A G R I C U LT U R E A N D F O O D S E R I E S

The Safe Food Imperative

Accelerating Progress in Low-
and Middle-Income Countries

Steven Jaffee, Spencer Henson,

Laurian Unnevehr, Delia Grace,
and Emilie Cassou
THE SAFE FOOD
IMPERATIVE
ACCELERATING PROGRESS
IN LOW- AND MIDDLE-
INCOME COUNTRIES
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THE SAFE FOOD
IMPERATIVE
ACCELERATING PROGRESS
IN LOW- AND MIDDLE-
INCOME COUNTRIES
Steven Jaffee, Spencer Henson, Laurian Unnevehr,
Delia Grace, and Emilie Cassou
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 CONTENTS

Foreword xi
Acknowledgments xiii
About the Lead Authors xv
About the Contributors xvii
Executive Summary xxi
Abbreviations xxxvii

Introduction 1
The Food Safety Context 1
Aims and Audiences 2
Study Methods 3
Structure of the Report 3
1. Why Safe Food Matters to Economic Development 5
Introduction 5
Food Safety and the Sustainable Development Goals 6
Understanding the Socioeconomic Impacts of Unsafe Food 7
The Food Safety Life Cycle 15
Summary 25
References 25
2. Evidence on the Burden of Unsafe Food in Low- and Middle-Income
Countries 27
Introduction 27
The Public Health Burden of Foodborne Diseases 28

v
 Economic Costs of Foodborne Disease 38
Food Safety Risks in LMIC Domestic Markets 43
Costs of Domestic Food Safety Failures 48
The Costs of Food Safety Failures in Trade 52
Summary 59
References 59
3. The Status of Food Safety Management in Developing Countries 69
Food Safety Capacity 69
Factors That Motivate Food Safety Capacity and Behavioral Change 73
Benchmarking Food Safety Capacity 77
The Public Sector’s Capacities for Managing Domestic Food Safety Risks 80
The Alternatives to Public Regulation 90
Enabling Smallholder Farmers to Be Food Safety Compliant 97
The State of Capacities for Managing Trade-Related Food Safety Risks 99
Moving toward Risk-Based Imported Food Controls 112
Summary 117
References 118
4. Strengthening Food Safety Management Systems 123
Introduction 123
Steps toward a More Effective Food Safety Policy Framework 125
Better Implementation: Moving from Policy to Action 134
References 154
5. The Way Forward 157
Conclusions 157
A Call to Action for Various Stakeholders 158
Priorities Among Countries at Different Stages of the Food Safety Life Cycle 165
Reference 168

Boxes

ES.1 Recommendations for Stakeholders in the Food Safety Life Cycle xxxi

1.1 Food Safety and the Sustainable Development Goals 7

1.2 Market Failures Associated with Food Safety 8

1.3 Dietary Changes in Low- and Middle-Income Countries 14

1.4 The Link between Supermarket Penetration and Income per Capita 18

1.5 Consumer Willingness to Pay for Food Safety 21

1.6 Personal and Institutional Trust in Food Safety Systems 23

2.1 Aflatoxins, Staple Crops, and Public Health 32

2.2 The “Good” and “Bad” Food Safety Practices of Consumers 35

2.3 Antimicrobial Resistance and Links to Food 36

vi Contents
2.4 Estimating the Economic Burden of Foodborne Disease 39

2.5 Sudan Red Dye in Chili Powder from India 51

2.6 Brazil’s Tainted Meat Scandal 52

3.1 Food Safety Culture: What Happens When No One Is Looking 72

3.2 Food Handlers, Training, and Behavioral Change 76

3.3 Tackling Risks from Animal-Based Foods in Vietnam 87

3.4 Shifting Paradigms and Responsibilities in Food Safety Regulation 90

3.5 Limitations of Market-Based Incentives: Aflatoxin Controls in Kenya 96

3.6 Investing in Ukraine’s Food Sector to Secure New Markets 109

3.7 Training of Trainers: Bangladesh Aquaculture and India Spices 110

4.1 Food Safety Lead Agencies in Chile and India 126

4.2 Uruguay’s Risk-Based Approach to Strengthening Food Safety Controls 129

4.3 Prioritizing Sanitary and Phytosanitary Investments for Market Access 133

4.4 Professionalizing Food Inspectors and Food Service Industry Workers 135

4.5 How Singapore Formalized Its Street Food Businesses 139

4.6 Investing More Smartly and Sustainably in Laboratory Testing Capacity 140

4.7 Whole Genome Sequencing and Food Safety 142

4.8 Cost-Benefit and Cost-Effectiveness Analyses in Food Safety 145

4.9 Investing in Food Safety for Small Importing Countries: The Case of
CARIFORUM 147

4.10 Gains from Multisector Coordination: The One Health Approach 149

4.11 Realizing Co-benefits for Tackling Farm Food Safety Hazards 150

4.12 India’s Behavioral Change Communication Principles for Food Safety 154

Figures

1.1 Public Health, Economic, and Social Outcomes of Unsafe Food 10

B1.3.1 Composition of Food Expenditures in Urban Indonesia, 1998–2013 14

B1.3.2 Estimated Food Demand in Southeast Asia, 2009 and 2030 15

1.2 Food Safety Life Cycle with Levels of Economic Development 16

B1.4.1 Link between Supermarket Penetration and per Capita Income 19

Contents vii
 2.1 The Global Burden of Foodborne Disease by Hazard Group and
Region, 2010 29
2.2 Foodborne Disease Burden Attributable to Animal Source Foods
by Region 33
2.3 Productivity Loss from Foodborne Disease by LMIC Income Group
and Region, 2016 40
2.4 Productivity Loss from Foodborne Disease by Country, 2016 41
2.5 Relative Burden of Foodborne Disease by per Capita Income, 2010 42
2.6 Rejection Rates of Fish and Fishery Product Imports to the EU by
Lower-Middle-Income Countries, 2014–16 56
2.7 Rejection Rates of Fresh Fruit and Vegetable Imports to the EU
by Low- and Middle-Income Countries, 2014–16 57
3.1 Food Safety Management Capacities and Functions 70
3.2 Cyclical Relationship between Incentives and Level of Capacity 75
3.3 Indications of Underinvestment in Animal Product Food Safety Capacity 82
3.4 Animal Products–Related Food Safety Capacity Index by
Country and Region 84
3.5 Animal Products–Related Food Safety Capacity Index versus Food Safety
Management Capacity Need Index by Income Group 85
3.6 Gap between Animal-Based Food Safety Need and Capacity
by Country and Income Group 86
3.7 Foodborne Disease Attributable to Animal-Based Foods among
Sub-Saharan African Countries with Adequate vs. Inadequate Veterinary
Service Funding 89
3.8 Smallholder Farmers, Agricultural Markets, and Varied Conformity
Requirements 98
3.9 LMIC Exports of High-Value Foods by Product Group, 2001–16 100
3.10 High-Value LMIC Food Exports by Income Group, 2001–16 101
3.11 LMIC High-Value Food Imports by Product Group, 2001–16 113
4.1 Framework for Action on Food Safety 127
4.2 Reducing Noncompliance versus Raising Compliance 137

Tables

ES.1 Priorities for Countries at Different Stages of the Food Safety Life
Cycle xxxiv

