Report No: AUS0001363 Eat Right India: A Case Study Attempting to Transform India's Food Ecosystem to Advance Public Health and Improve Lives Ashi Kohli Kathuria I Deepika Anand I Ishira Mehta © 2020 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522- 2625; email: pubrights@worldbank.org. Photo Credits: FSSAI Swasth Bharat Yatra: Mobilization and Sensitization of Frontline Workers, School Teachers, and Students. Ashi Kohli Kathuria Senior Nutrition Specialist The World Bank Deepika Anand Nutrition Specialist The World Bank Ishira Mehta Consultant Contents Acknowledgements ...................................................................................................................................... i Abbreviations and Acronyms .................................................................................................................... iii Executive Summary .................................................................................................................................. v I. Introduction......................................................................................................................................... 1 1. The Eat Right India Case Study: Capturing Knowledge in Implementation ............................. 1 2. Methodology for the Case Study ............................................................................................... 1 3. Structure of the Report ............................................................................................................... 2 II. The Eat Right India Program ......................................................................................................... 3 1. Context and Rationale ................................................................................................................ 3 2. Vision ......................................................................................................................................... 6 3. Design, Approaches, and Initiatives .......................................................................................... 6 4. Key Stakeholders and Stakeholder Engagement Approaches ................................................. 11 5. Examining Eat Right India’s New Directions and Approaches .............................................. 12 6. Conclusions .............................................................................................................................. 17 III. Implementation Status and Scale-up Plans................................................................................. 19 1. Implementation Status ............................................................................................................. 19 2. Scale-up .................................................................................................................................... 22 3. Conclusions .............................................................................................................................. 22 IV. Assessing the Potential of Eat Right India for Large-Scale Change ....................................... 25 1. Assessing Eat Right India: using the NHS Large-Scale Change Model as the guiding framework .................................................................................................................................... 25 2. Examining Eat Right India’s Systems Change Approach: drawing upon the CLEAR Framework for Leading Systems Change .................................................................................... 28 3. Conclusions .............................................................................................................................. 31 V. Areas Needing Further Attention, and Recommendations............................................................... 33 Annex 1: About FSSAI: Overview, Regulations and Panels .................................................................... - 1 - Annex 2: Eat Right India: Key Initiatives ............................................................................................. - 3 - List of Figures & Tables Figure 1 The Rising Burden of FBDs in India 3 Figure 2 Micronutrient deficiencies in India 4 Figure 3 Themes and subthemes of Eat Right India 7 Figure 4 Key initiatives: their development and current status 8 Figure 5 Key levers to maximize efficiency and achieve scale 9 Figure 6 The key elements of Systems Leadership 29 Table 1 Implementation status of Eat Right India initiatives 19 List of Boxes Box 1 Prevalence of Noncommunicable Diseases in India 4 Box 2 Examples of Eat Right India Partnership 9 Box 3 Developing and Leveraging a Private Ecosystem 10 Box 4 What is a Nudge? 15 Box 5 Some Lessons Emerging from Experience in the States 22 Box 6 The Ten Principles of Large-Scale Change 26 The Five Key Elements of the CLEAR Framework for Leading Box 7 30 Systems Change Acknowledgements This case study has been prepared as part of the World Bank’s technical assistance to the Food Safety and Standards Authority of India (FSSAI). We are very grateful to the FSSAI Chairperson, Rita Teaotia, and CEO, Pawan Agarwal, for providing valuable inputs for the case study, particularly the leadership vision and perspectives. We also thank the former FSSAI Chairperson, Ashish Bahuguna, for sharing his perspectives and thoughts. We are also grateful to the entire FSSAI team in New Delhi, the various department and initiative leads, and numerous Commissioners and Officers from the Food and Drug Control Administration of States for giving their inputs and time. We especially thank the wide range of stakeholders in the food system for taking the time to provide their valuable insights. Members of FSSAI’s Central Advisory Committee: Prabodh Halde, Head, Regulatory Affairs, Marico. Industry representatives: Hemant Malik, CEO, ITC Foods; Mohit Anand, CEO, Kelloggs India; and Suresh Narayanan, CEO, Nestle India. Chambers of Commerce: Meetu Kapur, Executive Director, CII FACE. Consumer group representatives: Ashim Sanyal, COO, Consumer Voice. Development partners: Alok Ranjan, Country Lead Nutrition, Bill and Melinda Gates Foundation; Deepti Gulati, Head of Programs, GAIN; Neeraj Jain, Country Director, PATH; and Vivek Arora, Senior Advisor, Tata Trusts. Independent professionals: Jagmeet Madan, President, Indian Dietetics Association; and K. Vijayraghavan, Chairman, Sathguru Consulting. We have drawn on “Leading Large-Scale Change – A Practical Guide,” developed by England’s National Health Service (NHS), and “Systems Leadership for Sustainable Development: Taking Action on Complex Challenges through the Power of Networks,” by the Harvard Kennedy School. We have used frameworks from both of these publications and have also borrowed sentences and language (with citations) wherever relevant. We are thankful to the peer reviewers—Jane Nelson (Director, CSR Initiative, Harvard Kennedy School), Lawrence Haddad (Executive Director, GAIN), Elaine Bayliss (Co-lead, Virtual Academy of Large Scale Change, NHS England), and Tom Frieden (President and CEO of Resolve to Save Lives)—for reviewing the draft report and for providing valuable inputs to strengthen it. The team is grateful to Trina S. Haque, Practice Manager, Health, Nutrition & Population Global Practice, South Asia, for her guidance and support throughout the case study and for overall technical assistance. We also thank the Lighthouse India team for their encouragement to document the case study. The team thanks Patricia N. Rogers for her skilled editing of the report. Financial support for this technical assistance from the Bill and Melinda Gates Foundation and the Government of Japan through the Japan Trust Fund for Scaling Up Nutrition is gratefully acknowledged. i ii Abbreviations and Acronyms ASHA Accredited Social Health Activist BHOG Blissful and Hygienic Offering to God CEO Chief Executive Officer CII Confederation of Indian Industry CII-FACE CII-Food and Agriculture Centre of Excellence DART Detect Adulteration with Rapid Test DO Designated Officer FAO Food and Agriculture Organization FBD Foodborne disease FBO Food business operator FoSTaC Food Safety Training and Certification FSO Food Safety Officer FSSAI Food Safety and Standards Authority of India GAIN Global Alliance for Improved Nutrition GDP Gross domestic product LBSNAA Lal Bahadur Shastri National Academy of Administration LSC Large-Scale Change M&E Monitoring and evaluation MIS Management information system MSMEs Micro, small and medium enterprises iii NCD Noncommunicable disease NGO Nongovernmental organization NetProFaN Network of Professionals in Food and Nutrition NetScOFaN Network of Scientific Organizations for Food and Nutrition NHS National Health Service (England) PDSA Plan-Do-Study-Act RUCO Repurpose Used Cooking Oil SBY Swasth Bharat Yatra SDG Sustainable Development Goal SMEs Small and medium enterprises SNF Safe and Nutritious Food SOP Standard operating procedure UNICEF United Nations Children’s Fund UT Union Territory WHO World Health Organization iv Executive Summary 1. This case study attempts to capture the story of Eat Right India, a program developed by the country’s food regulatory body, the Food Safety and Standards Authority of India (FSSAI), as it is taking shape and being rolled out. Eat Right India attempts to address the many challenges of ensuring that in a country the size, complexity, and diversity of India, the foods that people access are safe, healthy, and sustainable. 2. Eat Right India has been developed in response to the country’s public health, nutrition and environmental challenges associated with aspects of food. These include: the substantial burden of foodborne diseases (FBDs), with about 100 million cases of FBDs reported every year, and unsafe food costing the country an estimated $15 billion a year; more than a quarter of children and adolescents stunted, and pervasive micronutrient deficiencies such as anemia, and an estimated loss of US$12 billion in GDP every year due to vitamin and mineral deficiencies alone; the rapidly rising obesity and noncommunicable diseases such as diabetes, heart disease, and hypertension accounting for more than 60 percent of the deaths in the country; and environmental concerns arising from food loss, plastic in food packaging, and improper plastic disposal. Thus, there is a clear rationale for Eat Right India to address the interlinked aspects of food safety, nutrition, and sustainability in a holistic way. 3. Aspiring to transform India’s food ecosystem, the program envisions a future state when all people in the country will choose to consume and access food that is safe, healthy, and sustainable. To operationalize the vision, the program has adopted a collaborative food systems approach1 using a mix of regulatory, capacity building, collaborative and empowerment approaches. To support the food systems approach, FSSAI has also re-envisioned its role and has begun to make a shift from being only a “regulator and enforcer” to becoming also the “chief convenor and enabler” of change. 4. To drive the complex change, the program is engaging with stakeholders across sectors — government agencies and departments, food businesses, consumers, academia, professionals. In a departure from the traditional sequential program planning and implementation cycle, the program has taken a flexible, adaptive design and implementation approach. Existing initiatives2 were incorporated into the program, and new initiatives were developed and implemented over time, tested, and refined along the way through feedback from stakeholders. This emergent design has enabled the rapid development and implementation of a wide range of initiatives to reach multiple audiences in a variety of ways that meets their needs and contexts. This program approach is distinct from the Mission approach adopted by most national programs to address large challenges, it adds to India’s development experience. 5. To maximize reach and efficiency, the program uses five key overarching strategies or “levers of change”: (i) Establish partnerships with multiple stakeholders; (ii) Engage, excite, enable 1 “A food systems approach is a way of thinking and doing that considers the food system in its totality, taking into account all the elements, their relationships and related effects.” (Sustainable Food Systems Concepts and Frameworks, Food and Agriculture Organization, 2018.) 2 The term initiative in the Eat Right India program context refers to a specific venture (including all its related activities and sub- activities) under the program umbrella that works with a specific audience or set of partners, using specific approaches and a defined set of actions to achieve specific objectives and results. v (the 3E model) stakeholders; (iii) Leverage and develop a private ecosystem; (iv) Use of technology; and (v) Mass mobilization. Deploying these levers, beneficial partnerships that cut across sectors and traditional boundaries and bring in new stakeholders have been created. To illustrate, partnering with the Ministries of Health and Family Welfare and Petroleum and Natural Gas, state-owned oil manufacturing companies, and food business operators to convert used cooking oil to bio-diesel, an environmentally sustainable fuel, at the same time reducing the unhealthy multiple use of cooking oil; with the private sector, e.g., Confederation of Indian Industry Food and Agriculture Centre of Excellence (CII-FACE) to engage with industry for product reformulation; and with professional bodies to extend outreach. The creation of a cadre of “Food Safety Mitras,” private individuals enrolled and trained by FSSAI to support small food businesses in registration against a fee, and the use of the private sector for services such as laboratory, training, and audits also maximize reach and efficiency. 7. The program engages directly with consumers with a twofold purpose – to improve people’s dietary practices, and to raise the practice standards of food businesses in response to consumer demand. To promote behavior change, the program has employed theories from behavioral economics and developed and widely used a range of behavior change communication material – videos featuring celebrities, toolkits, e-courses, an online quiz, and so on, reaching them at various touch points – homes, schools, workplaces, institutions. All messages are simplified and linked to the three themes of safe, healthy and sustainable. These messages were disseminated countrywide through the Swastha Bharat Yatra, one of the largest cyclothons in the world. During the 104-day cyclothon, 21,629 volunteer cyclists collectively covered 2,156 places and 20,233 kms with 1 million participants joining hands to reach 25 million people with Eat Right India messages. 8. Given India’s over 1.4 million registered food businesses with varying capacities and a very large informal food sector, FSSAI is combining regulatory approaches with capacity building and empowerment approaches to take a graded approach suited to the capacities of various sizes of businesses. For large businesses it focuses on regulatory compliance, while encouraging the businesses to be in charge of their own compliance. For medium and small food businesses, Eat Right India focuses on building capacity and providing hygiene ratings to food service establishments, reaping a larger benefit through incremental improvements in the standards of large numbers of businesses. For petty businesses, the approach is to raise the quality, hygiene, and safety of their food. 9. While these are early days in program implementation, Eat Right India has rolled out and expanded several initiatives across states. To illustrate: under the Food Safety Training and Certification (FoSTaC) initiative, over 10,500 trainings have been conducted and 279,000 Food Safety Supervisors trained; under the Food Safety on Wheels initiative, 54 vans are operational in 32 States/UTs; 11 Clean Street Food Hubs across four states have been certified; 19 states and 5 Union Territories are using fortified commodities in Government safety net programs, and 82 companies (large and MSME) produce 122 fortified products; 31,758 schools are registered under the Eat Right School initiative and over 500,000 students have been reached with Eat Right School activities. True to its emergent design, new initiatives continue to be developed, tested, and refined. For example, expanding the clean street food hubs approach to clean fruit and vegetable markets and meat markets; the Eat Right campus approach tested in schools, workplaces, and other institutions is being applied to other spaces such as railway stations, places of worship, and tea-coffee plantations. vi 10. Over the next five years, FSSAI intends to scale up Eat Right India across the nation, involving individual states and both broadening and deepening its initiatives. Therefore, it is pertinent at this juncture to assess its design and approaches to reflect on its strengths as well as challenges and areas for attention and suggest possible ways to address the challenges. The following points summarize the key findings from an analysis of Eat Right India’s new directions and technical approaches and its potential for achieving large scale change: 11. Eat Right India’s technical and operational approaches, while grounded in modern food regulatory frameworks, expand beyond the typical regulatory approach to promote health, nutrition, and sustainability. Recent global thinking supports a food systems approach and multisector, multilevel action to promote healthy dietary patterns, reduce food loss, and improve food production practices. The food systems agenda is complex, vast in scope, cuts across several government portfolios, and presents many implementation challenges. FSSAI has brought these subjects together under the Eat Right India collaborative program mechanism rather than in policy ministries. Directly engaging with consumers to “promote public health” is a new approach among food regulators as most regulators limit their communication efforts to educating with the aim of providing “protection” through such measures as labeling, standards, and so on. Improving food safety in the informal sector is one of the largest challenges most lower-middle-income countries face. The capacity-building and enablement approaches to incrementally improve the practice standards in this sector—for example, through the cluster approach and Food Safety Mitras—could provide important examples for other lower-middle-income countries. Harnessing and leveraging the private sector not only help to extend reach, it also promotes private enterprise, creates employment, enhances the earning potential of a large number of people, and creates new platforms to complement government efforts. 