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External Mill Monitoring of Wheat Flour Fortification Programs: An Approach for Program Managers Using Experiences from Jordan
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    The fortification of wheat flour with micronutrients is a common strategy to increase vitamin and mineral intake. While wheat flour mills are often inspected by agencies affiliated with national ministries to ensure compliance with national fortification standards, few countries use data derived from these inspections to construct an external monitoring system for use in program management and evaluation. The primary objective of this paper is to assess the performance of the external monitoring system utilized in Jordan according to the US Centers for Disease Control and Prevention's Updated Guidelines for Evaluating Public Health Surveillance Systems. A secondary objective is to present mill monitoring results from 2009 to 2010 in order to demonstrate the data generated by the system. The review concludes that the data required for the system is representative, simple to collect, and can be collected in a flexible manner. The external monitoring system is acceptable to participating agencies and millers and is stable due to mandatory fortification legislation which provides the legal framework for external monitoring. Data on production of fortified flour and utilization of premix can be provided in a timely manner, but on-site mill monitoring and flour sample collection are more challenging due to resource constraints. The frequent collection of a small number of indicators can provide fortification program managers with timely information with which to base decisions. Jordan's external monitoring system successfully documented the performance of each mill and the entire flour fortification program, and can serve as a model for other national fortification programs considering external monitoring approaches.