viii Contents
1.1 Food Safety Hazards on the Farm-to-Fork Pathway 12

1.2 Sources of Foodborne Hazards by Stage of the Food Safety Life Cycle 17

1.3 Structural Change and Incentives for Enhanced Food Safety Action 24

2.1 Estimated Global Burden of Disease by Food-Related Hazards 29

2.2 Potential Market and Economy Costs from Food Safety Problems 49

3.1 Adequacy of the Finance for National Veterinary Services 81

3.2 Average Animal Source Food DALYs Burden by Country Category and
Funding Adequacy 88

3.3 Training and Certification in Informal Markets: Selected Cases 95

3.4 Area of GLOBALG.A.P.-Certified Fruit and Vegetable Production by Region
and Income Group, 2010 and 2017 102

3.5 GLOBALG.A.P.-Certified Area for Fruit and Vegetables in LMICs, 2017 103

3.6 Organic Production Area by Commodity and Country Income Group,

2017 104

3.7 Certified Organic Fruit and Vegetable Production Area in LMICs, 2017 105

3.8 LMIC Food Businesses Registered with U.S. Food and Drug Administration,
January 2018 106

3.9 Processing Facilities Approved for Chilled and Processed Fish Exports to the
European Union 108

3.10 Largest LMIC Importers of High-Value Food, 2006 and 2016 114

3.11 Scores for Applying Transparent Rules and Practices for Agri-Food Imports in
Middle- and High-Income Economies 116

B4.2.1 Comparison of Uruguay’s Traditional and Risk-Based Inspection

Approaches 129

4.1 Private Sector Food Safety Investments and Possible Constraints 143

B4.9.1 Case Study Costs and Benefits of Compliance 147

4.2 Evidence on Strategies for Aflatoxin Control in Kenya’s Maize Market 148

B4.11.1 Win-Win Responses to Farm Food Safety Challenges 150

5.1 Priorities for Countries at Different Stages of the Food Safety Life
Cycle 167

Contents ix
 F O R E WO R D

Every day around the globe, families and friends eat to provide themselves with
essential energy and nutrients to lead healthy and productive lives, as well as
for pleasure and comfort. Yet every day, on average, unsafe food makes close to
two million people sick, keeping them from school and work, and sometimes
dramatically degrading or curtailing their lives. Worst of all, foodborne illness
disproportionately strikes populations that can least afford to be sick. Low- and
middle-income countries in South Asia, Southeast Asia, and ­Sub-Saharan
Africa account for 41 percent of the global population but are afflicted with
53 percent of all foodborne illness, and 75 percent of related deaths.
Whether the consequences of unsafe food are measured in suffering, dis-
ability, and loss of life, or foregone income and wages, these personal and
social costs are unnecessarily high. According to estimates from the World
Health Organization, foodborne diseases made some 600 million people
sick and caused 420,000 premature deaths in 2010. Translated into economic
terms using 2016 income data, illness, disability, and premature deaths
induced by unsafe food lead to productivity losses of about US$95 billion
a year in low- and middle-income countries. Unsafe food undermines food
and nutritional security, human development, the broader food economy,
and international trade.
The Safe Food Imperative argues that much of the burden of unsafe food can
be avoided through practical and often low-cost behavior and infrastructure
changes at different points along food value chains, including in traditional
food production and distribution channels. In many countries, concerted
action on domestic food safety has been sporadic and reactive, coming in the

xi
 wake of major outbreaks of foodborne disease or food adulteration scandals.
Yet what is needed are sustained investments in prevention, including ones that
build countries’ core competencies to manage food safety risks, and motivate
and empower many different actors, from farm to fork, to act responsibly and
with consumer health in mind.
Drawing on experiences across the globe, the report highlights examples
of effective food safety management. It calls for a higher prioritization of food
safety along with more investment in the development of coherent national
food safety management systems in low- and middle-income countries.
Governments do not and cannot have sole responsibility for ensuring safe
food—it is a shared responsibility. Public agencies, farmers, food businesses,
and consumers all have constructive roles to play.
Apart from more and smarter public investment in food safety, there is also
a critical need for new regulatory approaches that place more emphasis on
facilitating compliance and engaging consumers. Countries as diverse as Chile,
India, Kenya, Ukraine, Uruguay, and Vietnam have demonstrated that better
health and commercial outcomes are possible with the joint involvement of
public agencies, businesses, and consumers in food safety.
Individuals across income levels, age groups, and regions all need safe food,
but food safety is also a national necessity. Countries need safe food to develop
their human capital—to fuel a healthy, educated, and resilient workforce, and to
feed a vibrant economy. More and better investments in food safety are needed
for countries to unleash their full potential to grow their economy inclusively
and sustainably.

Annette Dixon
Vice President, Human Development, World Bank
Laura Tuck
Vice President, Sustainable Development, World Bank

xii Foreword
 AC K N OW L E D G M E N T S

The report team was led by Steven Jaffee of the World Bank and involved a core
team of Spencer Henson (University of Guelph), Delia Grace (International
Livestock Research Institute), Laurian Unnevehr (University of Illinois at
Urbana-Champaign), and consultants Emilie Cassou, Mateo Ambrosio, and
Anissa Collishaw. Important contributions were provided by Arie Havelaar
(University of Florida), Clare Narrod (Joint Institute for Food Safety and
Applied Nutrition, University of Maryland), and Vivian Hoffman (International
Food Policy Research Institute); independent consultants Donald Macrae,
Shashi Sareen, and Jairo Romero; and World Bank Group staff Franck Cesar
Jean Berthe, Sarah Ockman, and Kateryna Onul.
The report was made possible by generous funding from the U.S. Food and
Drug Administration. The team thanks the administration, particularly Mary
Lou Valdez and Kristin Wedding, for their support and technical guidance.
The report benefited enormously from collaboration with several other institu-
tions; this included sharing restricted data and reports, without which impor-
tant analysis in this report would not have been possible. Special recognition
is given to the support provided by the World Health Organization and mem-
bers of its Foodborne Disease Burden Epidemiology Reference Group, and the
World Organisation for Animal Health. Special thanks go to Amy Cawthorne,
Brecht Devleesschauwer, Minh Li, and Francois Caya. The team also thanks
the secretariat team at GLOBALG.A.P., Robert Ahern at the Inter-American
Institute for Cooperation in Agriculture, the CGIAR Research Program on
Agriculture for Nutrition and Health, and Melvin Spreij and Marlynne Hopper

xiii
 of the Standards and Trade Development Facility for generously sharing
information and perspectives.
The team thanks Nathan Belete and the Global Food Safety Partnership
through Lystra Antoine for their guidance, and recognizes the contributions
made by peer reviewers Sudhir Shetty, Selma Rasavac, John McDermott,
Melvin Spreij, Paul Mayers, Chris Delgado, Ziauddin Hyder, and Julie Caswell
in helping to improve the quality of this report and its outputs.

xiv Acknowledgments
 ABOUT THE LEAD AUTHORS

Steven Jaffee is a lead agricultural economist with the World Bank’s Agriculture
Global Practice. His research, policy, and investment project work over
26 years at the World Bank has spanned many themes, including food secu-
rity, food safety, agricultural risk management, agricultural policy, value chain
development, and trade and standards compliance. He has field experience
in Africa and Southeast Asia. He has co-led major regional research projects
on rice and food security, agricultural pollution, agri-food system transforma-
tion, and agri-environmental measures in export industries. He has a BA from
the University of Pennsylvania and a DPhil in agricultural economics from
Oxford University.

Spencer Henson is professor in the Department of Food, Agricultural, and

Resource Economics and director of the Guelph Institute of Development
Studies at the University of Guelph, Canada. He is recognized internationally
for his research on the economics of food safety, food quality, and nutrition
in industrial and low- and middle-income countries. He has authored over
90 peer-reviewed journal articles and edited three books. His research has
involved fieldwork in over 60 countries for international organizations, public
and private sector institutions, and civil society organizations.

Laurian Unnevehr is professor emerita of agricultural and consumer econom-

ics at the University of Illinois at Urbana-Champaign. She has worked at the
U.S. Department of Agriculture’s Economic Research Service, the International
Food Policy Research Institute, and the International Rice Research Institute.

xv
 She has published extensively on the economics of food safety and other food
policy issues, including the economics of hazard analysis and critical control
points, food safety in international trade, new technology in food marketing,
and the role of food demand in shaping food value chains. The Agricultural and
Applied Economics Association made her a fellow in 2009 in recognition of her
contribution to the economics of food policy and demand. She has a PhD from
the Food Research Institute, Stanford University, and a BA in economics from
the University of California at Davis.

Delia Grace is an epidemiologist and veterinarian with more than 20 years of

experience in developing countries. She leads research on zoonoses and food-
borne disease at the Nairobi-based International Livestock Research Institute.
Her research includes food safety, emerging diseases, gender studies, and
animal welfare. Her career has spanned the private sector, field-level commu-
nity development, aid management, and research. She has worked in Asia and
Africa, and authored or coauthored more than 100 peer-reviewed publications,
as well as training courses, films, articles, and blogs. She has worked at several
universities, including University College Dublin, Edinburgh University, the
Free University of Berlin, and Cornell University.

Emilie Cassou is a sustainable food systems specialist working with both the
Agriculture and the Environment and Natural Resources Global Practices at
the World Bank. She has coauthored, managed, and contributed to various
studies, multistakeholder processes, and projects on agri-environmental and
climate policy, food system performance, and behavioral change in the con-
text of dietary transition. She has degrees from Brown University, Sciences Po,
the Friedman School of Nutrition Science and Policy at Tufts University, and
Columbia University’s School of International and Public Affairs.

xvi About the Lead Authors

 A B O U T T H E C O N T R I B U TO R S

Mateo Ambrosio is a development specialist with over 20 years of experience in

the analysis, design, and implementation of public policies and projects in agri-
culture and rural development. He has worked in Latin America, Africa, and
Asia for multilateral and bilateral development organizations. He has a BA in
economics and business management from universities in Spain and Germany
and a European PhD in rural development and geography from the University
of Cordoba and the University of Antwerp’s Institute of Development Policy.