12. These approaches draw on good practices that have worked elsewhere, although they add “Indian” characteristics to make them as relevant to India as they have been in other countries. The levers of change, the collaborative systems change approach, and the flexible design appear to be the right approaches to suit the change Eat Right India aspires to achieve; such a change could perhaps be difficult for any one agency or department to achieve. 13. Mapping the key elements of Eat Right India to the Large-Scale Change (LSC) model developed by England’s National Health Service3 reveals that the program is well grounded in the principles that underpin large-scale change. For example, it has a transformational vision; it has identified and communicated key themes that people can relate to and that will make a big difference; to distribute leadership, it has framed the issues in ways that engage and mobilize the imagination, energy, and will of a large number of diverse stakeholders, and it has been open to the contributions of many sources of leadership; it has used varied means of communication to attract new and active supporters; and its planning and design have been flexible and have been adapted in response to feedback. The lack of a robust M&E system, robust and systematic learning cycles, assessments to review progress and effectiveness and calibrate approaches are areas that do not measure up well with the LSC model. 14. A comparison of Eat Right India’s systems approach with the elements highlighted in the CLEAR Framework for Leading Systems Change indicates that FSSAI has done well in three of the five key elements of the systems change process—Convene and Commit, Look and Learn, and Engage and Energize. FSSAI has convened stakeholders; drawn upon ideas, perspectives, and 3National Health Service, England. Leading Large-Scale Change – A Practical Guide, 2018. (https://www.england.nhs.uk/wp- content/uploads/2017/09/practical-guide-large-scale-change-april-2018-smll.pdf) vii learning from many stakeholder consultations and brainstorming sessions; and engaged with and mobilized a wide range of stakeholders. However, the two elements of Act with Accountability and Review and Revise require further attention and effort in scaling up the program. For example, it will be crucial to excite and engage state leadership; establish and agree on frameworks for mutual accountability for results; and establish systems for “review and revision,” with measurement frameworks, monitoring and reporting mechanisms, and provisions for evaluation and learning. 15. Important insights have emerged from the analyses of Eat Right India’s technical approaches and its potential for large scale change using the LSC and Systems Leadership approaches, as well as from conversations with stakeholders. They highlight that the program can contribute to addressing the country’s challenges related to the safety, nutrition, and sustainability of food. Even though Eat Right India is a relatively new program, its vision, design, and early implementation reflect most elements of the LSC and Systems Leadership approaches and it has the ingredients to bring about large-scale, sustainable change. At the same time, there are program elements that need strengthening. The following points draw upon the areas that require further attention and present recommendations for FSSAI’s consideration: • To institutionalize Eat Right India’s systems approach, capacity of leaders at the central, state to implement such an approach is critical. Leadership development efforts will need to be designed, implemented, and institutionalized at all levels. • Eat Right India would benefit from formal connectivity across all ministries and agencies relevant to the food ecosystem as the lack of an overall, whole-of-government policy or legislative platform for such could be a major constraint. FSSAI and other key agencies should consider defining an overarching enabling umbrella policy framework for the food ecosystem, bringing together food safety, public health, and environment to harmonize policies for the food system across these sectors. • For timely and quality scale-up of the program, it will be important to get states on board; develop systems to build their capacity and systematically share new developments, tools, and resources. • FSSAI should set up platforms with defined structure, function, and resources to fulfill national and international learning needs and the knowledge creation and exchange needs of Eat Right India. Linkages and partnerships with national and international schools and universities could add value to the research and learning from Eat Right India. • Eat Right India should develop a comprehensive conceptual framework for knowledge management, including a strong monitoring and evaluation system. Specifically, a state-of-the- art management information system to meet the monitoring needs of Eat Right India and a dashboard to monitor progress and share it widely with all stakeholders will be key. In addition, it will be important to carry out periodic assessments and evaluations to determine the impact of current strategies and approaches and to inform future directions and improvements. • To ensure that resource availability matches the program scope and scale, FSSAI should undertake a full resource mapping and planning, including at the state level. It should urge, engage with, and consider incentivizing states to commit and allocate greater resources for Eat Right India. viii 16. Finally, it is important to note that the case study captures the program’s development and progress until February 2020—that is, just before COVID-19 was declared a global pandemic. The pandemic reinforces the need for such a program, serving as a stark reminder of the crucial role of safe, healthy, and nutritious food in boosting human immunity, and of the importance of strengthening food safety and sanitary practices along the value chain from production to final consumption to reduce the risk of the emergence of future infectious diseases with pandemic potential. It is probable that the program has undergone changes since then, especially in response to the pandemic, and adopted specific measures to address food-related vulnerabilities during the pandemic. Meanwhile, Eat Right India has received important international recognition, having been selected from among more than 1,300 submissions across the globe as one of 10 finalists for the Food System Vision Prize for envisioning a regenerative and nourishing food system by the year 2050. ix x I. Introduction 1. The Eat Right India Case Study: Capturing Knowledge in Implementation 1.1 India’s enactment of the Food Safety and Standards Act in 2006 and the creation of the national food regulatory body, the Food Safety and Standards Authority of India (FSSAI),4 in 2008 laid the foundation of India’s food regulatory approach. This change represented a paradigm shift from the “prevention of food adulteration”5 to FSSAI’s mandate to “ensure safe and wholesome food for the country.” India’s food regulatory system has continued to evolve since then, with FSSAI’s efforts to modernize the system in line with global developments and regulatory frameworks and to address India’s particular food safety challenges. In 2018 FSSAI launched a new program, Eat Right India, to help ensure the availability of safe, wholesome, and sustainable food across the country. Please refer to Annex 1 for more details about FSSAI. 1.2 This case study attempts to capture the story of Eat Right India, as it is taking shape and being rolled out. The study derives its value not from the ex post facto examination of a program—the results it achieved, its strengths and weaknesses, and the lessons it provides for future programs—but from capturing the living experience of a large-scale change program in its early implementation days. Several points about the program motivate its documentation at this stage. Eat Right India’s vision, design, and approaches aim to bring about complex, large-scale change in a country of the size, complexity, and diversity of India; its design and implementation are marked by flexibility and adaptability; it uses a “food systems” approach to address the interlinked aspects of food safety, nutrition and public health, and the environment; and it attempts to tackle such challenges as improving food safety in the informal food business sector. For all these reasons, at a recent knowledge-sharing event, Eat Right India Lighthouse, participants from several countries expressed great interest in documentation and wider sharing of this experience from India with other countries, particularly with other food regulatory authorities, academia, and development agencies. Furthermore, as FSSAI prepares to scale up Eat Right India, it is an opportune time to assess its strategies and approaches, acknowledge areas of strength and highlight those that need FSSAI’s further attention. 2. Methodology for the Case Study 2.1. This case study was developed using both primary and secondary qualitative research. • Primary research included in-depth interviews with a range of stakeholders across the food ecosystem that Eat Right India engages with: industry and chambers of commerce, development sector partners, consumer organizations, relevant networks, national and international food safety experts, state food safety authorities, members of FSSAI’s Central Advisory Committee, and FSSAI leadership and staff. • Secondary research consisted of review of relevant documents about FSSAI and Eat Right India sourced from FSSAI and other organizations. In addition, the team reviewed well- 4 Established by an Act of Parliament (2006): https://www.fssai.gov.in/cms/food-safety-and-standards-act-2006.php 5 Until 2006, food safety in the country was governed primarily by the Prevention of Food Adulteration Act of 1954. 1 developed and modernized food regulatory systems of selected countries/ areas6 to understand the global context of the public health, nutrition and food safety challenges, holistic food system approaches, and best practice food safety frameworks and interventions. 2.2. Two guiding frameworks were selected to assess Eat Right India’s potential to achieve complex and large-scale change. After reviewing several change models and leadership frameworks,7 we selected two to guide our assessment of elements of Eat Right India: the National Health Service (NHS) England Large-Scale Change (LSC) Model,8 and the CLEAR framework for Leading Systems Change.9 3. Structure of the Report 3.1. Following this Introduction, Chapter II lays out the rationale for Eat Right India, describes its design and approaches, and presents an analysis of the program’s key technical and operational approaches. Chapter III discusses Eat Right India’s implementation status and scale-up plans, and Chapter IV evaluates key elements of the program against the selected frameworks, highlighting its strengths and identify areas that need further attention. Finally, Chapter V summarizes the key gaps identified and presents recommendations for FSSAI’s consideration as it scales up. 3.2. Finally, it is important to note that the case study captures the program’s development and progress until February 2020—that is, just before COVID-19 was declared a global pandemic. The pandemic reinforces the need for such a program, serving as a stark reminder of the crucial role of safe, healthy, and nutritious food in boosting human immunity, and of the importance of strengthening food safety and sanitary practices along the value chain from production to final consumption to reduce the risk of the emergence of future infectious diseases with pandemic potential. It is probable that the program has undergone changes since then, especially in response to the pandemic, and adopted specific measures to address food-related vulnerabilities during the pandemic. Meanwhile, Eat Right India has received important international recognition, having been selected from among more than 1,300 submissions across the globe as one of 10 awardees for the Food System Vision Prize10. 6 Australia, New Zealand, Canada, the European Union, and the United States of America 7 We reviewed a range of globally known change models and frameworks developed by public policy schools, business management professors, psychologists, management consultants, and public sector organizations: Lewin’s 3 Step Change Management Model, Kottler’s 8 Step Change Model, The McKinsey 7S model, and the Nudge theory. 8 National Health Service, England. 2018. Leading Large-Scale Change – A Practical Guide. (https://www.england.nhs.uk/wp- content/uploads/2017/09/practical-guide-large-scale-change-april-2018-smll.pdf ) 9 Lisa Dreier, Jane Nelson, and David Nabarro, “Systems Leadership for Sustainable Development: Strategies for Achieving Systems Change,” Harvard Kennedy School Corporate Responsibility Initiative Research Paper, September 2019. (https://www.hks.harvard.edu/sites/default/files/centers/mrcbg/files/Systems%20Leadership.pdf) 10 The Food System Vision prize challenge, hosted by The Rockefeller Foundation, SecondMuse and OpenIDEO, invited organizations across the globe to develop their vision for creating a regenerative and nourishing food system by the year 2050. 2 II. The Eat Right India Program This chapter describes the context, vision, and design of the Eat Right India program, developed by FSSAI and launched in October 2018. It highlights some of the key approaches the program has adopted and presents a critical analysis of some of the new directions the program is taking. 1. Context and Rationale 1.1. Food safety, nutrition, food security, and sustainability are closely linked. Food plays a key role in public health and nutrition, and it has environmental impacts. A range of food safety hazards and unhealthy diets contribute to malnutrition and several noncommunicable diseases (NCDs), and unsafe food makes the vicious cycle of disease and malnutrition worse, particularly affecting infants, young children, the elderly, the immune-compromised, and the sick. Foodborne diseases (FBDs) obstruct socioeconomic development by straining health care systems and harming national economies, tourism, and trade.11 1.2. India’s burden of FBDs is high and has substantial costs for the economy. Globally over 420,000 people die each year, and some 600 million people – almost one in ten – fall ill after eating contaminated food (see Figure 1). India and China account for 49 percent of the total economic burden due to FBDs in low- and middle- Figure 1. The Rising Burden of FBDs income countries, and for 71 percent of the total burden in Asia.12 Every year 100 million cases of (Globally) FBDs are reported in India (see Figure 1), and unsafe food costs India as much as $15 billion13 annually— Number of foodborne disease cases in India a very high economic Source: WHO, 2019; Wageningen University & Research and ILRI, 2017 burden. The burden of FBDs is comparable to that of malaria, HIV/AIDS, and tuberculosis, and yet it does not get the required attention. 14 As food chains become longer, more complex, and more globalized, including in India, contamination of food leading to a rise in FBDs is a growing concern. 1.3. India’s triple burden of malnutrition—undernutrition, micronutrient deficiencies, and rising obesity—and NCDs has high economic costs. More than a quarter of children and adolescents in India are stunted: 35 percent of preschoolers, 22 percent of children in school, and 24 11 Lloyd’s Register Foundation. Foresight review of food safety: Feeding the world safely and sustainably. Report Series: No. 2109.2 Oct 2019 12 Jaffee, Steven, Spencer Henson, Laurian Unnevehr, Delia Grace, and Emilie Cassou. 2019. Th e Safe Food Imperative: Accelerating Progress in Low and Middle-Income Countries. Agriculture and Food Series. Washington, DC: World Bank. (http://documents.worldbank.org/curated/en/484371545400065950/pdf/133154-PUB-PUBLIC-9781464813450.pdf) 13 Ibid 14 World Health Organization, 2015. WHO Estimates of the Global Burden of Foodborne Diseases, Foodborne Disease Burden Epidemiology Reference Group 2007-2015. 3 percent of adolescents.15 Micronutrient deficiencies such as anemia, and deficiencies of vitamins A, D, B12, and folate, are pervasive (see Figure 2). NCDs such as diabetes, heart disease, and hypertension are estimated to Figure 2. Micronutrient Deficiencies in India account for more ANEMIA VITAMIN A DEFICIENCY VITAMIN D DEFICIENCY than 60 percent of Pre-schoolers 41 deaths in the School-age children 24 country.16 First- time data from m Adolescents 28 the recent Pregnant women Comprehensive Men 22.7 National Nutrition Women Survey 2016-18 show the high Source: CNNS, 2016-18; NFHS-4, 2015-16 (anemia figures for women, pregnant women, and men) prevalence of Box 1. Prevalence of Noncommunicable Diseases in India 3% of school children and 4% of adolescents have high cholesterol. 1 in 10 school age children and adolescents is pre-diabetic. 7% of school-age children and adolescents are at risk of chronic kidney disease. Cardiovascular diseases were responsible for 28% of total deaths in 2016 as compared to 15% in 1990*. 