive Consultant Trip to Sierra Leone (July 27-August 11, 2017) The Neurocognitive Consultant visited Pujehun, Sierra Leone to train the field research assistants on use of the eye-tracking machine and other testing methods for the neurocognitive function sub-study, and to begin to test the function of the machine in the field. A Research Aid was recruited and trained during the visit and a mobile laboratory for the study was successfully set up and tested at peripheral health units. The pilot part of the neurocognitive sub-study was launched after the visit in August 2017. For more information see the description under “Key Activities: Field Studies.”



• Super Cereal Plus (SC+) and Corn Soy Blend (CSB) Specification Update Workshop (August 2017) FAQR attended the SC+ and CSB Specifications workshop with USAID/FFP and supplier representatives. Discussion focused primarily on costs, data collection/use, packaging and questions regarding supply chain efficiencies. Suppliers cannot control the cost of inputs/materials and therefore struggle to compete with international sourcing and subsidies to international suppliers. Suppliers commented that they are unlikely to reduce headspace, change packaging or implement other changes to products (with associated costs) if these changes will not make a difference in decreasing the price of U.S.-sourced products and increasing the procurement of U.S. products. USAID/FFP and suppliers agreed that more feedback and data on product issues would benefit all stakeholders, in particular when the feedback gets passed on from USAID/FFP to suppliers. USAID/FFP continues to strengthen its collaborative efforts with suppliers. The group plans to reconvene in the Fall of 2017 to discuss specifications changes. Impacts on price and procurement/demand remain important considerations for any FAQR project recommendations related to the food basket and supply chain improvements.

• USAID/FFP Mid-Project Meeting (August 9, 2017) The FAQR team met with the USAID/FFP COR and COR Alternate in Washington, D.C. to review the progress made by each workstream, evaluate planned activities for the second half of the project and look at outputs and deliverables for each workstream.

• USAID Burkina Faso Preliminary Results (August 10, 2017) The Co-PI presented preliminary results from the Burkina Faso to USAID/FFP Representatives. For more information see the description under “Key Activities: Field Studies.”

• FAQR Team Meeting (August 23-25, 2017) The Annual FAQR team meeting was held in Boston, MA from August 23-25. The team meeting provided team members with an opportunity to receive updates from each workstream on the status of activities and future work plans. Additionally, team members met in smaller workstream groups to make progress on key areas of work. Finally, the team began to put together a Research Uptake Strategy for the FAQR Phase III project. The Research Uptake Strategy will serve as a roadmap to ensure dissemination of FAQR Phase III outputs across a wide range of platforms and stakeholders. The FAQR Knowledge Sharing team will continue to develop the Research Uptake Strategy as the project transitions from Project Year 2 to Project Year 3. The team also spent time developing ideas for the FAQR Evidence Summit to be held in the Fall of 2018.

• FANTA Knowledge Sharing Meeting (September 6, 2017) The Co-PI and Project Manager attended the FANTA Knowledge Sharing Meeting. The event highlighted the project’s research and multi-sectoral nutrition activities and innovations over the last six years, and the impact of its work at the global, country, and community levels.



It provided a special opportunity to interact with key stakeholders in the field of food aid and food security. The team benefited by participating in a diverse range of presentations on the importance of nutrition implementation science, social behavior change for improved nutrition, and monitoring and evaluation challenges.

• CORE Group’s Global Health Practitioner Conference (September 25-29, 2017) The Project Manager attended the Core Group’s Global Health Practitioner Conference which enabled community health advocates (NGOs, academics, donors, private sector, etc.) to collaborate, discuss ideas and form partnerships for improving programs that save lives around the world. The conference provided FAQR with the opportunity to learn about a new Nutrition Reference Guide which will be a helpful future tool for the team to determine which nutrition-specific tools and approaches to use for programming and research. The Project Manager also participated in the nutrition working group and was able to promote REFINE and FAQR activities as well as contribute to the work plan for the upcoming year to include FAQR initiative on food aid design and programming.



Annex 3. REFINE Twitter and Website Analytics @REFINEnutrition Twitter Analytics for this quarter: Total Followers: 143

Tweets Retweets Likes Link Clicks16

July 15 25 21 66 August 6 8 11 9

September 8 4 9 5 TOTAL 29 37 41 80

www.refinenutrition.org Google Analytics for this quarter:

Total number of Sessions17

New Sessions18 Average Pages Per Session19

July 84 72 1.31

August 83 60 2.31 September 87 72 1.83

TOTAL 254 204 1.81 Apr 2017 – June 2017 304 222 2.30

Change from last quarter

-16.4% -8.1% -21.3%

Jan 2017 – Sept 2017 881 609 2.12

16Derived from Hootsuite, a social media management dashboard.17“Session:” A user’s interaction on the site from the time a user logs onto the site until they are inactive on the site for 30 minutes.18 “New Session:” A user’s first visit to the site during that period of Google analytics. 19 “Average Pages per session:” Average number of pages visited by a user during one session.



Annex 4. FAQR Twitter and Website Analytics

@foodaidquality Twitter Analytics for this quarter: Total Followers: 54

Tweets Retweets Likes

July 1 0 1 August 5 2 3

September 6 4 4 TOTAL 12 6 8

www.foodaidquality.org Google Analytics for this quarter:

Total number of Sessions20

New Sessions21 Average Pages Per Session22

July 162 94 2.85 August 153 86 314

September 274 173 2.65 TOTAL 589 353 2.88

20 “Session:” A user’s interaction on the site from the time a user logs onto the site until they are inactive on the site for 30 minutes. 21 “New Session:” A user’s first visit to the site during that period of Google Analytics. 22 “Average Pages per session:” Average number of pages visited by a user during one session.


Annex 5. FAQR Decision Support Tool Web-based Interface

Image 1: Decision Support Tool Inputs A-D and Cost Effectiveness Indicators


Image 2: Decision Support Tool Input E


Image 3: Decision Support Tool Inputs F-G


Image 4: Decision Support Tool Inputs H-J



0

20

40

60

80

100

120

April May June July August September

Four Foods Study Sierra Leone: Monthly Enrollment by Arm (April-Sept. 2017)

RUSF CSB+ CSWB SC+

0%

5%

10%

15%

20%

25%

RUSF CSB+ CSWB SC+

3%1% 2%1%

5%6% 5%5%

5% 3% 5%5%

3%2% 3%4%

3%

3%5%4%

2%

1%

1%

Four Foods Sierra Leone: % of Sample Size Enrolled by Arm (April-Sept. 2017)

April May June July August September

Annex 6. Four Foods Study Sierra Leone Enrollment Figures

Documents

Food Aid Quality Review Phase III - United States Agency ...pdf.usaid.gov/pdf_docs/PA00N5CB.pdf · Food Aid Quality Review Phase III: ... HEB High-Energy Biscuit ... used to develop