Franck Cesar Jean Berthe is a senior livestock specialist at the World Bank’s
Agriculture Global Practice. A One Health practitioner, he works across the
agriculture, environment, and public health sectors on health issues at the
human-animal-environment interfaces. He is vice president of the World
Organisation for Animal Health’s Biological Standards Commission. Before
joining the World Bank, he headed the Animal and Plant Health Unit at the
European Food Safety Authority. He has a DVM, a PhD degree in molecular
taxonomy and epidemiology, and a Pasteur Institute diploma in bacteriology.

Anissa Collishaw is an applied economist whose main interest is the nexus

of food value chains, agriculture, nutrition, and strategies to reduce under-
nutrition. She has an MS in food, agriculture, and resource economics from
the University of Guelph. Her research primarily focuses on food safety and
willingness-to-pay for nutritious food products in Canadian and international
contexts.

xvii
 Arie Hendrik Havelaar is preeminent professor in the Animal Sciences
Department of the Institute for Sustainable Food Systems and the Emerging
Pathogens Institute at the University of Florida. His research focuses on epide-
miology and risk assessment of foodborne and zoonotic diseases and their pre-
vention. He is chair of the Foodborne Disease Burden Epidemiology Reference
Group and leads the Animal Disease Management and Food Safety Area at
the USAID-funded Feed the Future Innovation Lab for Livestock Systems. He
is a member of the external advisory boards of the College of Public Health
and Health Professions at the University of Florida and the New Zealand Food
Safety Research Consortium.

Vivian Hoffmann is a research fellow at the International Food Policy Research

Institute. Her research focuses on how markets and institutions in develop-
ing countries affect public health outcomes. She has conducted several studies
investigating the role of markets in aflatoxin control in settings where regulatory
enforcement capacity is limited. She led the first randomized controlled trial
testing the impact of aflatoxin on child growth. Her other areas of work have
included the targeting of subsidies for preventive health technologies. Before
joining the institute in 2013, she was assistant professor at the University of
Maryland and received a PhD in agricultural economics from Cornell University.
She is associate editor of the American Journal of Agricultural Economics.

Donald Macrae, a former civil servant in the United Kingdom reaching

director-general level, has built an international practice in advising on how
to make regulatory systems work. Since 2007, he has worked in some 30 coun-
tries for private sector and international organizations, including the United
Nations, World Bank Group, USAID, the Food and Agriculture Organization
(FAO) of the United Nations, the Organisation for Economic Co-operation
and Development, and the U.K. Department for International Development.
His focus is on the implementation of regulatory systems, including those for
food safety.

Clare Narrod is director of the Risk Analysis Program at the Joint Institute
for Food Safety and Applied Nutrition and leads the institute’s monitoring
and evaluation for capacity building. Before joining the institute, she worked
at the International Food Policy Research Institute, the U.S. Department of
Agriculture, and the FAO. From 1998 to 2000, she was an American Association
for the Advancement of Science Risk Analysis fellow at the Department of
Agriculture. She has a PhD in energy management and environmental policy,
and an MA in international development and appropriate technology from the
University of Pennsylvania. She has field and teaching experience in Africa,
Asia, and Latin America.

xviii About the Contributors

Jairo Romero is a food engineer with 29 years of experience working in food
safety management and international trade. His focus is on strengthening
national food control systems in accordance with international best practices
and guidelines. He is a Food Safety Preventive Controls Alliance lead instructor
on preventive controls for human foods. He is the author of many publications
and has been a presenter at over 100 international workshops and meetings. He
has worked throughout the Americas, Europe, and Asia. He is a fellow of the
International Academy of Food Science and Technology, and is a past president
of the Colombian Association of Food Science and Technology and the Latin
America and the Caribbean Association of Food Science and Technology.

Shashi Sareen has over 30 years of experience in food safety, quality, and nutri-
tion in the public and private sectors, and with international organizations.
From 2010 to 2016, she worked as a senior food safety and nutrition officer in
the FAO’s Asia Pacific Regional Office, providing support to countries on food
safety and quality policies and legislation, food control coordination mecha-
nisms, and inspection and certification systems. Before that, she worked for the
Government of India in various capacities, including director and chief execu-
tive, at the Export Inspection Council of India, the Bureau of Indian Standards,
and the Agricultural Produce Export Development Authority. She has also
worked in the retail private sector. She has MAs in food and nutrition, and
human resource and organizational development.

About the Contributors xix

 E X E C U T I V E S U M M A RY

THE FOOD SAFETY CONTEXT

F
ood safety is linked in direct and indirect ways to achieving many of the
Sustainable Development Goals, especially those on ending hunger and
poverty, and promoting good health and well-being. Food and nutritional
security are realized only when the essential elements of a healthy diet are safe
to eat, and when consumers recognize this. The safety of food is vital for the
growth and transformation of agriculture, which are needed to feed a growing
and more prosperous world population, for the modernization of national food
systems, and for a country’s efficient integration into regional and international
markets.
The safety of food is the result of the actions or inactions of many stakehold-
ers operating under diverse environmental, infrastructure, and socio-political
conditions. These stakeholders include farmers, food handlers and distributors,
food manufacturers, food service operators, consumers, regulators, scientists,
educators, and the media. Their behavior can be shaped by their awareness of
food safety hazards; their technical, financial, and other capabilities to apply effec-
tive mitigating practices; and prevailing rules, incentives, and other motivators.
Food safety outcomes can be strongly influenced by policies, investments,
and other interventions. These alter the awareness, capabilities, and practices
of stakeholders, from farm to fork. Well-functioning markets can provide
incentives for farmers and food business operators to supply products that
match the safety characteristics consumers demand. Even so, there are many
circumstances stemming from problems of information and costs where pure

xxi
 market signals fail and additional measures are needed. Problems of informa-
tion include the actual attributes of food products, and the location and origins
of food safety hazards.
For many developing countries, food safety has, until recently, received very
little policy attention and only modest investment in capabilities to manage
risks. Two main groups of factors contributed to this. The first group includes
the weak empirical base for the country-level incidence of foodborne hazards
and disease, the economic costs of unsafe food, and the efficacy of food safety
interventions. The second group includes institutional factors: the fragmenta-
tion of food value chains and public institutional mandates, and the absence of
effective consumer representation in most developing countries.
Because of scarce data and thematic leadership, food safety tends to appear
on national radar screens only during crises. A typical crisis would be a major
outbreak of foodborne disease (FBD) causing death, scandals involving delib-
erate food adulteration, trade bans, or widespread consignment rejections
because of noncompliance with standards. In developing countries, these epi-
sodes have tended to spur reactive and defensive damage control, resulting in
a flurry of regulatory actions or investments. When these are taken in crisis
management mode, they often differ in target, content, approach, and lasting
efficacy from when food safety measures are developed and adopted in a more
deliberative, evidence-based, forward-looking, and consultative manner.
Years of inadequate policy attention and underinvestment have stunted the
development of coherent national food safety management systems in many
low- and middle-income countries (LMICs). Most of these countries have
weak food safety systems in terms of scientific evidence, necessary infrastruc-
ture, trained human resources, food safety culture, and enforceable regulations.
Governance of national food safety systems in LMICs—whereby stakeholder
roles and accountabilities are well defined and understood—is also weak.
While many LMICs have islands of strong food safety management capacity,
these support only segments of the agri-food system and consumers (often the
wealthiest). An especially weak area is the infrastructure and services needed
to mitigate the food safety risks faced by the poor. Their FBD burden is often
invisible and voiceless.
The dominant discourse on food safety in LMICs has focused on trade, but
this needs to change. Complying with food safety regulations and the standards
of international trade partners has been a prime objective of investments in food
safety by LMIC governments and bilateral and multilateral donors. Trade-related
compliance challenges have been highly visible to policy makers, and stakehold-
ers have taken effective action. That said, most LMICs would benefit from wid-
ening or redirecting their food safety focus. Changing demographics and dietary
patterns are creating new commercial opportunities in domestic food markets,
but these are also increasing the exposure of LMIC populations to food safety
hazards. Although statistically invisible, the domestic economic costs of unsafe
food are significant and growing in many LMICs.

xxii Executive Summary

 In recent years, various major international initiatives have given increased
attention and resources to mitigate risks from unsafe food in LMICs. Examples
include the work of the World Health Organization’s Foodborne Disease Burden
Epidemiology Reference Group (FERG), CGIAR’s food safety research under its
Agriculture for Nutrition and Health program, the Global Food Safety Partnership’s
country and regional initiatives, the Partnership for Aflatoxin Control in Africa,
the World Bank Group’s expanded investment lending and advisory services,
and the African Union’s initiative on food safety; the continued technical sup-
port provided to countries by the Food and Agriculture Organization, World
Health Organization, and the Standards and Trade Development Facility; sup-
port by the U.K.’s Department for International Development, the U.S. Agency for
International Development, and the Bill & Melinda Gates Foundation for research
on FBDs and their control in developing countries; and various regional initiatives.