1% of school-age children and adolescents are diabetic. 5% of adolescents have hypertension. Source: Comprehensive National Nutrition Survey 2016-18; *Global Burden of Disease Study 1990-2016, 2018 NCDs and NCD-risk factors in the country (see Box 1): 34 and 26 percent of school-age children, and 16 and 28 percent of adolescents, have high serum triglycerides and low levels of high-density lipoproteins, respectively. These are major risk factors for NCDs. Each year India loses over US$12 billion in GDP to vitamin and mineral deficiencies.17 For example, the intangible costs of anemia are estimated at 1.3 percent of GDP for children and 4 percent of GDP for children and adults combined.18 15 Comprehensive National Nutrition Survey (2016-18), Ministry of Health and Family Welfare, Government of India, UNICEF and Population Council. See also National Family Health Survey-4 (2015-16), Ministry of Health and Family Welfare, Government of India. 16 Indian Council of Medical Research, Public Health Foundation of India and Institute of Health Metrics and Evaluation. India: Health of the Nation’s States – The India State Level Disease Burden Initiative. 2017. 17 UNICEF and the Micronutrient Initiative. 2004. Vitamin and Mineral Deficiency: a Global Progress Report. See also World Bank, 2009, World Development Indicators (database). 18 Plessow R, et al. 2015. Social Costs of Iron Deficiency Anemia in 6-59 months old children in India. PLoS One. 2015;10(8):e0136581. See also Horton, S., and J. Ross. 2003. “The economics of iron deficiency.” Food Policy 28(1): 51-75. In 4 1.4. Dietary practices and behaviors are major contributors to this burden. Suboptimal feeding practices, particularly for infants and young children, pregnant and nursing mothers contribute to undernutrition, while high consumption of fats, salt, and sugar contribute to obesity and diet-related NCDs. The diet and nutrition transition taking place in the country is contributing to the situation. This transition is influenced by complex food choice drivers, such as income, cultural perceptions, convenience, seasonality, access and markets, and family influence. It is marked by such behaviors as lower fruit and vegetable intakes and a shift from millets and coarse grains to refined grains, and from consuming largely home-food to consuming a combination of home-cooked, processed and packaged, delivered, and out-of-home food. 1.5. The importance of food goes beyond health and safety to environmental issues. The global food production system is one of the biggest contributors to greenhouse gas emissions.19 Food lost and wasted each year accounts for an estimated 8 percent of annual greenhouse gas emissions, consumes a quarter of all water used by agriculture, and requires an agricultural area the size of China.20 The annual market value of lost and wasted food globally is estimated at an astounding US$940 billion.21 The economic loss for India’s agriculture sector in 2012-13 due to food loss was estimated at US$15 billion, or around 6.2 percent of India’s GDP.22 The global proliferation of plastic packaging and the improper disposal of plastics affects the marine environment as well as terrestrial and groundwater ecosystems. A recent study found that of 150 samples of tap water from countries including Germany, India, and the United States, 81 percent contained microplastics.23 1.6. India’s size, large population, and diversity, and the multiple stakeholders and sectors involved, add further complexity to FSSAI’s task. The size of a subcontinent, India has 1.3 billion people living in diverse settings, with even more diversity in diets and food habits. It also has millions of big, small, and petty24 food businesses, including a huge informal sector, involved in the production and distribution of food. Addressing the interlinked issues of food safety and nutritious and sustainable diets holistically requires collaborative efforts by several sectors, government departments, and stakeholders. It also requires collective action, new ways of thinking, new approaches, different leadership models and management approaches. 1.7. The rationale for a program such as Eat Right India is clear. The magnitude of the country’s FBD and malnutrition issues, and the food-related environmental impacts the country faces, form the rationale to promote safe, healthy, and sustainable food, and to do so holistically, with the engagement of all concerned sectors and stakeholders. Gragnolati Michele, Shekar Meera, Das Gupta Monica, Bredenkamp Caryn, and Lee Yi-Kyoung, India’s Undernourished Children: A call for reform and action. HNP Discussion Paper, World Bank, 2005. 19 Lloyd’s Register Foundation, op. cit. 20 Katie Flanagan, Kai Robertson, and Craig Hanson. Reducing Food Loss and Waste: Setting a Global Action Agenda, World Resource Institute, 2019. (https:// wriorg.s3.amazonaws.com/s3fs-public/reducing-food-loss-waste-global-action-agenda_1.pdf). 21 FAO. 2015. Food Wastage Footprint & Climate Change. Rome: FAO. 22 Jha, S., R. Vishwakarma, T. Ahmad, A. Rai, and A. Dixit. 2015. Report on Assessment of Quantitative Harvest and Post-harvest Losses of Major Crops and Commodities in India. Ludhiana: ICAR-All India Coordinated Research Project on Post-harvest Technology, ICAR-CIPHET. http://www.ciphet.in/upload/sphl/ MOFPIpercent20REPORT1.pdf. 23 Kosuth M, SA Mason, and EV Wattenberg. Anthropogenic Contamination of Tap Water, Beer, and Sea Salt. PLoS ONE 13 (4):e0194970, 2018. https://doi. org/10.1371/journal.pone.0194970. 24 Under the Food Safety & Standards (Licensing and Registration of Food Business) Regulations, 2011, “petty” refers to a small- scale food business such as a “manufacturer, retailer, hawker, itinerant vendor, temporary stall holder,” and so on. 5 2. Vision 2.1. Eat Right India envisions transforming India’s food ecosystem to ensure safe, healthy, and sustainable food for the country. It visualizes a future state when all food that people in the country choose to consume and access to will be safe, healthy, and sustainable. According to FSSAI, Eat Right India seeks to redefine how the citizens of the country relate to food, changing mindsets to think of food in the following terms: “If it is not safe…it is not food; if it is not healthy...it is not food; and if it is not good for the environment...it is not food.” The vision is ambitious, and the change envisaged is massive, deep, and pervasive. “The Eat Right India movement is a collective effort of all stakeholders to transform the food ecosystem of the country through a judicious mix of regulatory, capacity building, collaborative and empowerment approaches. This citizen-centric initiative aims to bring about large-scale social and behavior change to create a culture of safe, healthy and sustainable diets.” - Pawan Agarwal, FSSAI CEO 2.2. To operationalize the vision, FSSAI has adopted a food system25 approach and re- envisioned its role. To address elements of food safety, health, and environment in an interconnected manner, the program has adopted a collaborative food systems approach. FSSAI realized that, as a small regulatory body with modest resources, it would need to involve many stakeholders—government agencies and departments at the national and state levels, food businesses, consumers—and would need to go beyond pure regulatory approaches. Therefore, it began making a shift from being only a “regulator and enforcer” to becoming also the “chief convenor and enabler” of change. These strategic choices have driven Eat Right India’s design, strategies, approaches, and actions. 3. Design, Approaches, and Initiatives 3.1. Guided by the vision, all Eat Right India activities are anchored in three overarching, easy-to-understand themes: Eat safe, Eat healthy, and Eat sustainable. Each of these themes is further divided into subthemes (see Figure 3). All program activities and messages – consumer- facing or industry-facing, regulatory or capacity building, direct or in partnership – are guided in their conceptualization, design, and implementation by one or more of the main themes and their subthemes, and thus contribute to the overall program vision (Figure 4). 25“A food systems approach is a way of thinking and doing that considers the food system in its totality, taking into account all the elements, their relationships and related effects. It is not confined to one single sector, sub-system (e.g. value chain, market) or discipline, and thus broadens the framing and analysis of a particular issue as the result of an intricate web of interlinked activities and feedbacks. It considers all relevant causal variables of a problem and all social, environmental, and economic impacts of the solutions to achieve transformational systemic changes.” (Sustainable Food Systems Concepts and Frameworks, Food and Agriculture Organization, 2018.) 6 3.2. The flexible program design has evolved organically over time and continues to do so. The design draws on global models of advanced regulatory systems, blending in innovations and approaches that are designed to address India’s unique challenges. Moving away from the traditional sequential program planning and implementation cycle, Eat Right India adopted a flexible, adaptive approach: existing initiatives were incorporated into the program, and new initiatives26 were developed and implemented rapidly, tested, and refined along the way through periodic informal reviews and feedback from stakeholders. This approach is in many ways comparable to the Lean Start-up approach,27 in which ideas are tested immediately using a prototype or a minimum viable product to get market feedback, allowing the rapid development of a relevant and realistic product that is in line with market needs and demands and with the ability Figure 3. Themes and Subthemes of Eat Right India Demand Eat Eat Eat Safe Healthy Sustainable Businesses Citizens Combat What to What Not No Food • Home • Capacity Adulteration Eat to Eat Waste • Workplace Building • Eating Out • Pledges • Hospitals • Self compliance Personal and Balanced Reduce Surrounding Trans-Fat Hygiene Diet Plastic Safe Food Fortified Conserve HFSS Practices Foods Water Supply and resources of all stakeholders involved. For example, the Safe and Nutritious Food initiative was started with a limited audience of school and home in mind. Learning and discussion with relevant stakeholders helped shape it over time into an overarching “Eat Right Campus” initiative that could be applied to many different types of campuses (spaces with defined premises and food- handling activities like cooking, processing, retail), such as educational institutes, corporates, prisons, defense and paramilitary establishments, hospitals and health institutions, tea and coffee estates, airlines, and railway stations. (Annex 2 describes some key Eat Right India initiatives). Given the ability of the program to respond to new learning and evolving contexts, it is inevitable that over time new initiatives will evolve, some existing ones might be refined and revised, consolidated, or even dropped, and the most robust ones will continue to grow and expand. 3.3. To maximize reach and efficiency, the design uses five key “levers of change.” To meet the challenge of reaching across the wide expanse of India and its food system, the design set out five strategic ways (see Figure 5) to engage with its multiple stakeholders, extend outreach, and maximize cost-effectiveness. 7 Figure 4: Key Eat Right India Initiatives and Their Development Over Time 26 The term initiative in the Eat Right India program context refers to a specific venture (including all their activities and sub- activities) under the program umbrella that works with a specific audience or set of partners, using specific approaches and a defined set of actions to achieve specific objectives and results. 27 A core component of the Lean Startup methodology is the build-measure-learn feedback loop. The first step is figuring out the problem that needs to be solved and then developing a minimum viable product (MVP) to begin the process of learning as quickly as possible. Once the MVP is established, a startup can work on tuning the engine. This will involve measurement and learning and must include actionable metrics that can demonstrate cause and effect. http://theleanstartup.com/principles 8 Figure 5. Key Levers to Maximize Efficiency and 3.3.1. Establishing partnerships with Achieve Scale multiple stakeholders: Many partnerships have been forged to further and support the program’s agenda and to expand the Eat Right India leadership base and create NetScoFaN ownership (see Box 2 for examples). These partnerships cut across conventional boundaries to include a range of partners, with FSSAI playing the role of convenor and facilitator. Box 2. Examples of Eat Right India Partnerships With the government Repurpose Used Cooking Oil (RUCO): In a partnership with the Ministry of Health and Family Welfare and the Ministry of Petroleum and Natural Gas, state-owned oil manufacturing companies, food business operators (FBOs), and aggregators collect used cooking oil for conversion into bio-fuels, thereby reducing consumers’ consumption of unhealthy oil and helping the creation of an environmentally sustainable fuel. Railways: Partnering with the Indian Railways and Indian Railway Catering and Tourism Corporation, FSSAI provides training, audit, and certification of Eat Right railway stations to ensure that they provide safe and wholesome food. FSSAI has certified Chhatrapati Shivaji Maharaj Terminus, Mumbai, and Mumbai Central as Eat Right Stations. With the private sector Confederation of Indian Industry Food and Agriculture Centre of Excellence (CII-FACE): This partnership encourages food businesses to become joint stakeholders in providing safe and nutritious food. As part of this association, 12 companies made voluntary pledges that they will not advertise foods that are high in fat, salt, and sugar to children. In addition, the National Bakery Association and Oil Solvent Extractors Association have pledged their commitment to a trans-fat-free India by 2020. CII-FACE and FSSAI track progress and reward good performers. With training institutions and professional bodies Network of Professionals in Food and Nutrition (NetProFaN): This partnership, with a network of seven professional organizations in the food and nutrition space, seeks to leverage their collective strength to promote public health and nutrition—both by professional members individually and through regional chapters. (The seven professional bodies are Indian Dietetic Association, Nutrition Society of India, Indian Medical Association, Association of Food and Scientists Technologists, Indian Federation of Culinary Associations, Association of Analytical Chemists, India Chapter, and Indian Public Health Association.) The members also provide technical inputs to FSSAI and to the state Food Safety authorities. Lal Bahadur Shastri National Academy of Administration (LBSNAA): This institute, which trains India’s civil servants, is helping to build Eat Right India champions across the country and spread expertise among the administrative leadership of the future. The institute has set up a Centre of Food, Planet and Health with this objective in mind. With others Places of worship: Under the Blissful and Hygienic Offering to God (BHOG) initiative, FSSAI has partnered with the management of places of worship to train the food handlers who cook and handle prasad (food offering to God) at their premises. The training is followed by audit and certification of the place of worship. 9 3.3.2. Engage, excite, enable (the 3E model): The 3E model has helped Eat Right India to engage and mobilize the imagination, energy, and will of many stakeholders—for example, ministries like Health and Family Welfare, Women and Child Development, and Petroleum and National Gas; state governments; institutions such as the Lal Bahadur Shastri National Academy of Administration (LBSNAA); the food industry and industry associations; celebrities; international and national development organizations; and professional bodies. The list of engaged stakeholders continues to grow as Eat Right India expands its vision and activities. But mere engagement was not sufficient; by exciting (e.g., involving them in planning) and enabling (e.g., providing guidance, start-up resources, coordination and facilitation support) stakeholders, Eat Right India helps them play a part in bringing about the desired change, creating ownership and making it “everyone’s work.” 3.3.3. Leverage and develop a private ecosystem: Eat Right India is developing and harnessing a private ecosystem—an ecosystem that is outside the government system but complements and supports the government’s efforts, extending the services without any additional cost to the exchequer. (Box 3 describes several examples of private ecosystems.) 