THE PUBLIC HEALTH BURDEN AND ECONOMIC

COSTS OF UNSAFE FOOD

Research is shedding new light on the global burden of FBD. Until recently, data
on the incidence of FBD and its associated costs were limited to ­high-income
countries and regions, including the United States, Canada, and parts of Europe.
To address this gap, FERG has been working on global estimates of the inci-
dence of FBD since 2006. This work covers 31 of the most important foodborne
hazards in 14 regions. The estimates are expressed in terms of disability-adjusted
life years (DALYs) associated with ill-health and premature death.
For 2010, the base year, the global burden of FBD is estimated at 600 mil-
lion illnesses and 420,000 premature deaths. This aggregates to the equivalent of
33 million DALYs (Havelaar et al. 2015). For comparison, the estimated 2015
global burden of tuberculosis was 40 million DALYs, and 66 million for malaria.
These FBD estimates are considered to be highly conservative. For example, the
incidence of illness associated with chemical hazards was substantially underes-
timated in FERG’s earlier work because of data limitations, as will be confirmed
by updated estimates to be published in late 2018.
The global burden of FBD is unequally distributed. Asia and Sub-Saharan
Africa have the highest incidence of FBD, as well as the highest rate of deaths due
to FBDs and the greatest loss of DALYs. LMICs in South Asia, Southeast Asia,
and Sub-Saharan Africa, which make up 41 percent of the global population,
are estimated to account for 53 percent of all foodborne illnesses, 75 percent of
FBD-related deaths, and 72 percent of FBD-related DALYs. A disproportion-
ate share of the burden falls on children under the age of five, who account
for 9 percent of the global population but 38 percent of all cases of illness
and 40 percent of the DALYs. An estimated 30 percent of premature deaths
due to FBD are in children under the age of five. Geographically, children are
most likely to die from FBD in Sub-Saharan Africa, followed by South Asia.
Epidemiological studies show that the people most vulnerable to foodborne

Executive Summary xxiii

 disease are the young, old, malnourished, poor, pregnant, and those who are
immuno-compromised.
The economic costs of unsafe food take multiple forms and have both short-
and long-term dimensions. Valuing these costs is challenging because of data
and methodological limitations. Examples of these costs include the public
health costs and loss of productivity associated with FBD, disruptions to food
markets when outbreaks of illness occur as consumers avoid implicated foods
or shift to alternatives that are perceived to be safer, impediments to agri-food
exports due to real or expected food safety problems, and the costs of com-
plying with food safety regulations and standards in foreign markets. More
indirect and harder-to-measure costs include the costs of prevention and those
associated with wary consumers shifting from high-nutrient fresh produce to
processed foods. For most LMICs, reliable estimates of these costs and how
they are distributed within society are lacking.
This report estimates the cost of FBD on the basis of “productivity losses,” as
measured by gross national income per capita and associated with disability or
premature death captured in DALYs. The report uses FERG’s DALYs by coun-
try or subregion for 2010 and the gross national income per capita estimates for
2016 from the World Bank’s World Development Indicators Database. The total
productivity loss associated with FBD in LMICs is estimated at US$95.2 ­billion
a year. Of this, upper-middle-income countries account for US$50.8 b ­ illion,
or 53 percent of the total. Lower-middle-income countries account for
US$40.6 billion (43 percent), and low-income countries for US$3.8 ­billion
(4 percent). By region, LMICs in Asia account for US$63.1 billion, and those in
Sub-Saharan Africa for US$16.7 billion. The cost of treating foodborne i­ llnesses
should be added to this. These are estimated at US$15 billion a year in LMICs.
Even without factoring in the hard-to-measure costs of domestic food mar-
ket disruptions and consumer product avoidance, the domestic costs of unsafe
food would aggregate to at least US$110 billion among LMICs.
Food safety performance and compliance costs affect the agri-food trade
in LMICs, but the size of these costs is much smaller than the impacts on
domestic public health and market development. Effectively competing in the
international agri-food trade may entail considerable compliance costs for the
public and private sectors, particularly to meet food safety requirements in
high-income markets. Factors affecting the level of these costs include firm and
industry size, the gap between preexisting food safety management capacity
and the capacity required for compliance, and levels of collective action among
exporting firms. The evidence suggests that the fixed costs of meeting stricter
food safety requirements in export markets tend to favor established and
larger exporters. In 2016, LMIC agri-food exports totaled US$475 billion. This
report estimates that the value of LMIC food trade—which is either detained
by food safety regulatory authorities, not initiated due to standard compliance
concerns, or adversely impacted by very high compliance costs—totals some
US$5 billion–US$7 billion per year, equivalent to between one-fifteenth and
one-twentieth of the estimated domestic costs of unsafe food.

xxiv Executive Summary

 The burden of unsafe food generally evolves in a systematic manner, in line
with processes of economic development; this can be called the food safety life
cycle. The economic costs of unsafe food, in both absolute and relative terms,
vary across countries according to their level of economic development. This
variation is linked to the complex interplay of a wide range of economic, demo-
graphic, dietary, and environmental health factors. These affect the incidence
and potential exposure of populations to food safety hazards, the strength of
incentives for actors in agri-food value chains to prevent or manage these haz-
ards, and the costs of food safety missteps. All LMICs are experiencing changes
in diets, food sourcing and preparation patterns, and in the structures and gov-
ernance arrangements in food value chains. But where they are positioned in
this process of food system transformation varies considerably.
The food safety life cycle across countries and over time reflects evolv-
ing food safety challenges, and the degree of mismatch with food safety
management capacity in the public and private sectors. The level of food safety
management capacity reflects the market-based and political incentives for
public and private sector actors to make required investments. While low-
income countries ­certainly face a significant burden of food-related illness,
diets in these traditional food markets tend still to be dominated by starchy sta-
ples, and policy attention is focused on the availability and affordability of these
foods and on other public health issues (for example, malaria, HIV/AIDS, and
waterborne diseases). Food safety concerns generally become more important
in transitioning lower-middle-income countries that are experiencing rapid
demographic and dietary change, giving rise to dynamic and visible food safety
hazards, which typically overwhelm latent food safety management capacities.
And because of greater access to media, improving wealth and a variety of psy-
chological mechanisms, consumers become ever more concerned about food
safety. The gap between need and capacity begins to close as countries advance
through and beyond upper-middle-income status, as a result of which the rela-
tive economic burden of FBD subsides in the modernizing stage of the food
safety life cycle. At more advanced levels of economic development—that is,
countries at the postmodern stage—attention needs to switch to the manage-
ment of periodic lapses in food safety, where the associated economic costs can
still be considerable. This is also needed to respond to emerging hazards and
changing consumer perceptions of food safety.

THE STATUS OF FOOD SAFETY MANAGEMENT

No representative and comprehensive benchmarking program exists for food

safety management capacities in LMICs. This contrasts with the situation in
Organisation for Economic Co-operation and Development countries, where
several detailed comparative assessments of food safety performance have been
carried out. For many LMICs, detailed assessments have been completed of the
status of public food control systems; for example, the World Organisation for

Executive Summary xxv

 Animal Health’s framework for the performance of veterinary services. Yet the
findings are generally not conducive to ­quantification—and thus, ­comparison—
and many of these studies are not in the public domain. Various other studies
and databases offer partial indications, while those providing greater breadth
tend to reflect actions on paper (the presence of a law or agency, for example)
more than institutional performance or functionality in practice. Food safety
metrics and targets are generally not covered in development planning and
monitoring initiatives.
A review of often non–publicly disclosed assessments points to common
shortcomings in the national food safety systems of LMICs. These include:

• The absence of a comprehensive national food safety policy, translating into

a lack of prioritization of investments;
• A focus on hazard rather than risk, often leading to the misallocation of
resources;
• The presence of many regulations and standards, yet a lack of clarity on the
extent to which these are voluntary or mandatory;
• The fragmentation of institutional responsibilities, especially for market
surveillance and inspecting food production, processing, and handling
facilities
• Fragmented systems for laboratory testing that do not function as a system
and fail to reveal comprehensive inferences on the causes of FBD;
• The lack of effective food safety engagement with consumers, whether in
relation to education, risk communication, and other matters;
• The failure to empower and incentivize the private sector to deliver food
safety; and
• The lack of consistent and transparent border measures to address growing
food imports.