3.3.4. Use of technology to expand reach and efficiency: Eat Right India has leveraged technology in several ways—for example, simplifying registration and licensing processes by making most of them online; creating Eat Right online training courses to build the capacity of front-line grassroots workers in health; and sharing knowledge with stakeholders across the food ecosystem through extensive online content that includes videos, brochures, flyers, guidance notes, and so on. To generate interest among consumers and engage them, an Eat Right Quiz and Eat Right online shop have been created. Box 3. Developing and Leveraging a Private Ecosystem Food Safety Training and Certification (FoSTaC): FoSTaC is a large-scale framework for training on food safety and hygiene. The trainings, delivered through a well-designed training mechanism leveraging the network of 224 third-party training partners and 2,040 sector-specific certified trainers and auditors across India, cover General Hygiene and Manufacturing Practices as mentioned in Schedule 4 of FSS (Licensing and Registration of Food Business) Act, 2011. Those involved in or intending to become involved in the food business, students, and food professionals are eligible to enroll for training and certification as a Food Safety Supervisor (FSS) to carry out periodic on-site training of all food handlers and maintain records for audits and inspections. Food Testing Laboratory Network: FSSAI has recognized 267 laboratories in India to assist in food testing. The National Food Laboratory (NFL), Delhi NCR, is a public-private partnership and the first of its kind in the food laboratory sector in the country. The laboratory, equipped with the latest technologies, performs analyses and testing according to global testing and calibration standards. The establishment of similar NFLs in Mumbai and Chennai is planned for the near future. Food Safety Mitras: FSSAI has created an ecosystem of facilitators designated as “Food Safety Mitras” —private individuals who are trained, certified, and regulated by FSSAI to provide standardized, good-quality, and cost-effective services to food businesses. The Mitras perform selected actions on behalf of/for FBOs with respect to the implementation of the FSS Act and its rules and regulations, primarily assistance in online registration and licensing. By 2025, FSSAI plans to certify and deploy about 50,000 Mitras across all districts in the country, including inducting them for training of food handlers on food safety and hygiene. Source: FSSAI 10 3.3.5. Mass mobilization: Mass mobilization is a strategy Eat Right uses to reach out directly to people across the country with Eat Right messages, leveraging a range of stakeholders and their creativity. For example, the nationwide cyclothon Swasth Bharat Yatra (SBY) mobilized 21,629 volunteer cyclists to collectively cover 20,233 kms across the country in 104 days to reach 25 million people with the key Eat Right messages of eating safe, healthy, and sustainable food. Other examples include large-scale celebrity-powered media campaigns, locally organized Eat Right Melas for the public, and the Eat Right Creativity Challenge for schoolchildren in which about 3,500 schools and over 75,000 students participated. 4. Key Stakeholders and Stakeholder Engagement Approaches 4.1. Eat Right India takes a “whole of government” approach to collaborate with multiple ministries and departments. The program is well aligned with the Government of India’s priority to reduce the burden of undernutrition, arrest the rising incidence of NCDs, and improve public health. It is also aligned with the National Nutrition Policy (1993) and National Nutrition Strategy (2016), and it complements ongoing flagship programs – Poshan Abhiyan, National Health Mission, Swachh Bharat Abhiyan – mainstreaming Eat Right messages into these programs. For example, Eat Right India’s online courses complement the programs’ training curricula for front-line workers, and Eat Right India promotes the use of fortified foods in food-based safety net programs. Collaboration with the Ministry of Agriculture Cooperation and Farmer’s Welfare, and with the Ministry of Animal Husbandry, Dairying and Fisheries will be crucial to address food safety, especially at the farm level. 4.2. Direct engagement with consumers for empowerment and behavior change is a new direction for FSSAI. Educating and inspiring consumers empowers them to make healthy and sustainable food choices at a personal and family level, and their increasing demand for such foods exerts pressure on industry to produce healthy, safe and sustainable food. Consumer Connect, Food Smart Consumer Portal, Consumer Guidance Notes, and messaging on food labels provide consumers with information on making healthy and safe food choices. The effort has been to reach consumers through a range of consumer- and child-friendly literature on healthy and safe food practices,28 wherever they are-in their individual settings (all places that people are at and go to in the course of their daily life-home, outside, places of worship, restaurants, roadside vendors) or in campuses (where groups of people regularly gather and eat—offices, schools, universities, and institutes). New directions and approaches guide the program’s engagement with food businesses. FSSAI’s approach to industry has been evolving as it works to modernize the country’s food regulatory system. FSSAI recognizes that food businesses—a constituency that they regulate—are also important stakeholders in efforts to produce safe, healthy, and sustainable food and can contribute to the greater vision of Eat Right India—for example, by voluntarily reformulating products or fortifying them to make them healthier (see Box 2). Thus, FSSAI has been encouraging a culture of “self-compliance” by food businesses—that is, food businesses take prime responsibility for the safety and suitability of their food, and the onus is on them to demonstrate compliance, rather on the government to detect and prove noncompliance through inspections. FSSAI takes a “trust but verify” stance, along with a mix of hard and soft approaches. 28 Some examples: The Yellow Book for schools, The Pink Book for homes, The DART Book for testing for food adulterants at home, The Orange Book for workplaces, and Eat Right Toolkit. All these materials are available on the FSSAI website (https://fssai.gov.in/) 11 4.3. FSSAI uses a “graded” approach to engage with food business operators (FBOs) across the spectrum of capacity and size—large, small and medium, and petty (a category that includes India’s vast numbers of informal food businesses). Given that each of these food business segments has different capacities, and that each requires an approach that is suited to its context and capacity, the graded approach includes a mix of regulatory, enabling, and capacity-building approaches. • For large food businesses, the approach is focused on traditional regulatory instruments and tools such as third-party audits. Eat Right India also promotes self-compliance by encouraging businesses to have their own food labs and to train and appoint Food Safety Supervisors in their operations using FoSTaC training modules (described in Box 3). • For small and medium food businesses, the focus is largely on building capacity to improve hygiene, particularly at the manufacturer level. An overall larger benefit can be reaped through incremental improvements in the hygiene standards of large numbers of food business operators. An example is FSSAI’s hygiene rating initiative, under which it rates licensed food businesses’ hygiene and food safety compliance on a scale of 1 to 5. The purpose is twofold: (a) ratings enable consumers to make informed choices about the hygiene status of the food establishment, and (b) they motivate businesses to improve their hygiene standards and thus reduce the incidence of foodborne illness. Currently, selected stand-alone restaurants and small hotels, meat and fish shops, sweets and halwai shops (small confectionary shops making local sweet and savory dishes), and places of worship are covered under the hygiene rating program. • With petty food businesses—a sector that is not regulated, and that presents greater risk— the approach focuses on building capacity and enabling the businesses to improve their compliance with food safety standards rather than on sanctioning. Applying a systematic “cluster” or “hub” approach, the effort is to engage with these businesses in clusters rather than as individuals. As an example, under the “Clean Street Food Hub” initiative, a group of street food vendors are provided training and are connected with services such as electricity, hot running water, and waste management facilities through collaboration with municipal bodies, and the hub is certified after inspection. Clean fruit and vegetable market hubs are in the pipeline, where the focus is on limiting poor practices (such as use of non-permitted food colors, acids, and other chemicals) in cleaning fruits and vegetables before selling. Plans for the future include bringing in bakeries, small halwai shops, and meat shops. 5. Examining Eat Right India’s New Directions and Approaches Eat Right India has made many bold and ambitious strategic choices, adopting new directions, technical approaches and tactics to bring about complex, sustained change at large scale to achieve its vision. This section examines four of its key technical and operational directions and approaches—the food systems approach, private sector engagement, graded approach to food businesses, and consumer empowerment—in light of recent global thinking, good practices, and their suitability to address India’s specific context and challenges. 5.1 Adopting a food systems approach 5.1.1 Recent global thinking supports a food systems approach. Many authorities believe that food will be a defining issue of the 21st century, and that unlocking its potential will catalyze the 12 achievement of both the SDGs and Paris Agreement.29 In particular, food safety and nutrition will be critical to achieving SDGs 1, 2, and 3, and will contribute to achieving several other goals.30 Given the importance of comprehensive, sustained, multitarget and multilevel approaches and multi-stakeholder solutions to improve health and reduce the economic burden of diet-related illness,31 dialogue is mounting around the need for governments to deal with food issues in a far more interconnected way.32 The EAT Lancet Commission report, among others, calls for widespread multisector, multilevel action, including a substantial global shift toward healthy dietary patterns; large reductions in food loss and waste; and major improvements in food production practices.33 5.1.2 A food systems agenda is complex as it cuts across several government portfolios. Implementing a food systems approach would essentially involve several sectors, primarily health, agriculture, and environmental protection, each of which is broader than the element of food. Each has its own set of policies, legislation, and implementation/enforcement agencies, and unless the policy and regulatory integration process is seamless, there could be possibilities for policy and regulatory “clash” or overlap. 5.1.3 However, it is possible to develop a collaborative program to implement the food systems approach that combines interests and builds on synergies. This is indeed the approach taken by FSSAI in bringing these subjects together in the program mechanism of Eat Right India rather than in policy ministries. In its capacity as the country’s food regulator and in line with its broad mandate of ensuring safe and wholesome food, FSSAI is well positioned to make this food systems approach work through collaborative engagements with various government ministries and departments. 5.1.4 Although new in its breadth and scale, FSSAI’s work is based on techniques and ideas that have been tried in other countries and is in line with modern thinking on food regulatory delivery. At this stage there does not appear to be an example of a government dealing with “food safety,” “nutrition,” and “food and environment” under one banner from an administrative or policy perspective – not at least to the full extent that could be implemented if taking a holistic “food systems” approach. However, individual elements of the food systems approach adopted in Eat Right India are grounded in good practice in food hygiene, nutrition, and the environmental impact of food packaging. It is a bottom-up approach, based on what and how consumers eat, which in turn influences how the food retail, distribution, and catering sectors work. In particular, it may bring more order and higher practice standards to the vast informal markets in these sectors, which could also be of significant socioeconomic benefit. 5.1.5 A significant drawback for Eat Right India is FSSAI’s lack of involvement in primary production at the farm. FSSAI does not have jurisdiction/mandate on “on-farm” food production, yet on-farm activities have implications for food safety and environment. In terms of a food systems approach, that may be regarded as a limitation rather than negating the approach. The systems and whole-of-government approach, working in partnership with other ministries and 29 EAT Lancet Commission Report, op. cit. 30 Jaffee et al., 2019, “The Safe Food Imperative,” op. cit. 31 Mozaffarian, D. Role of government policy in nutrition – barriers to and opportunities for healthier eating. BMJ 2018;361: k2426. 32 Lloyd’s Register Foundation, op. cit. 33 EAT Lancet Commission Report, op. cit. 13 departments, are enablers in this regard. For example, FSSAI has proposed harmonized and coordinated action with the agriculture sector to develop and operationalize guidelines to address farm-level issues—an approach that can be helpful in overcoming this limitation. 5.1.6 While the merits of the food systems approach are undeniable, there are also challenges. Implementing a program of such a vast scope, especially across the country, nurturing and managing the multisectoral collaborations across the board, and ensuring that the program has resources to match the mandate are major challenges the program leaders will face. Furthermore, because a food systems approach cuts across traditional government portfolios, the lack of an overall, whole-of-government policy or legislative platform where all relevant ministries and agencies are connected could be a major constraint. Eat Right India would benefit from formal connectivity across all relevant agencies. 5.2 Developing and Leveraging a Private Ecosystem 5.2.1 An innovative operational strategy for private-public partnership, the private sector ecosystem complements and supports the government’s efforts and extends reach in a cost - efficient manner. FSSAI’s role is to create the platforms for engagement, develop protocols and rules of engagement, and provide training. The scale and pace of expanding the services would far exceed what would be possible through expansion/growth of the services within the government. For example, the Food Safety Mitras, an attempt to tackle the daunting challenge of reaching the country’s large informal sector, is a far more cost-efficient approach than hiring and developing this large workforce within the government. Similarly, the two-thirds of the country’s food testing laboratories that are managed by private partners are a cost-effective force for strengthening food testing in the country, and leveraging private players for training and auditing of food businesses helps reach far larger numbers more rapidly than could be possible through only the government system. 5.2.2 The approach promotes private enterprise, creates employment, and enhances the earning potential of a large number of people. Making the Mitras self-sustaining through charging consultancy fees, helped by official accreditation by FSSAI, is an example of catalyzing the creation of jobs by the government. For example, 50,000 Food Safety Mitras will earn an income by charging the food businesses a fee for their services, while helping the program to reach out to many of India’s 1.4 million FBOs. 5.2.3 Creating platforms outside the government enables the engagement of new stakeholders. Co-creation of the NetProFAN platform with professional bodies in the food and nutrition space has brought about the engagement and commitment of large numbers of nutritionists, dieticians, doctors, chefs, and analytical chemists. Not only has this helped expand outreach to the masses, but it also helps ensure that these hundreds of thousands of professionals use and deliver Eat Right messages in the course of their daily work. The approach is indeed innovative, as these groups would not be seen as part of the food safety business in other countries. That is partly because of the program’s expansion of food safety to include nutrition. 5.2.4 Examples from many countries and sectors demonstrate the effectiveness of private- public partnerships in expanding services—for example, by providing laboratory services and delivering training. There are also some parallels to the Mitras approach. Developing a cadre of quasi-inspectors who do not have legal powers can extend the numbers of staff on the ground; as an example, some EU member states use private practice veterinarians with appropriate training 14 and certification as official veterinarians to perform work on behalf of the state. However, usually such a private cadre is paid for their services by the appointing authority, whereas the Mitras model is self-sustaining as they are authorized to charge a fee from the food businesses that they support. This is a new and innovative approach. 5.2.5 A possible challenge could be to ensure the quality and robustness of this rapidly expanding ecosystem across the country. This is a considerable risk to mitigate, especially given the shortage of officials for food safety and the constrained availability of resources in most states and at sub-state levels. Building in formal systems for feedback, instituting periodic skill and competency checks, and requiring recertification could help to maintain quality. Additionally, it will be important to establish adequate controls and checks to mitigate the risk of issues such as corruption, and systems for grievance redress. 5.3 Empowering Consumers 5.3.1 Along with enabling industry, empowering consumers is a key pillar of FSSAI’s approach to promoting public health. Whereas most regulators limit their communication efforts to educating with the aim of providing “protection” through such measures as labeling, standards, and so on, Eat Right India takes a “public health promotion” approach, directly engaging with consumers to raise their own practice standards and understanding, and educating them to demand good standards from business. The approach is new among food regulators. 