Data and information gathered for this report are consistent with this pic-
ture of underdeveloped food safety management systems, especially in the pub-
lic sector. For example, animal source foods account for a high proportion of
FBD in many LMICs, yet underlying capacities to manage food safety hazards
from animal sources are generally weak. This is especially true for functions
that are considered critical public goods. Among the 34 Sub-Saharan African
countries for which assessment data are available, only four are deemed to have
adequate capacity for identifying and tracing animals and animal products, and
only a similar number can adequately inspect abattoirs. Capacities for quaran-
tine and border security are somewhat better, yet these are deemed adequate
in only 21 percent of the 34 countries. Among the 35 lower-middle-income
countries worldwide assessed by the World Organisation for Animal Health,
only 6 percent were found to have adequate capacities for animal product iden-
tification and traceability, and 11–17 percent were deemed to have adequate
capacities for inspecting abattoirs or meat distribution facilities, had effective
regulations for veterinary drugs, or were able to ensure the quality of laboratory

xxvi Executive Summary

testing of animal products. The situation is different among upper-middle-
income countries, where 30–45 percent of 29 rated countries had adequate
capacities in these areas.
For the private sector, the situation is more varied in low- and lower-middle-
income countries and, again, substantially more advanced in countries in later
stages of economic development. What can be seen here are lead firms (major
food manufacturers and supermarkets) requiring their suppliers to adopt good
agricultural or manufacturing practices. However, in domestic markets, these
do not affect most of the population because informal distribution channels
and traditional community markets continue to play a predominant role, at
least in Africa and Asia.
Within the private sector, more stringent primary production standards
are being applied over a broader area. For example, the LMIC coverage area
for certified GLOBALG.A.P. fruit and vegetable production, most of which is
destined for export, increased from 700,000 hectares in 2010 to 1.87 m ­ illion
hectares in 2017, yet most of this expansion occurred in upper-middle-income
countries. In 2017, these countries accounted for 80 p ­ ercent of the total (ver-
sus 18 percent for lower-middle-income countries and 2 percent for l­ ow-income
countries). Upgrades are also being made at the level of food manufactur-
ing. In January 2018, some 118,000 food companies from outside the United
States were registered with the U.S. Food and Drug Administration. Of these,
59 ­ percent were from high-income countries. Of the over 48,000 LMIC-
registered companies, 72 percent were from upper-middle-income countries,
while 2 percent were from low-income ones.
The widest gaps between needed and actual food safety management capac-
ity are in lower-middle-income countries. Especially the larger of these coun-
tries are important food safety “hot spots,” where the exposure of populations to
hazards is increasing, consumer food safety confidence is waning, and neither
decentralized food safety regulatory capacity nor the governance arrangements
of the formal private sector food industry are able to match the emerging chal-
lenges. These countries need comprehensive measures to curb what is likely to
be a substantially higher health and economic burden of FBD in the coming
years. Setting aside upper-middle-income China, the world’s lower-middle-
income countries accounted for 70 percent of the estimated human capital pro-
ductivity loss from FBD of all developing countries in 2016.
The growing attention to domestic food safety has probably had little posi-
tive impact on the poor. The consumption of unsafe food by low-income
­populations stems from a combination of factors, including low access to
potable water, the cohabitation of humans and animals, high exposure to envi-
ronmental contaminants, the suboptimal use of inputs and other practices of
semisubsistence farmers, poor rural infrastructure, poor hygienic conditions
in urban community markets, and the widespread presence of food safety haz-
ards in street food. A particularly high investment deficit relates to the physical
condition of traditional community markets and small shops, where most poor
people shop for fresh produce. Some market-based standards initiatives may be

Executive Summary xxvii

 having the unintended consequence of securing safe produce for targeted distri-
bution channels, but leaving the more contaminated, test-failing produce for the
markets of lower-income consumers.
For many countries, capacities to manage food safety risks for exports
appear to be considerably stronger than capacities to protect domestic consum-
ers. Trade-related compliance with food safety regulations and standards has
undoubtedly been the catalyst for the significant upgrading of food safety man-
agement capacity in many low- and middle-income countries, especially the
latter. Thus, efforts to meet some of the toughest regulations and standards in
high-income countries have driven many early and sustained upgrades in laws,
control systems, and systems of private value chain governance for food safety.
Unfortunately, evidence of substantive spillovers between trade-related capac-
ity development and domestic systems is limited. And as noted earlier, many
LMICs are not applying risk-based approaches to managing food imports.
Inconsistent or burdensome border measures do not ensure safer food, but
preventive and science-based measures can.
Compliance costs are not a big burden for leading LMIC exporters. Data
on LMIC agri-food exports and on border rejections in high-income countries
suggest that, while compliance with food safety regulations and standards does
indeed involve costs, these are often little more than a “bump in the road” for
the established export sectors and their lead firms in major exporting LMIC
countries. Developing country exporters have been meeting the challenges of
higher food safety standards in high-income markets for over two decades.
Indeed, compliance with food safety regulations and standards might serve to
accentuate the established competitive advantage of these countries, industries,
and firms, reflecting their preferential access to support services and reliable
logistics. In 2016, two-thirds of LMIC exports of food-safety-sensitive high-
value foods came from 10 countries, nine of which were also the top exporters
at the beginning of this century.
Compliance costs can be a burden for smaller LMICs. It is in these coun-
tries, and their less established and smaller sectors and firms, where the costs
of compliance with food safety regulations and standards is more challeng-
ing. These costs can potentially be a make or break trade issue. Economies
of scale in food safety management arise from high initial fixed investments
in upgraded facilities and when new procedures and systems for value chain
coordination and governance are established. Yet, the challenges of compliance
typically accompany and can magnify wider weaknesses in competitiveness.
Food safety is rarely the whole or a very large part of the story.
Emerging new trends in global agri-food trade will strongly affect the
discourse on food safety and trade, and will have strategic implications for
LMICs. High-income countries remain important buyers and sellers of high-
value foods, yet their shares in both are declining. High-value food imports by
LMICs have been growing at double-digit rates since 2000 and were just below
US$150 billion in 2016. For low-income countries, two-thirds of their high-
value food exports and imports involve trade with other developing countries.

xxviii Executive Summary

For lower-middle-income countries, imports from and exports to other devel-
oping countries are growing at a fast pace. Trade among developing countries
will account for most future growth in high-value food trade because of higher
income elasticities and demand for dietary diversity, especially in middle-
income countries.
Exporting to other developing countries poses challenges that differ from
those in high-income markets. For high-income countries, standards are gen-
erally stringent, yet these are typically clear and consistently applied, though
there are of course exceptions. In contrast to these markets, cross-border or
longer distance South-South trade is often characterized by a lack of transpar-
ency in rules and procedures, limited use of science-based evidence in applying
technical barriers to trade and sanitary and phytosanitary measures, high bor-
der transaction costs, and rapidly changing consumer demands for quality and
safety (APEC Business Advisory Council 2016). Exporter country compliance
often seems to be as much a political as a technical matter. This brings consid-
erable uncertainties, especially for small and medium-sized enterprises lacking
the connections or resources to negotiate or maneuver through the necessary
steps to gain and maintain market access. In many LMICs, informal or ille-
gal cross-border trade is very common and is perhaps equivalent to formal
legal trade in size, and animals and food products following this route lack any
structured sanitary inspection.

THE WAY FORWARD

A significant share of food safety problems and associated costs can be avoid-
able if a concerted set of preventive measures are put in place. While various
indicators support the notion of a food safety life cycle that tracks economic
development, the typical rapid upward trajectory of public health costs and
trade disruptions is not inevitable. Indeed, a significant share of food safety
problems and associated costs is avoidable. Food safety issues and challenges
evolve not only with the level of economic development and food system trans-
formation, but also in relation to measures that are taken to ensure that food
safety management capacity keeps up with emerging hazards. It is noteworthy
that some countries do considerably better than others in terms of the bur-
den of FBD, despite having similar constraints. With a proactive strategy and
a proper prioritization of problems and measures, countries can avoid losses
from the burden of FBD amounting to hundreds of millions of dollars a year
(and these losses can run up to several billion dollars for larger countries). In
doing so, countries can minimize disruptions to markets and livelihoods that
come from periodic food safety scares and prevent these episodes from domi-
nating consumer perceptions about the underlying quality and safety of local
foods (and the integrity of the food governance arrangements in place).
While the safety of food is a “public good,” governments do not and cannot
have the primary responsibility for safe food. Rather, food safety needs to become

Executive Summary xxix

 a shared responsibility. Operationalizing this concept effectively is a ­significant
challenge in many LMICs. Governments need to play effective vision-setting
and convening roles; provide reliable information to other stakeholders; and
effectively deploy a wide set of policy instruments, both carrots and sticks, to
involve, incentivize, and leverage the actions of farmers, food business ­operators,
and consumers. While practitioners once emphasized effective “­official food
control” systems, the most critical roles for government are now recognized to
be facilitative ones that induce investments and behavior changes by actors that
share with government the goal of and responsibility for safer food.
This inclusive concept of food safety management may require a paradigm
shift in how emerging countries approach food safety regulation. The tradi-
tional model centers on enforcement through inspections of food facilities and
product testing, and systems of legal and financial penalties for infractions.
This strict authoritative model is seemingly appealing to the public, media, and
therefore political decision makers, yet it is not altogether an effective model
and it can be highly misplaced in contexts in which smallholder farmers, micro
and small enterprises, and informal food channels predominate, and both sur-
veillance and inspectorate capacities are limited. A shared management model
implies a move from a regulator-regulated relationship toward efforts by gov-
ernments to better incentivize and facilitate safe production, processing, and
distribution of food. The role of regulation then becomes one in which the
absolute minimum food safety standard is applied, thereby leaving food busi-
ness operators with some degree of flexibility in how they attain that standard,
and for government to offer information and other resources and support to
motivate and assist compliance. Thus, the results of regulation are measured in
terms of compliant enterprises and food safety outcomes rather than the num-
ber of fines or business closures.
Governments of LMICs not only need to invest more in food safety but also
to invest more smartly. This means investing with a clear purpose and tracking
the impacts of interventions; investing in the foundational knowledge, human
resources, and infrastructure for food safety systems; balancing attention to
hardware and software; realizing synergies among investments and in the pur-
suit of goals (One Health initiatives); ensuring the sustainability of investments
and outcomes; and using public investment to leverage private investment.
Not all investments that can reduce the burden of FBD are ones typically
regarded as “food safety” investments. Critical investments may be ones that
address environmental health issues, such as those that increase access to
potable water and improve sanitation or lessen environmental contaminants
in soil, water, and air. Measures like these reduce the propensity for cross
contamination in food supply chains. Also important are investments in pub-
lic health systems, including those that improve the quality of and access to
medical treatment, which can reduce morbidity and mortality related to FBD.
Indeed, many countries with high estimated DALYs for FBD are also the ones
where rates of access to potable water, improved sanitation, and local health
services are relatively low.

xxx Executive Summary

A CALL TO ACTION

This report offers two sets of recommendations to national governments. The

first is for more effective policy frameworks to govern food safety; the second
is for better implementation. The first set of recommendations emphasizes the
adoption of both systemic and inclusive concepts of food safety management,
shifting the focus from hazards to risks, addressing risks from farm to fork,
changing from a reactive to a proactive orientation on food safety, and adopting
a consistent approach to prioritized decision making. To improve implementa-
tion, this report offers guidance for reforming food safety regulatory practices,
investing more smartly in essential public goods, institutionalizing a structured
approach to food safety risk management, and leveraging consumer concerns
over food safety.
This report makes tailored recommendations for different stakeholders, and
general priorities are highlighted for countries at different stages of the food
safety life cycle. The recommendations for different stakeholders are summa-
rized in box ES.1 and are discussed more fully in the report. Table ES.1 high-
lights priorities for countries at different stages of the food safety life cycle.
These emphasize core principles and reflect the study team’s perspective on
what is most important and feasible for countries at different levels of eco-
nomic development and food system modernization. More specific priorities
and action plans will need to be determined and created by stakeholders at
country or regional levels.

BOX ES.1 Recommendations for Stakeholders in the Food

Safety Life Cycle

For ministries of finance or other coordinating economic ministries in low- and

middle-income countries (LMICs):
• Calibrate public expenditures for food safety to the economic costs of unsafe
food and the benefits of investing in its prevention and management.
• Emphasize forward-looking preventive measures to minimize future costs
(avoidable losses) for, among other things, public health and market development.
• Balance public expenditures and investment between “hardware” (laboratories,
market places) and “software” (management systems, human capital, awareness-
raising for behavioral change).
• Ensure that proposals for significant public investments or programs are
justified using cost-benefit or cost-effectiveness analysis, and that alternative
approaches, including regulatory measures and facilitating private investment,
have been considered.
• Use public investment and programs to leverage and incentivize private investment
and other activities to build food safety capacity and improve outcomes.
• Strategically focus resource allocations by linking them to coherent, system-
wide strategies for food safety investment and management.

(Continued)

Executive Summary xxxi

 BOX ES.1 Recommendations for Stakeholders in the Food
Safety Life Cycle (Continued)

For lead food safety agencies or other coordinating bodies in LMICs:

• Develop a unified food safety strategy that defines priorities and responsibilities,
guides the coordination of measures by government and private entities, and
establishes funding needs.
• Using a structured approach, define evidence-based priorities using risk analysis
and regularly update them to make more strategic use of resources.
• Redefine institutional roles to be less about finding and penalizing noncompliance
and more about facilitating compliance by providing information, advice,
incentives, and interventions to motivate and leverage investments and actions
by value chain actors.
• Provide consumers with the tools to become partners in food safety through
their own actions and through incentivizing and motivating food suppliers.
• Incorporate the science of behavior change by redesigning training programs,
information campaigns, and other interventions.
For technical ministries—agriculture, health, trade, environment—in LMICs:
• Change key performance indicators to be less about noncompliant outcomes
(infringements, value of fines collected, number of businesses closed) and
more about food safety outcomes (magnitude of food safety risks, incidence of
foodborne disease, standards-compliant trade).
• Take measures to minimize hazard entry into the food supply from farms, especially
measures that offer co-benefits for public health and environmental protection.
• Direct attention to small and informal actors in the food system, with an
emphasis on awareness-raising, adopting safer food handling practices, and
improving physical operating conditions (that is, access to clean water and
waste management facilities).
• Develop technical standards that help to correct the asymmetry of information
that divides buyers and sellers of food from farm to fork.
• Remove policy, regulatory, or other barriers to private investments and services
for food safety.
• Apply risk-based approaches to govern food trade, together with improved
trade facilitation capabilities.
For chambers of commerce and food industry associations in LMICs:
• Participate in national processes for food safety policy development and
prioritization.
• Play active advocacy roles by ensuring that small-actor constraints are factored
into policy making and advocating for the least burdensome means and realistic
time frames for regulatory compliance.
• Organize collective action to build food operator awareness; facilitate the
adoption of good agricultural, manufacturing, and industry code practices; and
strengthen food quality and the safety management of industry leaders, small
and medium-sized enterprises, and organized primary producers.

(Continued)

xxxii Executive Summary

BOX ES.1 Recommendations for Stakeholders in the Food
Safety Life Cycle (Continued)

• Support programs to improve food and pathogen traceability and transparency

by establishing industry- wide norms and standards for record-keeping and
sharing information along the value chain.
For research institutes and academia:
• Build capacity in the basic disciplines to address food hazards and use this
capacity to conduct research on the epidemiology of foodborne disease, carry
out risk assessments, and evaluate feasible alternatives for risk management.
• Develop, adapt, and pilot food safety technologies and approaches in partnership
with industry and civil society organizations; evaluate the efficacy and cost-
effectiveness of these technologies and approaches.
• Develop and contribute to professional training and accreditation programs for
food safety professionals to create a cadre of trained personnel for industry and
the public sector.
For bilateral development and trade partners:
• Strengthen incentives for preventive actions by LMIC trading partners by
instituting more streamlined trade consignment inspection protocols, and
act through memorandums of understanding and twinning arrangements to
achieve mutual recognition of sanitary and phytosanitary management systems.
• Give increased priority to food safety interventions focused on promoting
domestic public health in LMICs to make a significant contribution to achieving
the Sustainable Development Goals.
• Improve the quality of bilateral food safety capacity support programs by
applying more rigorous economic analysis and monitoring and evaluation,
placing greater emphasis on capacity sustainability, and taking advantage of
potential synergies, such as One Health initiatives.
• Promote low-cost, high-impact investments in food safety management capacity
through the experimentation, demonstration, and facilitation of technology
transfer and practice adoption.
For multilateral organizations and partnerships:
• Develop and apply a “food safety commitment index” as a global or regional
benchmarking tool to monitor the level of commitment that LMIC governments
are making to food safety, and to motivate them to take additional measures to
improve underlying capacities and performance.
• Promote active experience sharing among LMICs, and document and promote
good practices in food safety management upgrading policies and programs.
• Promote the application of formal processes of prioritization as part of the
development of national strategies for enhancing food safety management
capacity.
• Promote multidisciplinary research to better inform strategies, policies, and
programs.