5.3.2 Eat Right India promotes a package of messages about food safety, nutrition, and sustainable food. One of the key questions that arise is whether it is more effective to promote a package than a single message. Public health issues, including those associated with food, are multifactorial. The FAO background paper for the International Conference on Nutrition34 suggests that “actions are most effective when they involve multiple components, e.g. information provision, behavior change communication (including skills training), and policies to change the food environment.” That is, large, multi-component interventions—like Eat Right India’s—are likely to be more effective than the provision of information or single education-focused interventions. 5.3.3 Eat Right India’s social and behavior change communication efforts to shape consumer behaviors have drawn on theories of behavioral economics. Through the power of gestures, catchy phrases, branding, and symbols, efforts have been made to nudge (see Box 4) people to adopt healthy and sustainable diets. For example, Aaj Se Thoda kum (today onwards... a little less) combines the catchy phrase thoda kum in a film with a gesture to match by a leading Box 4. What is a Nudge? According to Nobel prize-winning behavioral economists Richard Thaler and Cass Sunstein, authors of the award-winning book Nudge: Improving Decisions about Health, Wealth and Happiness, a nudge is an aspect of the choice architecture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives. To count as a mere nudge, the intervention must refer to something that is easy and cheap to do. Nudges are not mandates. Putting fruit at eye level counts as a nudge; banning junk food does not. 34Hawkes, C. 2013. Promoting healthy diets through nutrition education and changes in the food environment: an international review of actions and their effectiveness. FAO. http://www.fao.org/3/i3235e/i3235e.pdf 15 Bollywood actor, Rajkummar Rao, nudging people to gradually reduce fat, sugar, and salt in their daily diets. The simplicity and do-ability of the message suggest that this small change is possible, leaving the choice to each person. Branding and symbols are used to make healthier food options easily identifiable, and to help increase mental recall of messages—for example, +F for fortified foods. 5.3.4 Measuring the effectiveness of the consumer-centric approaches, and particularly the social and behavior change efforts to refine them, will enhance their potential impact. So far Eat Right India has not taken any steps to test the effectiveness or impact of its behavior change approaches. While public demand is expected to influence businesses to respond to the demand, to what extent that will happen can only be known with time and will have to systematically evaluated. The program has not so far mobilized consumers to demand change from food businesses as specific campaigns. The UK’s Food Standards Agency expressly mobilized customers to demand lower salt levels in processed food over a period of years—a campaign that successfully altered the food producers’ practices and is a precedent for a food safety authority to use customer buying choices as a lever35. 5.4 Graded Approach to Food Businesses 5.4.1 Eat Right India’s graded approach is designed to work with food businesses across the spectrum to improve safety standards. Given the over 1.4 million registered food businesses in the country, and the very large informal sector, applying conventional regulatory and enforcement systems is not realistic,36 and a one-size-fits-all approach would be not only ineffective, but also untenable. The graded approach combines traditional enforcement and inspection approaches with capacity building and sensitization, applied in a differentiated mix to suit the needs of businesses of different sizes and capacities. The overall aim is to improve the safety standards of a vast majority of food businesses rather than ensure the compliance of a smaller number and appears to be a feasible way to improve practice standards of informal food businesses. For example, a five percent improvement across 200,000 small producers may be a much greater public benefit than a five percent improvement in an already largely compliant large business. 5.4.2 The approach to large food businesses reflects a key shift in FSSAI’s regulatory approach. FSSAI moved from a traditional enforcement- and inspection-driven approach to detect noncompliance to a prevention-based system with “self-compliance” by industry. Its focus is on regulatory instruments and tools for self-improvement, such as setting up or strengthening of in- house laboratories, certified food safety supervisors, and third-party audits. This is in line with global directions of taking a preventive approach, which is much more beneficial for overall food safety than relying solely on after-the-fact measures.37 5.4.3 With reduced regulatory oversight and greater reliance on “self-compliance” comes the risk that industry may undermine public health. While their own business interest and reputation are incentives for food businesses to provide safe food to their customers, there are examples of businesses that have ignored public health concerns. To mitigate this risk, government 35 World Health Organization, 2010. Creating an Enabling Environment for Population-based Salt Reduction Strategies: Report of a Joint Technical Meeting held by WHO and the Food Standards Agency, United Kingdom, July 2010. 36 F Blanc, “From Chasing Violations to Managing Risks,” 2018, Edward Elgar, pp. 130 -156. 37 Hong Jin and Desmarchelier Patricia on behalf of Food Standards Australia New Zealand. 2019. Asia Pacific Economic Cooperation (APEC) Food Safety Modernisation Framework to Facilitate Trade, APEC Secretariat, Singapore. (https://www.apec.org/Publications/2019/06/APEC-Food-Safety-Modernisation-Framework-to-Facilitate-Trade) 16 and industry need to establish a trusted partnership, with strong accountability mechanisms and with a mix of hard approaches (government regulatory and fiscal interventions) and soft approaches (involving education and industry voluntary codes). 5.4.4 For small and medium food businesses the goal is improvement rather than compliance. The rationale for the focus on capacity building and hygiene ratings to promote self- compliance appears sound. An overall larger benefit can be reaped through incremental improvements in the hygiene standards of large numbers of food business operators. However, it will be important to continually raise the bar to ensure that over time capacity and standards in the sector improve. 5.4.5 For petty businesses operating in the informal sector—a sector that is not regulated, and that presents greater risk—the approach is to raise their practice levels. Improving food safety in the informal sector is one of the largest challenges most lower-middle-income countries face. These businesses provide products and services for which there is a market, and they provide employment, particularly for women. Individually, each business may be low risk because it has a limited impact on a large number of people, but cumulatively they can present a significant risk. A combination of approaches is being used to reach this sector and help improve their practice standards. The Food Safety Mitras approach is an important effort in this direction. 5.4.6 The “cluster approach” draws on good practices and appears to be working well. Working with a group of small vendors in a hub or cluster to improve food safety and hygiene is an efficient and effective way to reach larger numbers. Besides, it offers the opportunity to engage relevant bodies to provide basic infrastructure and services, such as hot running water and electricity, that these vendors lack, issues that FSSAI is working to have recognized in urban planning. This approach was used in Singapore in the 1950s, and the Mayor of Mandalay in Myanmar is also developing hubs or food halls in municipal markets as an element in urban planning. Eat Right India is striving to do this at scale—supporting 500 clean food hubs across India, and challenging states and supporting them to increase that to 15,000. 6. Conclusions 6.1 Eat Right India, while grounded in modern food regulatory frameworks, expands beyond the typical regulatory approach to promote health and nutrition and takes a food systems approach. There is a strong rationale for the program to address the interlinked challenges of food safety, nutrition and sustainability through a combination of regulatory, capacity building, collaborative and empowerment approaches. Mobilizing the public behind a lifestyle change, if done well, allows for the possibility of truly massive change in society. Besides applying more traditional techniques for the larger companies in the formal sector, Eat Right India is finding ways to have an impact on the informal sector, with positive support to improve standards. Harnessing and leveraging the private sector to extend its reach and efficiency, it attempts to tackle India’s unique problems of scale and resource constraints. The program draws on good practices that have worked elsewhere, although it adds “Indian” characteristics to make them as relevant to India as they have been in other countries. The levers of change, the collaborative systems change approach, and the flexible design appear to be the right approaches to suit the change Eat Right India aspires to achieve; such a change could perhaps be difficult for any one agency or department to achieve. 17 6.2 The graded approach seems promising, particularly as it attempts to improve the provision of safe and wholesome food through the informal sector. While industry moves toward self-compliance, attention to establishing clear accountability mechanisms with industry, including the appropriate amount of regulatory oversight, will be useful. For small and medium enterprises and the petty vendors, over time raising standards in a calibrated manner could add to food safety. The experience and impact of Eat Right India on the informal food sector should be closely monitored as the learnings will be of interest to other countries. 18 III. Implementation Status and Scale-up Plans 1. Implementation Status 1.1. Although these are early days in program implementation, Eat Right India has registered on-the-ground progress (see Table 1). FSSAI has recently begun to engage actively with states, including through visits to meet with the state food safety officials and departments of health and family welfare and other relevant departments to understand implementation opportunities, challenges, and needs, and to support states and other stakeholders in taking up various initiatives in a sustained manner.38 Table 1. Implementation Status of Eat Right India Initiatives, February 2020 FOSTAC • 18 FoSTaC and 3 FoSTaC plus courses • 224 empanelled training partners • 2040 certified trainers; 279,000 trained Food Safety Supervisors • Over 10,500 trainings conducted Food Fortification • 19 states and 5 Union Territories using fortified commodities in Government safety net programs • 82 companies (large and MSME) produce 122 fortified products • 47% of top 10 companies producing refined edible oil and 36.6% of the organized milk industry fortifying their products as per FSSAI standards Eat Right School • 31,758 schools registered • 1,051 School health and wellness coordinators certified • 23,053 Eat Right School activities completed • 525 master trainers trained • 360 SNF Fellows reaching out to 0.5 million students • 75,137 students participated across 3500 schools in Phase 1 of the Eat Right Creativity Challenge Eat Right Campus • 16 Eat Right Campuses certified across 8 states • More than 70 campuses registered Eat Right Quiz • Available on Amazon Alexa with more than 550 questions • 100,000 people have played the online quiz on My Gov platform Swasth Bharat Yatra • 21,629 volunteer cyclists collectively covered 2,156 places and 20,233 kms in 104 days. • 1 million participants and 25 million people reached 38 FSSAI develops the overall vision, regulations, guidelines, and projects, in consultation with all relevant stakeholders, but the last-mile implementation and enforcement are primarily carried out by the Food Safety Commissioners of States/Union Territories (UTs), along with Designated Officers (DOs) and Food Safety Officers (FSOs) at the state/UT level. Several Eat Right India initiatives are rolled out and managed centrally by FSSAI—for example, Eat Right School, Eat Right Station, Eat Right Campus, Eat Right Quiz—whereas others, such as Street Food Hub and Food Safety on Wheels, are implemented by states. 19 Learning Content • Videos and e-courses: 15 series on different topics include 400+ episodes, 100+ hours of content • Books and learning material: 31 books, 13 guidance notes available in various languages • Creatives and promotional material: 75+ banners/posters on Eat Right Food Safety on Wheels • 54 vans operational in 32 States/UTs Clean Street Food Hub • 11 Clean Street Food Hubs certified (6 in Gujarat, 3 in Maharashtra, 1 each in Madhya Pradesh and Punjab) Eat Right Mela • 2 national-level melas organized (2018 and 2019), each with a footfall of over 10,000 citizens • 3 state-level melas organized (Madhya Pradesh, Tamil Nadu, and Maharashtra) • 1 district-level mela organized (Barpeta district, Assam) BHOG • 5 places of worship certified (3 in Madhya Pradesh and 2 in Tamil Nadu) • Over 300 places of worship have been reached with training and are to be certified NetProFaN • Institutional structures established for national, state and city level chapters; 15 State Chapters formed Hygiene Rating Scheme • 2,184 food establishments enrolled Save Food Share Food • 84 food distribution agencies active across 200 cities • Interactive Voice Response food donation helpline to be launched in 2020 Eat Right Station • 3 railway stations certified (1 in Mumbai, 2 in New Delhi) • 9 station certifications under way Food Safety Mitras • 4,500 Digital Mitras enrolled Source: FSSAI 1.2. FSSAI has also made progress in strengthening core food safety regulatory functions. The following examples demonstrate some innovative ways adopted to enhance regulatory oversight: • Risk-based third-party inspections and audits. 24 agencies have been approved to conduct regulatory audit of food businesses dealing in some high-risk food products. Two such large-scale audits have been commissioned across the country—one for 300 central- and state-licensed slaughterhouses and the other for mithai and meat shops; results are expected towards the last quarter of 2020. • Enhanced testing and inspection. In the milk sector, tests and checks are mandated at prescribed points and frequencies to ensure quality throughout the process: 52 food safety vans visit cities and villages to carry out simple tests for common adulterants in food; build awareness around food safety, health, and hygiene; and conduct simple training and certification programs for food handlers and supervisors in food businesses, particularly petty food businesses. This 20 approach can be extended to other sensitive sectors. • Sharing regulatory responsibility. In areas where command-and-control systems already exist—for example, the railways and ports—DOs and FSOs have been appointed from the railway cadres for the railway network, and Port Health Officers have been appointed at airports and ports. Further expansion of the model to other central institutions such as paramilitary forces, Army canteens, and so on is planned. Systems audits to evaluate such entrusted food safety ecosystems are planned to that appropriate processes for food safety are in place and followed. • E-commerce platforms. Licensing requirements for e-commerce entities selling food have been established, and audit checks of their compliance with various regulatory requirements are being instituted. Regulating such new business models with complex structures such as inventory- based services, marketplace models, and hybrids of various kinds has been a challenge for FSSAI. 