Executive Summary xxxiii

TABLE ES.1 Priorities for Countries at Different Stages of the Food Safety
Life Cycle
Priority area Traditional Transitioning Modernizing
Policy, strategy, Integrate food safety Integrate food safety concerns Integrate food safety concerns in
and regulation concerns in national food into national strategies for national strategies for managing
and nutritional security agricultural transformation and trade public health costs.
strategies to mobilize diversification to mobilize attention. Strengthen regulatory
attention. Align sanitary and phytosanitary convergence with trading
Establish a basic legislative standards with the potential for trade partners and international
framework for food safety in relevant commodities. standards. Negotiate equivalence
(roles and responsibilities, Develop a national multisector agreements to facilitate trade
legal authority). food safety strategy that sets with important partners.
Update regulations for priorities, addresses institutional Conduct cost-benefit analyses of
the use and marketing of strengthening and coordination, proposed regulatory measures
agricultural chemicals and and lays out approaches for private and incorporate regulatory
veterinary drugs. sector collaboration and consumer impact assessments into policy
engagement. making.
In line with available enforcement and
compliance capacity, strengthen the
legal framework and align it with the
Codex Alimentarius.
Participate in regional harmonization
efforts.
Risk assessment Undertake qualitative Set up programs for monitoring food Draw up a national research plan
assessments and quantitative consumption and purchasing patterns, to address food safety, with input
risk ranking, where feasible, and for estimating total dietary from industry.
to identify the most exposure to hazards. Set goals of continuous
significant risks to public Develop an FBD surveillance and reduction in FBD (as reported
health. reporting system. by surveillance system).
Incorporate information Pay particular attention to microbial Pay particular attention to
from other health reporting hazards, and hazards-related emerging FBD and novel
systems. adulteration and use of agricultural technologies.
Pay particular attention inputs. Apply mechanisms for the
to issues associated with Establish programs to monitor food systematic collection, evaluation,
neglected zoonoses and safety hazards of public health concern and use of FBD surveillance data.
staple foods. and supplement them with studies to Ensure that laboratory systems
Undertake value chain generate additional surveillance data to
are internationally accredited,
assessments to determine prioritize risks. effectively networked, and
the locus and nature of risks Invest and facilitate investment in more financially sustainable.
in relation to food-safety- extensive and professional quality
sensitive exports. assurance laboratory testing capacities
Develop basic laboratory
testing capacities while using
regional and international
labs for specialized or low-
volume testing.
(Continued)

xxxiv Executive Summary

 TABLE ES.1 Priorities for Countries at Different Stages of the Food Safety
Life Cycle (Continued)
Priority area Traditional Transitioning Modernizing
Risk Ensure that synergies Develop a registry of food businesses Build attitudes and incentives
management between water and sanitation in the formal sector and undertake risk to mix robust enforcement and
upgrade initiatives and profiling. Implement programs for the constructive compliance support
community-level food hygiene hygiene grading of food premises. for businesses.
programs. Professionalize food inspectors and Incentivize the adoption of
Improve basic hygiene implement risk-based inspection plans. food safety management
conditions in markets by Introduce local good agricultural and systems by small and medium-
investing in infrastructure, animal husbandry practice programs sized enterprises (SMEs) and
especially targeting markets targeting specific commodities in internationally benchmarked
where poor populations buy emerging formal sectors. standards by larger enterprises.
high-nutrient and perishable Leverage consumer awareness and Remediate important
foods. demand for safer food. environmental hazards.
Improve access to basic Invest in (through public-private Strengthen fully documented
health services to minimize partnerships, if possible) improved national food recall and
serious complications from food market infrastructure for traceability systems.
FBD. perishable foods.
Strengthen decentralized
Support community- Mainstream the adoption of good capacities for regulatory
based and peer-to-peer agricultural and animal husbandry oversight and advice.
mechanisms for improving practices through technical and
food safety in smallholder market support programs, and ensure Use emerging information,
agriculture and the informal multisector synergies (through One biological, and other technologies
food sector linked with Health, for example). in regulatory delivery and supply
development initiatives. chain management.
Introduce procedures for investigating
Establish border controls and responding to food safety incidents Ensure that border controls for
with a focus on likely high- and emergencies, and for early warning food imports are consistent and
risk products. systems. effective.
Target important single- Strengthen border controls on a risk Ensure that procedures for
source hazards for feasible basis, and ensure that controls follow recalls and food emergencies are
control measures. good trade facilitation practices. well established.
Undertake public-private Develop an early warning system and
initiatives to develop contingency plan for food emergencies.
compliance with external
requirements for sectors
with significant export
growth potential.
Information, Educate consumers on basic Implement national food safety Establish a mechanism to
education, and food hygiene and avoidance awareness programs, targeting all systematically monitor public
communication of specific hazards. stakeholders and age groups. perceptions to inform food
Develop targeted training for Work with industry and universities safety communications and
SMEs, informal food retailers, to develop training and advanced education programs.
and street food vendors. education programs in food safety Develop communication
Raise awareness of synergies management. strategies to correct public
and trade-offs between Develop and implement various misperceptions.
food safety, nutrition, and elements of a risk communications Use behavioral science
equity; and food safety and program, including guidelines for principles and empirical
Sustainable Development different stakeholders and use of testing methodologies to
Goals. electronic platforms. design programs that influence
consumer and food handler
behavior.
Support private efforts to label
and certify products to promote
consumer trust and reduce
information asymmetry.

Source: World Bank.

Executive Summary xxxv

 REFERENCES

APEC Business Advisory Council. 2016. Non-Tariff Barriers in Agriculture and Food Trade
in APEC: Business Perspectives on Impacts and Solutions. Los Angeles: University of
Southern California.
Havelaar, A., M. D. Kirk, P. R. Torgerson, H. J. Gibb, T. Hald, R. J. Lake, N. Praet, et al. 2015.
“World Health Organization Global Estimates and Regional Comparisons of the Burden
of Foodborne Disease in 2010.” PLOS Medicine 12 (2).

xxxvi Executive Summary

 A B B R E V I AT I O N S

ASEAN Association of Southeast Asian Nations

COMESA Common Market for Eastern and Southern Africa
DALY disability-adjusted life year
EU European Union
FDA Food and Drug Administration
FBD foodborne disease
FERG Foodborne Disease Burden Epidemiology Reference Group
GAP good agricultural practice
GNI gross national income
HACCP hazard analysis and critical control points
IFC International Finance Corporation
LMIC low- and middle-income country
PVS performance of veterinary services
SDG Sustainable Development Goal
SPS sanitary and phytosanitary
WTP willingness to pay

xxxvii
 Introduction

THE FOOD SAFETY CONTEXT

F
ood safety hazards are increasingly being recognized as a major pub-
lic health problem worldwide, which has significant and wide-ranging
socioeconomic consequences for human welfare and economic perfor-
mance. For industrial countries, a considerable body of research now exists on
the nature and magnitude of these consequences; the economics of food safety
regulations; and the efficacy of various approaches to strengthen food safety
awareness, behavior, and management capacity. For developing countries, hard
evidence in these areas is more limited and less accessible to policy makers,
especially those who are not experts in this field. Because of this, the economic
case for public investment in food safety systems is generally less well under-
stood in low- and middle-income countries.
Many developing countries lack rigorous and comprehensive data on the
level and nature of foodborne hazards and the prevalence of associated food-
borne illnesses, though this situation is by no means uniform. In developing
countries, most cases of foodborne illness are sporadic rather than occurring
as part of a substantive outbreak, making them inconspicuous.1 The 2015 pub-
lication of the long-awaited World Health Organization–sponsored report on
the global burden of foodborne disease was a major advance. Yet, the findings

1
This is not limited to developing countries. The U.S. Centers for Disease Control and Prevention
estimate that 48 million cases of foodborne disease occur annually in the United States. Yet, only
around 30,000 cases a year are reported as outbreaks.

1
 were only for regions rather than countries, making the report something of a
challenge for nonspecialists to understand and draw policy implications from.
Country data are frequently missing or unreliable on the incidence and
level of food safety hazards, the occurrence of foodborne illness, and the finan-
cial costs to farmers and enterprises from market disruptions because of unsafe
food. Food safety hazards and practices within informal food marketing chan-
nels are not assessed on a regular basis, despite the great importance of these
channels for the food supply to the poor and often to the whole population.
And the economic impacts of foodborne hazards are often complex, involving
multiplier and feedback effects that can be difficult to identify—and even more
difficult to quantify. Somewhat better proxy indicators are available to gauge
the impact of food safety hazards on the export performances of developing
countries, although this is also a challenging area to accurately quantify.
Thus, while many policy makers and other stakeholders in developing
countries recognize that there are gaps and shortcomings in food safety sys-
tems, less well understood are the socioeconomic impacts of these weaknesses
and, importantly, the size of the benefits from remedial or forward-looking
investments or other measures to influence incentives and behavior.
And the playing field is changing. This includes significant demographic
and economic changes that are resulting in major shifts in dietary and food
purchasing patterns, and a fundamental and rapid process of restructuring
domestic agri-food systems. Along with these forces are significant changes
in the magnitude and types of hazards associated with the food of developing
countries. Different countries are currently at different stages in the processes
of dietary and food system structural transformation.
The limited evidence base on the costs of food safety lapses and on the
benefits of preventive measures has contributed to underinvestment in food
safety management systems in many developing countries. And the growing
complexity of food safety hazards in many urbanizing middle-income coun-
tries is straining or outpacing food safety management capacity. This includes
regulatory control systems, enterprise and value chain management systems,
and associated infrastructure and human resources. In developing countries,
investments in food safety are often reactive and defensive, occurring after a
serious food safety outbreak or the imposition of a trade ban. Experience has
shown that reactive investments turn out to be to be very expensive, not only
financially but also in the cost to the reputation of the affected industry and
the disruptive impacts on value chain actors. Yet, fragmented structures for
food safety governance are common, and these tend to inhibit the development
and application of forward-looking, preventive approaches to food safety risk
management.