1.3. States are also beginning to make progress, registering some successes and gaining useful lessons (see Box 5). • Madhya Pradesh. Through the efforts of the state food safety officials, Ujjain Mahakal temple of Indore was given the BHOG certificate on World Food Safety Day, June 7, 2019. Khajrana Temple is due to be certified soon. In addition, Chappan Dukan, Indore, has been certified as a Clean Street Food Hub. • Gujarat. Under the leadership of the Gujarat food safety officials, India got its first Clean Street Food Hub at Kankaria Lake on September 4, 2018. Kankaria Lake, which has been an Ahmedabad landmark for almost 500 years, has around 66 street food vendors that serve approximately 12 million people each year. Since then four more Clean Street Food Hubs (two in Ahmedabad, and one each in Gandhinagar and Surat) have been awarded, and two are in the pipeline. • Kerala. Prioritizing the reduction of trans fats in the state, Kerala’s food safety team has begun cracking down on the use of trans fats, after their initial testing of fats and oils showed that 11 of the 40 samples tested were not in compliance with the regulations for trans fats (FSSAI recommends that trans-fat levels not exceed 2 percent of total fats in all products). To better understand the situation, they thereafter expanded the collection and testing of fat and oil samples from manufacturing units, restaurants, bakeries, and street vendors in two districts (Ernakulam and Kozhikode). • Chandigarh. The Chandigarh food safety officials were the first to create a Mobile Food Testing Lab prototype in 2016, which led to the Food Safety on Wheels initiative that is now scaled up nationally. The Mobile Food Testing Labs have since been used creatively for awareness building campaigns on safe, healthy, and sustainable food across a range of audiences, including the use of live demos of adulteration tests using Eat Right India’s Detect Adulteration with Rapid Test (DART)39 book. Such campaigns have been undertaken in collaboration with different stakeholders, e.g., across 70 schools in collaboration with the Education department, and 63 neighborhoods by engaging with their Resident Welfare Associations. • Maharashtra. Street food vendors at two large beach side locations in Mumbai, Juhu Chowpatty and Girgaon Chowpatty, have been awarded the status of Clean Street Food Hubs. 39 FSSAI. https://eatrightindia.gov.in/EatRightIndia/rbook/?rf=spice&viewFilePath=file/DARTBook.pdf#rbook/ 21 • Punjab and Delhi. Inspired by Eat Right India, the states of Punjab and Delhi have launched their own missions: Tandrust Punjab and Sehatmand Dilli, respectively. Both missions take an integrated approach by involving various stakeholders in creating awareness about food safety and healthy diets. Tandrust Punjab also focuses on curbing air and land pollution. Box 5. Some Lessons Emerging from Experience in the States The Eat Right India Lighthouse knowledge-sharing event held September 26, 2019, in Goa, was an opportunity to learn early lessons in implementation. These are valuable as Eat Right India is set for scale-up. The following key lessons emerged from the states. Local leadership matters. Steady, committed, and enthusiastic state leadership with a clear vision appears to be correlated with the uptake of Eat Right India initiatives at the field level. Even though the rules and guidelines are the same in all states, it is not unusual to see variability in implementation from state to state. Important to start, even on a small scale. The states where results have emerged are those that have chosen initiatives to start with and have focused on implementing them to get the momentum for Eat Right India going. Resources – financial, human, and infrastructure – are critical. Even as the momentum for and interest in Eat Right India is picking up, the focus of the state governments in terms of budget and resources has yet to match the scale of the need on the ground. Existing budget, human resource, and infrastructure constraints can affect implementation. 2. Scale-up 2.1. Having tested, refined, and implemented a number of initiatives in several states, Eat Right India is poised for scale-up to reach even more people and institutions. For example, the Eat Right Challenge, proposed to be launched later in 2020, is designed to motivate and engage cities/districts to implement the Eat Right initiatives. They will be encouraged to choose from the menu of Eat Right initiatives the ones they would like to implement, and FSSAI will support them with rollout by providing toolkits and technical and mentoring support. The participating cities/districts will be evaluated against such criteria as the number of initiatives implemented, the scale and outreach of those initiatives, responsiveness within the given timelines, and the level of local resources mobilized. 2.2. As the program scales up over the next five years, continued improvements and institutional strengthening will be key priorities. Strengthening and expanding core food regulatory functions, improving hygiene standards across the food value chain, and expanding the focus on sustainable eating will be prioritized. Efforts will focus on transforming food environments, influencing consumer food choices, and on promoting institutional development and strengthening both at the national and state levels. 3. Conclusions 3.1. On-the-ground testing and implementation of initiatives indicates progress as well as success of approaches and strategies. Several initiatives have matured and achieved good 22 progress, others developed more recently are also progressing, and the program is poised for scale- up. Many learnings have emerged to inform the program’s expansion, with state engagement and support emerging as key priorities for FSSAI. As FSSAI prepares for this scale-up, it needs to consider whether Eat Right India has the elements it will need to achieve the large-scale change envisioned. To help answer this question, in the next chapter we analyze the program and its leadership approaches, highlighting areas that are working well, identifying potential constraints and challenges, and suggesting possible ways to address them. 23 24 IV. Assessing the Potential of Eat Right India for Large- Scale Change Eat Right India is still a very new program. Although it has registered some successes in a short time, it is reasonable to ask whether it is likely to be sustainable over time, and whether it can be scaled up to become a truly national program. This chapter uses two frameworks that relate to aspects of transformational and complex change – the NHS Large-Scale Change Model (LSC)40 and the CLEAR Framework for Leading Systems Change41—to assess the potential for Eat Right India to achieve its vision of sustainable and transformational change. The chapter identifies program strengths, as well as areas that need further attention and strengthening, and suggests ways to address the constraints. This is particularly useful at this juncture to ensure a strong core, calibrate strategies and strengthen systems as the program expands and scales up. 1. Assessing Eat Right India: using the NHS Large-Scale Change Model42 as the guiding framework 1.1. The LSC model provides a meaningful framework to assess Eat Right India. The NHS defines LSC as “the emergent process of mobilizing a large collection of individuals, groups, and organizations toward a vision of a fundamentally new future state by means of high- leverage key themes, a shift in power and a more distributed leadership, comprehensive and active engagement of stakeholders, and mutually reinforcing changes in multiple systems and processes.” It is thus a useful framework to guide the assessment of Eat Right India, given the breadth of its ambition, its large and diverse range of stakeholders, and the complex and multilayered issues it faces. Moreover, LSC brings a public sector institution’s practical experience in health and care, making it all the more relevant for a public health movement led by a government regulator, FSSAI. The model outlines 10 key principles (see Box 6) that are important to large-scale change endeavors. 1.2. Assessing Eat Right India’s vision and design through the lens of the 10 LSC principles shows remarkable congruence with the framework. Several of the principles are inherent in Eat Right India’s vision and design—for example, working across boundaries with the involvement of several stakeholders, often with different agendas and priorities; its flexible design; engaging and exciting to gain the commitment of many. Although there is variability in how well the finer details within the individual principles match up with those of the LSC model, the overall congruence is sufficient to conclude that Eat Right India has all the ingredients—vision, design, strategies and approaches, and leadership—to make large-scale change happen. The following paragraphs unpack these finer details to understand areas that are well developed and can be enablers of large-scale change; and those that require further development, sharpening, and rigor to enhance the program’s potential to achieve the change it aspires to bring about. 40 National Health Service, England. Leading Large-Scale Change – A Practical Guide, 2018. (https://www.england.nhs.uk/wp- content/uploads/2017/09/practical-guide-large-scale-change-april-2018-smll.pdf) 41 Drier, Nelson, and Nabarro, 2019. Op. Cit. 42 National Health Service, 2018. Op. Cit. 25 Box 6. The Ten Principles of Large-Scale Change Movement toward a new vision that is better and fundamentally different from the status quo: Goes across geographical boundaries, multiple organizations and groups; is deeply challenging to current mental models. It is such that if someone fell asleep today and woke up five years from now, they would remark, “This is very different!” Identification and communication of key themes that people can relate to and that will make a big difference: True LSC is so much in contrast with people’s current reality that it may feel overwhelming or impossible. To get engaged, they have to understand why they should be involved and what they can do, now or soon. Multiples of things (“lots of lots”): LSC activities are usually complex, with multiple stakeholders, agendas (both hidden and open), points of view, needs and wants, details, and systems that need change. Framing the issues in ways that engage and mobilize the imagination, energy, and will of a large number of diverse stakeholders to create a shift in the balance of power and distribute leadership: Tight, centralized planning and control works against LSC. The key lies in gaining the commitment of others to act, not merely their compliance in doing what you tell them to do. Mutually reinforcing change across multiple processes/subsystems: If the vision and collection of key themes is clear enough, changes across multiple systems connect with and build upon one another. Continually refreshing the story and attracting new, active supporters: Touching people’s hearts along with impressing their minds is crucial. This requires constant framing and reframing of the vision and communicating through transformational storytelling. Emergent planning and design, based on monitoring progress and adapting as you go: Because of the complexity and uncertainty involved, LSC outcomes are impossible to predict at a detailed level. Do not spend too much time on detailed plans before you start actually doing something, and do not be surprised if every detail does not work out as planned. Flexibility, adaptability, and engagement are key Many people contribute to the leadership of change, beyond organizational boundaries: LSC relies on “distributed leadership” – a variety of different sources of leadership expertise moving into play and spreading around the system. Transforming mindsets, leading to inherently sustainable change: When LSC is done well, sustainability is the natural by-product. If people have become engaged and believe that the vision is more desirable than the status quo (and you have addressed multiple structures, processes, and patterns underpinning the change) they will be committed to, and will fight to keep, the new way Maintaining and refreshing the leaders’ energy over the long haul: Case studies on LSC make it clear that large-scale change can take some time to unfold completely. Too many leaders simply run out of steam. Source: National Health Service, England. Leading Large-Scale Change – A Practical Guide, 2018. (https://www.england.nhs.uk/wp-content/uploads/2017/09/practical-guide-large-scale-change-april-2018-smll.pdf ) 26 1.3. The analysis highlights many strengths of the program that can be enablers of the large-scale change that Eat Right India aspires to achieve. In particular, these include: 1.3.1. Vision. Eat Right’s vision is aligned with LSC’s definition of a transformational vision. It envisions a future state that is very different from the current situation. The change that Eat Right India seeks to achieve is large (national in scope and coverage), pervasive (includes a range of systems, sectors, and stakeholders), and deep (it envisions changing how people relate to food). (LSC principle 1). 1.3.2. Messages. While the vision is large, pervasive and deep, it is communicated through three clear messages: Eat safe, Eat healthy, and Eat sustainable. These messages are easily understood, do not overwhelm, and are positioned almost as personal goals to resonate well with all stakeholders. Beneath the three simple high-level themes are layers and layers of lots and lots of things, each clearly linked to one or more high-level themes and subthemes and contributing to the larger vision. A range of guidelines and guidance notes, tools, training programs, and communication material help explain and detail the many initiatives, activities, and sub-activities to drive forward the program’s many moving parts. Eat Right’s multiple initiatives are linked to and build on one another to connect with the three high-level themes. (LSC principles 2, 3, 5) 1.3.3. Engagement strategy. With its 3E strategy, Eat Right India has been able to engage, excite, and enable a number of key “believers” and “change agents” across the food ecosystem who have demonstrated commitment and the will to do their part. It has also generated passion and enthusiasm for the program in creative ways, leveraging opportunities to reiterate its vision and messages, expand the supporter base, and keep the public and food ecosystem engaged and excited. For example, the launch of events to highlight the program during the year of the 150th anniversary of Mahatma Gandhi’s birth, modelling the SBY cyclothon after Mahatma Gandhi’s famous Daandi March, and taking his messages of healthy eating and living to the public are ways the program has used to touch hearts and minds. Further enthusiasm has been created by the mention of Eat Right India by the Honorable Prime Minister of India, Shri Narendra Modi, in his monthly radio talk to the nation, Mann ki Baat, and by the frequent social media messages of Dr. Harsh Vardhan, India’s Health and Family Welfare Minister. (LSC principles 4, 6) 1.3.4. Flexibility. As described earlier, emergent planning, flexibility, and adaptability are in the DNA of Eat Right India. A good idea is quickly turned into an initiative and launched for testing, without waiting for the “perfect” plan. The idea is to learn along the way from feedback and informal reviews and then to refine, revise, and detail further as necessary. (LSC principle 7) 1.4 The analysis also highlights areas that need further strengthening to ensure a strong core for the program. While Eat Right India has demonstrated a good beginning even in respect of the following areas, as it scales up it will be critical to focus attention on them to ensure that the wheels of change set in motion continue to move ahead. 1.4.1 Leadership. While engaging with Eat Right India’s many stakeholders, FSSAI has assumed the role of chief convenor and enabler and has worked to create multiple nodes of distributed leadership. SBY succeeded because of the full engagement and leadership of the state, district, and local leadership across the country, with FSSAI playing the role of facilitator. The voluntary pledges made by food businesses to reduce the content of salt, sugar, and fat in their key product items or to introduce new variants of the same products appears to be a good example 27 of industry commitment to change, and not simply to ‘comply with regulations’. However, as Eat Right India scales up through states, state leadership will need to play larger leadership roles and adopt distributive leadership by creating many additional leadership nodes with other departments in the state, district officials, and industry and other stakeholders. FSSAI will also need to continue its efforts to engage and involve other government departments and ministries, state food safety teams, and other public programs that Eat Right India leverages. (LSC principle 8) 1.4.2 Monitoring and evaluation. Eat Right India’s has so far relied on informal reviews and feedback to inform its planning, testing and implementation. The absence of formal reviews, testing, and repeated learning is a gap that needs to be filled, particularly in the following areas: • Design and initiatives. The current system of informal reviews and feedback to inform the program’s design and its initiatives does not measure up well with the robust learning mechanisms of the LSC model. To enhance the effectiveness of its initiatives it will be crucial to strengthen M&E and establish systematic learning cycles to continually improve, streamline, revise or even drop something that isn’t giving the desired results. One robust way to monitor the progress of the large-scale change being attempted, and to measure the results being achieved is through repeated Plan–Do–Study–Act (PDSA) cycles43 suggested in the LSC model. • Communication. Eat Right India has invested considerable time, effort, and resources in developing communication material that has been widely used. It appears that a good start has been made in communicating the themes of Eat Right India, but the effectiveness and impact of the media approaches has not yet been tested. It will be important to examine the effectiveness of the communication material in influencing consumer behavior change, and to make appropriate changes in the content and approaches to make them even more relatable and effective. • Multiple activities. Given India’s size, managing the scale-up of Eat Right India’s many “lots” is a huge challenge. As Eat Right India enters a phase of rapid and exponential growth over the next few years, the need for focused and sustained attention to each of the initiatives, activities, and sub-activities cannot be understated. A comprehensive monitoring system to inform stakeholders and leaders about what is going well, what is not, and what needs to change will be crucial. 2. Examining Eat Right India’s Systems Change Approach: drawing upon the CLEAR Framework for Leading Systems Change44 2.1 The CLEAR Framework for Leading Systems Change is a highly pertinent tool to assess Eat Right India systems change and leadership approach. This framework characterizes the systems approach to implementing change as one that requires a departure from traditional top- down, hierarchical, and linear approaches. It requires innovative and adaptive approaches that engage broad networks of diverse stakeholders to advance progress toward a shared vision45. The CLEAR framework defines Systems Leadership as a set of skills and capacities that any individual or organization can use to catalyze, enable and support the process of systems-level change. Eat Right India’s design and approaches resonate well with this definition and other elements of the 43 National Health Service, England, 2018. Op. Cit. 44 Lisa Dreier, Jane Nelson, and David Nabarro, “Systems Leadership for Sustainable Development: Strategies for Achieving Systems Change,” Harvard Kennedy School Corporate Responsibility Initiative Research Paper, September 2019. (https://www.hks.harvard.edu/sites/default/files/centers/mrcbg/files/Systems%20Leadership.pdf) 45 Dreier, Nelson, and Nabarro, 2019. Op. Cit. 28 framework, thus deriving value and insights from this analysis. 2.2 For systems change, transformation and action must take place at three levels -the individual (which can be an individual or an organization), the community, and the system (see Figure 6). To bring about systems transformation, leaders must have the Figure 6. The Key Elements of Systems Leadership ability to (a) understand the system that shapes the challenge they seek to address (complex systems insight); (b) catalyze and support collective action among relevant stakeholders (coalition building and advocacy tactics); and (c) listen, learn, and lead through coordination with and empowerment of others (collaborative leadership). 2.3 The CLEAR framework describes five key elements of the systems change process. (see Box 7). The five elements are not strictly Source: Dreier, Nelson, and Nabarro, 2019. Op. Cit. chronological: elements may overlap or may repeat in cycles and feedback loops throughout the course of an initiative. 2.4 Eat Right India’s leadership approaches map well to three of the five elements of the CLEAR framework. As described below, these reflect well developed areas and are strengths that the program can further build on. 2.4.1 Convene and Commit. This has emerged as one of the program strengths. In light of the complexity and scale of the challenge of ensuring safe, healthy, and sustainable food for all, the program has done well to build a constituency of partners and collaborators (often with differing priorities, incentives, and constraints), discovered shared interests, and gained their commitment. For example, the creation of NetProFaN, an expanding and energized group of stakeholders committing their time and efforts to achieve the vision of Eat Right India in their spheres of influence; the initiation of the RUCO program in partnership with the Ministry of Petroleum and Oil Manufacturing Companies to create an ecosystem for collecting used cooking oil and converting it to bio-diesel. The changed dynamics of working with food businesses - from “issuing directives” to “listening and collaborating” has helped gain the commitment of businesses e.g., voluntary pledges to make healthier products. 29 2.4.2 Look and Learn. Drawing ideas, perspectives, and learning from many stakeholders, both national and international, has helped the program to understand the food system and its players. This contributed to leveraging opportunities and partnerships to develop a holistic food systems approach integrating food safety with health, nutrition and sustainability. Box 7. The Five Key Elements of the CLEAR Framework for Leading Systems Change Convene and Commit: Systems-change efforts often begin in response to a serious problem or challenge within a complex system. Stakeholders who have found that they cannot solve this problem alone are motivated to begin exploring, with others, how to change the existing system dynamics. Dialogue among diverse stakeholders – often with quite different interests and perspectives – can lead to the recognition of a shared interest and highlight the potential value of taking collective action. Look and Learn: To change a complex system, stakeholders must first understand how the system works – the components, actors, dynamics, and influences that together create the system and its current outcomes. This requires learning and inquiring with an open mind. Most stakeholders have experienced and learned about the system from one point of view. Truly understanding its many dimensions requires absorbing new information and learning from other stakeholders’ viewpoints and perspectives. This means constant dialogue, underpinned by radical and empathic listening, enabling each actor to have a deeper appreciation of the multiple perspectives on a particular system. Engage and Excite: Complex systems function as they do because they are full of life – made up of people, other species, and elements that interact with each other and their environments. They are living systems. Relationships between people profoundly influence the ways in which their living systems behave. People who are inspired to work toward system change will seek to exercise their influence, personal capabilities, and access to resources to influence the direction and manner of change. Doing that in concert with other actors magnifies the impact. As a result, building and nurturing relationships between stakeholders in a system, and encouraging them to get engaged and energized, is a key role of the Systems Leader. Act with Accountability: Making systems change a reality requires action that demonstrably influences the system or drives specific outcomes. In large-scale systems-change initiatives, a wide array of stakeholders throughout the system can take action in a decentralized manner, in pursuit of a shared goal. Systems leaders can galvanize and support distributed, multi-stakeholder action that is self-directed but aligns with the broader network’s shared vision and goal. At the same time, they need to be able to demonstrate results and encourage mutual accountability for both individual actions and collective impact. Review and Revise: Systems change is an ever-evolving process of adaptive experimentation, learning, growth and change. It is important for systems-change initiatives to embrace these dynamics with an agile, flexible, innovative and learning-centered approach. Such an approach encourages stakeholders to apply innovations with a spirit of entrepreneurship – testing new approaches, evaluating the results, learning from the outcomes, and applying those learnings to a strengthened approach in the next round. Source: Lisa Dreier, Jane Nelson, and David Nabarro, “Systems Leadership for Sustainable Development: Strategies for Achieving Systems Change,” Harvard Kennedy School Corporate Responsibility Initiative Research Paper, September 2019. (https://www.hks.harvard.edu/sites/default/files/centers/mrcbg/files/Systems%20Leadership.pdf) 2.4.3 Engage and Excite. Going beyond “engage and excite,” the program added a third element, “enable” to get the full buy-in of stakeholders. This appears to have created a feeling of ownership and leadership among the many stakeholders brought into the program, making it “everyone’s work” with FSSAI playing the role of convenor and enabler. The list of stakeholders continues to increase as Eat Right India expands its vision and activities. As the program scales 30 up, states are the next frontier for action. Enthusiasm and ownership of state leadership, and percolation of the 3E approach to expand Eat Right India’s partnership base in the states will be crucial. 2.5 Eat Right India needs to give more deliberate attention to strengthening the “Act with Accountability” and “Review and Revise” elements of the CLEAR framework. 2.5.1 Act with Accountability. As the CLEAR principle highlights, a system of accountability across different stakeholders and interest groups encourages accountability for both individual actions and collective impact. Moving forward, it will be important for Eat Right India to develop and agree with stakeholders on goals and core principles that reflect agreed values or desired outcomes, coordination frameworks, accountability mechanisms, independent evaluations, and a conflict resolution framework. 2.5.2 Review and Revise. While “review and revise” is a key feature of Eat Right India’s design, until now the program has depended on informal reviews and feedback from relevant quarters to revise initiatives. Formal monitoring is nascent, and no evaluations are yet planned. As the program is scaled up it will be important to address these elements and ensure that robust systems for measurement, regular monitoring and reporting, periodic evaluations, and knowledge and experience exchanges are built into the program and its leadership strategy. 3. Conclusions 3.1. The two sets of analyses using different but complementary frameworks point to remarkably similar findings regarding Eat Right India’s strengths as well as areas that need attention. Even though Eat Right India is a relatively new program, its vision, design, and early implementation reflect all the elements of the LSC and Systems Leadership approaches. Thus, it has the ingredients to bring about large-scale, sustainable change. At the same time, there are also areas that need urgent attention to further enhance its potential for achieving its vision. 3.2. The analyses of Eat Right India’s technical approaches highlight their potential to effect change. If well implemented, the approaches can contribute to addressing the country’s challenges related to the safety, nutrition, and sustainability of food. While Eat Right India has the potential for impact, the program has a long and challenging journey ahead. The following chapter discusses the areas that will require attention if Eat Right India is to be successfully scaled up. 31 32 V. Areas Needing Further Attention, and Recommendations Many insights to inform Eat Right India’s scale-up and future have emerged from this case study. This section synthesizes the key points that have emerged from the analyses of Eat Right India using the LSC and Systems Leadership approaches, as well as from conversations with FSSAI leadership and officials, state Food Safety Commissioners, and other stakeholders. It particularly focuses on key areas that require further attention and presents recommendations for FSSAI’s consideration. As mentioned earlier, the COVID-19 pandemic has sharply highlighted the urgency and need to strengthen food safety and healthy and nutritious diets, thus underscoring the need for program strengthening and scale-up. 1. Area for attention: Continued strong and dynamic leadership over the long haul, including at the state level. As Eat Right India is taken to every corner of the country, continued expansion of its supporter base, commitment building, and leadership at all levels will be required to sustain the program’s momentum and energy in new and innovative ways. Challenges inevitably arise and will need to be identified and addressed as they arise. Given the systems leadership approach the program has taken, systems leadership capabilities will need to be built and expanded at the central, state, and district levels. The dynamic leadership at FSSAI has been instrumental in shaping and driving Eat Right India. While this is very positive, given the inevitable change in leadership upon completion of tenure or for other reasons, it also raises concerns about potential loss of energy and drive that could come with transition in leadership. Therefore, developing a second line of leadership is important for continuity and institutionalization. Recommendations Leadership development efforts at all levels need to be designed, implemented, and institutionalized, particularly to build systems leadership capabilities and lead large-scale change efforts: a) At the national level, to sustain commitment and direction, develop a second line of leadership, and establish a prestigious Eat Right leadership development program for new leaders of Eat Right India. b) Given the diversity of contexts across the country, create local-level opportunities for leaders from across the set of stakeholders to develop a shared understanding of the broad Eat Right India vision and to develop their context-specific visions aligned to the larger vision. A variety of ways— e.g., series of workshops, leadership development trainings—can be considered. Such efforts could be carried out in partnership with LBSNAA or other leadership development institutions. 2. Area for attention: More intense state engagement and implementation support for time-bound and quality scale-up The architecture and design of Eat Right India are in place, and momentum and excitement have been generated among a large number of stakeholders, including states. The next step is time- bound and quality scale-up of the program at the state and sub-state levels. While regular meetings, videoconferencing, and visits to states are already a regular feature, specific activities to onboard states are required. Furthermore, the constraints of capacity and resources – physical, financial, 33 and human—in most states are challenges that will require innovative solutions, considering federal-state structures and roles. Dedicated leaders and staff for food safety exist in only a few states, and the Food Safety Commissioner is held as an additional charge within the Department of Health. States’ commitment to prioritize and provide sufficient resources for implementing Eat Right India activities will be important. Recommendations • Prioritize getting states on board for scaling up Eat Right India activities. Build commitment within state leadership to accord priority to Eat Right India activities, allocate appropriate funding, and depute officials. Creative use of incentives (financial and nonfinancial), rewards, recognition, and the possibility of financing specific activities and creating challenge funds could be considered. The planned district/city challenge initiative is a good example to build enthusiasm and create action at the local levels. • In addition, systems to build state capacity and to share new developments, tools, and resources for use by states should be considered. Support and facilitation for systems change through leadership development programs and by proactively connecting the various non-state stakeholders with state officials to work toward common goals and objectives should form an integral part of capacity-building and implementation support. A model along the lines of the NHS Virtual Academy of Large-Scale Change is a possible one to consider for ongoing capacity building. 3. Area for attention: Institutionalize the change initiated To continue and sustain the large-scale change initiated by Eat Right India, mutually reinforcing change in multiple systems, subsystems, processes, procedures, relationships, resources, and power structures is essential to support the functioning of the larger food ecosystem in the changed way. To ensure that the approach is implemented in letter and spirit, it will be important to have in place enabling and coordinated policies for effectively integrating food safety, nutrition, and environment as well as for the entire spectrum of food businesses in India. Realigning organizational structures at FSSAI, its regional offices, and state health departments as appropriate to support Eat Right India implementation will be vital to sustain the program’s large-scale change effort. Recommendations • Consider defining an overarching enabling umbrella policy framework for the food ecosystem, bringing together food safety, public health, and environment to harmonize policies for the food system across these sectors. For example, establish mechanisms for the regulation of on-farm agriculture practices (which are currently not regulated), because they have implications for safety, health, and the environment. • Undertake an analysis of the changes to existing national- and state-level policies, guidelines, procedures, processes, and organizational structures in the food regulatory and associated systems that are required for the robust implementation of Eat Right India, ensuring the required flexibility for its adaptable design. A task force comprising FSSAI and state leaders and institutional development and human resources expertise could be considered to undertake such an exercise. While the larger effort is getting started, in the immediate term undertake the necessary reorganizing of organizational structures and hierarchies at FSSAI and its regional offices to assign roles, responsibilities, and accountability for Eat Right India initiatives and their scale-up and 34 monitoring, and institutionalize the culture of “engage, excite, and enable” as a way of doing business. 4. Area for attention: Learning and knowledge creation and exchange Both the LSC and the Systems Leadership approaches underscore the importance of institutionalized systematic continuous learning. While the design of Eat Right India has been based on a “plan-test-learn-refine” approach, the “review and revise” principle in the CLEAR framework and the “repeated PDSA cycles” in the LSC approach point to the need to set up institutional mechanisms for learning. Given the many new approaches being used, it is crucial to make a careful study of their functioning, opportunities and challenges, and use of the emerging knowledge to inform directions during scale-up. For example, well designed studies to answer questions such as: Is the balance of self-compliance and enforcement right, or does it need calibration? Are consumer empowerment approaches working, and how can they be improved? Are the checks and balances for the private ecosystem ensuring quality, and what more is needed? Institutionalizing a culture of knowledge creation and sharing is crucial in a program like Eat Right India, with multiple states implementing the program in different contexts and with the involvement of many stakeholders. A beginning in this direction has been made through the World Bank’s Lighthouse India knowledge exchange program, and plans are afoot to set up an institutionalized platform at FSSAI for this function. Given the potential of the Eat Right India approach, learning from it will be of interest globally. Recommendations • Set up FSSAI’s proposed learning and knowledge platform with a defined structure, function, and resources to meet the national and international learning and knowledge exchange needs of Eat Right India. Linkages and partnerships with national and international schools and universities could add value to the research and learning from Eat Right India. 5. Area for attention: Monitoring and evaluation Eat Right India has yet to develop a comprehensive monitoring and evaluation (M&E) system. While some individual reporting systems are in place, and some are being upgraded, there is as yet no comprehensive system to collect, analyze, and use information. For example, annual returns from FBOs; training information from FoSTaC; import and registration/licensing data from the Food Import Clearance System and Food Licensing and Registration System, respectively; samples and lab data from Indian Food laboratory Network; Food Safety Compliance through Regular Inspection and Sampling (FOSCORIS); and monthly reports from states and the State Food Safety Index—all of these systems operate independently, are at different stages of evolution, and are used to different degrees. Lead persons at FSSAI assigned to each initiative review progress with states and help solve problems for the initiative under their charge. Several new directions have been charted for Eat Right India, but concrete plans to evaluate their effectiveness are not in place. As Eat Right India is scaled up, future policy and program directions will need to be based on objective evidence drawn from appropriate M&E. The program requires a robust digital platform to meet its monitoring needs across the wide range of initiatives and activities. There is a need to develop a good overarching conceptual framework for information management to ensure that data captured across platforms are centrally collated, analyzed, and distributed to relevant decision- makers. 35 Recommendations Develop a comprehensive conceptual framework for the knowledge management function that identifies all information needs for the full set of activities and stakeholders. • Within this, develop and make functional a state-of-the-art Management Information System (MIS) to meet the monitoring needs of Eat Right India. Specifically, develop a dashboard to monitor progress, generate output reports to inform decision-making and share information with all stakeholders. A progress/achievement-based recognition and reward system linked to the MIS could be valuable for the continued engagement of all stakeholders. • Periodic evaluations should form part of the research and learning and should be embedded as a function with the proposed knowledge platform. 6. Area for attention: Resource sufficiency at all levels Given the ambitious agenda of Eat Right India, resource analysis, planning, and generation will be critical. State-level resources – human, physical, and financial – are a constraint: only a small percentage of the health budget is allocated to Eat Right India. FSSAI’s resource allocation has expanded about six-fold—from less than INR 500 million (US$7.1 million) in 2014-15 to over INR 3 billion (US$43 million) in 2019-20. Given the funding levels of existing large-scale national programs, such as the National Nutrition Mission, the National Health Mission, Swachh Bharat Mission, the resources appear insufficient to fulfill Eat Right India’s ambitious mandate, even though the Eat Right India model is based on leveraging partnerships, technology and resources. It will be important to map all sources of funding and amounts being leveraged, identifying gaps and finding ways to fill them. Recommendations • Undertake a full resource mapping and planning exercise for Eat Right India’s resource requirements, including at the state level, to ensure that resource availability matches the program scope and scale. • Urge, engage with, and consider incentivizing states to commit and allocate greater resources for Eat Right India. 7. Conclusions In less than two years of existence, Eat Right India has successfully established an institutional framework for a collaborative approach to address the inter-linked aspects of food safety, healthy, nutritious and sustainable diets, tested and scaled-up several initiatives and is poised for scale-up. Assessment of its design, approaches, and change processes highlights that while it has the potential to become a sustained, nationwide movement that can make a real impact on Indians’ health and even their socioeconomic status, there are also areas that require careful attention and strengthening. Over the coming months and years, as the program scales up, institutionalization of its strengths and careful consideration to addressing issues emerging from the analyses and discussed above will enable the program to grow and achieve its vision, becoming an enduring, credible force in improving the lives of India’s people. 36 Annex 1: About FSSAI: Overview, Regulations and Panels To implement the Food Safety and Standards Act (2006), a national food regulatory body, the Food Safety and Standards Authority of India (FSSAI), was created under the Ministry of Health and Family Welfare in 2008. FSSAI was established as an independent statutory authority, the sole body responsible for laying down science-based standards and regulating the manufacture, storage, distribution, sale, and import of food products to ensure the availability of safe and wholesome food for human consumption. FSSAI at the national level and State Food Authorities at the state level are jointly responsible for the implementation and enforcement of the Food Safety and Standards Act. FSSAI develops the overall vision, regulations, guidelines, and projects, in consultation with all relevant stakeholders, but the last-mile implementation and enforcement are primarily carried out by the Food Safety Commissioners of States/Union Territories (UTs), along with Designated Officers (DOs) and Food Safety Officers (FSOs) at the state/UT level. There are institutionalized structures for collaboration and coordination between FSSAI and the state authorities: the Central Advisory Committee, which has all states and other stakeholders as members, and periodic FSSAI-state meetings. FSSAI began the notification for rules and regulations in 2011, undertaking numerous amendments in 2012-13, including harmonization of the new/revised standards with the Codex Alimentarius. FSSAI has to date notified six key regulations, and has streamlined processes and inspections to facilitate imports, a long-standing area of pain for industry. FSSAI created institutional mechanisms to formulate guidance documents, codes of practice, and inspection metrics and to review food standards. These include a Scientific Committee consisting of eminent Indian scientists, 21 scientific panels, 8 standards review groups, and 9 technical panels. The details follow: Six principal regulations 1. The Food Safety and Standards (Licensing and Registration of Food Businesses) Regulations, 2011. 2. The Food Safety and Standards (Packaging and Labelling) Regulations, 2011. 3. The Food Safety and Standards (Food Products Standards and Food Additives) Regulations, 2011. 4. The Food Safety and Standards (Prohibition and Restrictions on Sales) Regulations, 2011. 5. The Food Safety and Standards (Contaminants, Toxins and Residues) Regulations, 2011. 6. The Food Safety and Standards (Laboratory and Sample Analysis) Regulations, 2011. Other Important Regulations Notified Regulations 1. Food Safety and Standards (Food or Health Supplements, Nutraceuticals, Foods for Special Dietary Uses, Foods for Special Medical Purpose, Functional Foods and Novel Food) Regulations, 2016 2. Food Safety and Standards (Food Recall Procedure) Regulations, 2017 3. Food Safety and Standards (Import) Regulations, 2017 4. Food Safety and Standards (Organic Food) Regulations, 2017 5. Food Safety and Standards (Fortification of Food) Regulations, 2018 6. Food Safety and Standards (Food Safety Auditing) Regulations, 2018 7. Food Safety and Standards (Advertising and Claims) Regulations, 2018 -1- Draft Regulation 8. Draft Notification on Food Safety Standards (Safe Food and Healthy Diets for School Children) Regulations, 2019 Scientific Panels 1. Panel on Food Additives, Flavourings, Processing Aids, and Materials in Contact with Food 2. Panel on Pesticides Residues 3. Panel on Genetically Modified Organisms and Foods 4. Panel on Functional Foods, Nutraceuticals, Dietetic Products, and Other Similar Products 5. Panel on Biological Hazards 6. Panel for Contaminants in the Food Chain 7. Panel on Labelling and Claims/Advertisements 8. Panel on Method of Sampling and Analysis 9. Panel on Fish and Fisheries Products 10. Panel on Milk & Milk Products 11. Panel on Meat & Meat Products, including Poultry 12. Panel on Cereals, Pulses & Legume and their Products (including Bakery) 13. Panel on Fruits & Vegetables and their Products (including dried fruits and nuts, salt, spices, and condiments) 14. Panel on Oils & Fats 15. Panel on Sweets, Confectionery, Sweeteners, Sugar & Honey 16. Panel on Water (including flavoured water) & Beverages (alcoholic/non-alcoholic) 17. Panel on Nutrition and Fortification 18. Panel on Antibiotic Residues 19. Panel on Spices and Culinary Herbs 20. Panel on Packaging 21. Panel on Alcoholic Beverages -2- Annex 2: Eat Right India: Key Initiatives Regulatory: To build a safe food environment in the country, FSSAI is strengthening efforts to enhance food safety - setting up robust standards, developing codes of practices, credible food-testing and surveillance systems, and strengthening compliance, enforcement and emergency response systems. As part of its 360-degree approach, Eat Right India has combined regulatory efforts with a range of initiatives and approaches to empower, build capacity and collaborate with all stakeholders. Some examples are: Consumer Empowerment and Awareness Creation: Eat Right Schools is a nationwide campaign to inculcate in young people the habit of eating safe and healthy food. A Resource Book for schools (the Yellow Book), developed by FSSAI along with a Teachers Training Manual, helps children learn in a fun, interactive way, through curricular and extracurricular activities. Eat Right mascots, Master and Miss Sehat (health), are used to generate enthusiasm. Swasth Bharat Yatra (SBY) is an example of mass mobilization. Inspired by Mahatma Gandhi’s Dandi March, it stands out as one of the world's biggest cyclothons, spanning 100 days with 21,000 volunteer cyclists, who covered 20,000 kms across India to deliver the message of Eat Right India and create awareness about safe and healthy diets through direct outreach among citizens. Hygiene Rating is a user-friendly, technology-driven scheme under which food service establishments are rated on their hygiene and food safety compliance with a score from 5 (high) to 1 (low). This score encourages businesses to ensure hygiene standards and empowers consumers to make an informed choice when they eat out. Food Safety on Wheels: Food Safety on Wheels are mobile units for conducting simple tests for common adulterants in milk, water, edible oil and other items of food of daily consumption. These mobile units are used for awareness building around food safety, hygiene and promoting healthy eating habits in citizens at large and for conducting training and certification program for food handlers and supervisors in food businesses, particularly petty food businesses. In addition, these mobile units also help the field functionaries in the States to enhance their outreach and conduct surveillance activities in far-flung areas. Eat Right Melas are organized to make people aware of and encourage them to adopt the concept of “Eat Right” through an infotainment model. Activities like a food quiz, a master class for the Eat Right toolkit, live cooking demos of healthy recipes, panel discussions with experts, displays of regional street food, and street theater and cultural performances are conducted. Eat Right Quiz, designed for the Amazon Alexa platform, aims to enhance citizens’ knowledge of the basics of food safety and nutrition, in a simple, playful, and engaging manner. Food Fortification: Food Fortification is a scientifically proven, cost-effective, scalable and sustainable global intervention that addresses the issue of micronutrient deficiencies. In October 2016, FSSAI operationalized the Food Safety and Standards (Fortification of Foods) Regulations, -3- 2016 for fortifying staples namely Wheat Flour and Rice (with Iron, Vitamin B12 and Folic Acid), Milk and Edible Oil (with Vitamins A and D) and Double Fortified Salt (with Iodine and Iron) to reduce the high burden of micronutrient malnutrition in India. The ‘+F’ logo has been notified to identify fortified foods. Food Safety and Standards (Fortification of Foods) Regulations, 2018 were notified in the Gazette of India on 09.08.2018. Collaboration: Repurpose Used Cooking Oil (RUCO) is an initiative under which used cooking oil is collected and converted to biodiesel, thus reducing unsafe consumption by customers and creating sustainable fuel. Partnerships with the Ministry of Petroleum and Natural gas, oil companies, and start-ups make it possible. Save Food, Share Food, Share Joy helps to reduce and curb food waste by ensuring the safe collection of surplus food and distributing it to feed the hungry. It connects food business operators, surplus food distribution organizations, and those in need of food. Currently 84 such organizations are functioning in 200 cities in India. Network of Professionals in Food and Nutrition (NetProFaN) is a large network of six professional bodies that support Eat Right India in reaching citizens, higher education institutions, and professionals who are not specifically targeted by current public health and nutrition programs. Network for Scientific Co-operation for Food Safety and Applied Nutrition (NetScOFaN) consists of eight research and academic institutions working in the area of food and nutrition. The network shares information on recent developments in food testing methodologies and techniques for strengthening the quality of food testing, generating/sharing of scientific data, and information for food standards. Capacity Building: Eat Right Toolkit and e-courses provide interactive training modules on safe and healthy diets to front-line health workers such as Anganwadi and ASHA workers and at government-run health and wellness centers. This initiative helps to engage and educate people about safe and healthy diets in a simple and effective manner. Blissful Hygienic Offering to God (BHOG) helps build the capacity of food handlers at places of worship to adopt and maintain food safety and hygiene in prasad (devotional offering) and food preparation for a large number of devotees. Clean Street Food Hub helps raise the quality, hygiene, and safety of street food. Vendors are trained and certified to meet basic hygiene and sanitary requirements so that consumers can have a safer and better local-eating experience. Similar cluster initiatives are being developed, such as Clean and Safe Meat Shop, Clean and Safe Halwai Shop, and Clean and Fresh Fruit and Vegetable Market. The steps for setting up clusters such as Clean Street Food Hubs are clearly defined: (a) cluster identification; (b) licensing and registration of all vendors under the cluster; (c) pre-audit by a state FDA- and FSSAI-approved audit agency; (d) FOSTAC training of all food handlers; (e) post-audit by an approved audit agency; and (f) FSSAI certification of the hub upon its achievement of compliance with a minimum of 80 percent of the defined criteria. The certification is valid for one year and can be renewed after a third-party audit. A complete guidance document provides details -4- of benchmarks for basic hygiene and sanitary requirements, SOPs, an audit checklist, and details of partners. Eat Right Campus are micro food ecosystems, where consumers demand food and the supply mechanisms are in place to cater to their needs. The initiative helps to empower and enable campuses—including workplaces, universities, railway stations, jails, hospitals, and tea estates— to serve safe, healthy, and sustainable food for residents and visitors. At the same time, it encourages consumers to make healthy and safe food choices. The initiative includes awareness creation, training and building the capacity of food handlers, facilitating third-party audits, and a certification process. The certification process involves self- assessment, training, third-party audit, and rectification of gaps. Any registered campus can apply for certification. The certificate is valid for 2 years, after which internal audits are conducted regularly and jointly with the local Food Safety Officer. To date 16 campuses are certified across eight states in India. Food Safety Mitras. Food Safety Mitras are private individuals who are trained, certified, and softly regulated by FSSAI to provide standardized, good-quality, and cost-effective services to food businesses. They perform limited actions on behalf of/for FBOs with respect to the implementation of the FSS Act and its rules and regulations, providing assistance in registration and licensing on the online platforms (Digital Mitra). Future plans include mitras for training of food handlers about hygiene and food safety concerns (Trainer Mitra), and training to improve hygiene (Hygiene Mitra). There are eligibility criteria and a certification process for each category of mitra. The certification is valid for two years, but FSSAI may cancel mitras’ certification if they fail to perform their duties and functions. Any complaints/grievances against mitras are handled directly by FSSAI. Some 4,500 of these food safety foot soldiers (Digital Mitras) have been enrolled, and the plan is to certify about 50,000 mitras to ensure the availability of their services in every district in the country. -5- Funding support for this work was provided by the Bill and Melinda Gates Foundation and the Government of Japan through the Japan Trust Fund for Scaling Up Nutrition.