AIMS AND AUDIENCES

Developing countries face a multitude of competing demands for limited invest-

ment funds. The economic case for more significant and sustained investment

2 THE SAFE FOOD IMPERATIVE

in food safety systems needs strengthening. To do this, empirical evidence will
need to be compiled on the impacts of foodborne hazards for public health,
trade, and domestic market development among countries at different levels of
economic development. This will also require additional evidence of the eco-
nomic benefits of improvements in food safety and how these are distributed.
Based on this evidence, recommendations can be made for food safety sys-
tem investments and other public policy initiatives that lead to safer practices
from farm to fork.
This report aims to increase the awareness of policy makers of the socioeco-
nomic impacts of foodborne hazards in low- and middle-income countries, pro-
vide a rationale for greater policy attention and public resources to strengthen
food safety capacities and incentives, and provide guidance on how to go about
doing this. The report is primarily aimed at policy makers and policy analysts in
low- and middle-income countries, both those associated with technical minis-
tries (especially, agriculture, health, and trade) and those involved with economic
and development planning and budgetary and fiscal management. The analysis
and strategic perspectives offered in this report will also be relevant to develop-
ment practitioners and partners seeking to devote greater attention to food safety
matters in their support for public health, trade, and agricultural and food system
transformation in low- and middle-income countries.

STUDY METHODS

The work on this report involved data analysis, literature reviews and synthesis,
case studies, and some use of crowdsourcing techniques to gather material that
has not been documented or put in the public domain. The report benefited
enormously from collaboration with several other institutions; this included
sharing restricted data and reports, without which important analyses for this
report would not have been possible.
The report aims to advance the strategic prioritization of investments and
other public policy initiatives related to food safety in developing countries.
It does this by (1) positioning food safety challenges within the context of the
broader Sustainable Development Goals; (2) combining insights from food
safety specialists and various social science disciplines; (3) integrating evidence
across different types of food safety hazards, product lines, and domestic and
international markets; (4) contrasting the food safety challenges and experi-
ences of countries at different levels of economic development; and (5) making
these findings accessible to nonspecialists.

STRUCTURE OF THE REPORT

The report has four main sections. The first examines why safe food fundamen-
tally matters for economic development. The second looks at the evidence on
the costs of unsafe food in developing countries. The third section discusses

Introduction 3
 the status of food safety management in these countries, and the fourth ana-
lyzes the strategic, policy, and institutional issues and options for strengthening
food safety management systems. The report closes by offering recommenda-
tions for different stakeholders and proposes priorities for countries at different
stages of economic development.

4 THE SAFE FOOD IMPERATIVE

 CHAPTER ONE

Why Safe Food Matters to

Economic Development

INTRODUCTION

U
nsafe food contains microbiological, chemical, or physical hazards that
can make people sick, causing acute or chronic illness that in extreme
cases lead to death or permanent disability. Unsafe food reduces the
bioavailability of nutrients, particularly for vulnerable consumers, and is asso-
ciated with malnutrition. The presence of food safety hazards can lead to food
losses and reduce availability for food-insecure populations. For these reasons,
food safety is seen as an integral part of food and nutritional security. Food safety
hazards that have been addressed by public policies include microbial pathogens
(for example, Salmonella spp.); zoonotic diseases (for example, highly patho-
genic avian influenza); parasites (for example, intestinal worms); adulterants (for
example, melamine); naturally occurring toxins (for example, aflatoxin); antibi-
otic drug residues; pesticide residues; and heavy metals (for example, cadmium).
Food safety hazards are not only a public health issue for low- and
­middle-income countries (LMICs) but they also affect the growth and mod-
ernization of domestic food markets and income and employment opportu-
nities in food production, processing, and distribution. This is especially true
where increases in income and urbanization—and the transformation of diets,
among other factors—are generating increased demand for safe food (Ortega
et al. 2012; Lagerkvist et al. 2013). Furthermore, the quality and safety of food is
often a strong attraction—or, conversely, a deterrent—for domestic and inter-
national tourism (Croes and Rivera 2015).

5
 Food safety is an increasingly important determinant of the trade perfor-
mance of many LMICs, especially those competing in markets for high-value
foods, including fresh fruit and vegetables, fish and fishery products, meat,
spices, and nuts. To the extent that the enhancement of agri-food exports
contributes to sustainable economic development and poverty reduction,
­
investments in food safety can have significant positive development impacts.
Thus, countries, and their agri-food sectors and firms, that have a limited
capacity to manage food safety might find themselves excluded from lucrative
export markets or face periodic yet costly rejections of product consignments
and uncertainty about sustained market access.
In economic terms, costs associated with unsafe food are potentially high in
both the short and long terms—and are manifested most directly in the pub-
lic health costs and loss of labor productivity from foodborne disease (FBD).
Food safety failures can also impose costs on producers, food manufacturers
and distributors, and consumers. For example, concerns over food safety may
force consumers to pay higher prices for “safe” food or lead them to avoid foods
considered “unsafe,” with possibly negative nutritional consequences. Affected
businesses might incur costs in recalling products or face a loss of market
access or brand reputation. Entire industries might see a contraction in con-
sumer demand or a loss of access to lucrative export markets. Evidence on the
public health and commercial costs of unsafe food is presented in chapter 2.

FOOD SAFETY AND THE SUSTAINABLE DEVELOPMENT

GOALS

Of paramount importance for LMICs is the impact of unsafe food and invest-
ments in food safety management capacity on efforts to reduce poverty. Food
safety intersects with poverty in two critical ways: the poor as consumers of
food and as agents in agri-food value chains. A growing body of literature
identifies the extent of food safety hazards in informal food markets, which
are the predominant source of food for the poor, especially in urban areas
(Grace et al. 2008; Feglo and Sakyi 2012; Jarquin et al. 2015). Food safety can
affect the livelihoods of poor people employed in agri-food value chains as,
for example, small-scale farmers, operators of micro and small food process-
ing and distribution enterprises, and employees in commercial food enter-
prises. Thus, even a single food safety event can undercut livelihoods and
push people into poverty—or back into poverty—if it causes consumers to
shift purchasing and consumption patterns. Attempts to improve food safety
by banning street food vendors can have negative consequences for liveli-
hoods and nutrition. But there can be significant positive impacts on pov-
erty if investments in increasing the capacity to manage food safety enhances
agri-food markets in a way that is inclusive of the poor.
Improving food safety and building the capacity to do this will play an impor-
tant role in achieving the Sustainable Development Goals (SDGs). Indeed, food

6 THE SAFE FOOD IMPERATIVE

BOX 1.1 Food Safety and the Sustainable Development Goals

Food safety will be vital for achieving many of the Sustainable Development Goals
(SDGs), and particularly the following:
• SDG 1: End poverty. Foodborne disease (FBD) is a major cause of ill-health
among the poor and is associated with a range of costs affecting them, including
lost workdays, out-of-pocket expenses, and reduced value of livestock and other
assets.
• SDG 2: End hunger. FBD has multiple complex interactions with nutrition. For
example, toxins may directly lead to malnutrition, some of the most nutritious
foods are the most implicated in FBD, and concerns over food safety may lead
consumers to shift consumption away from nutritious foods.
• SDG 3: Good health and well-being. The health burden of FBD is comparable to
that of malaria, HIV/AIDS, and tuberculosis, and the people most vulnerable
to FBD are infants, pregnant women, the elderly, and those with compromised
immunity.
• SDG 5: Gender equality. Women are the gatekeepers of household food safety,
play important roles in traditional food chains, and often derive their livelihood
in agri-food value chains.
• SDG 6: Clean water and sanitation. Lack of clean water increases the risk of food
being unsafe, injudicious use of chemicals in food production can pollute water
sources, and infectious FBDs can be transmitted via water.
• SDG 8: Decent work and economic growth. Inclusive food markets provide liveli-
hoods and are a way out of poverty for many poor people.
• SDG 11: Sustainable cities and communities. Hundreds of millions of poor peo-
ple work in urban agriculture and food-related services, and vibrant traditional
food markets and street food make important contributions to culture, tourism,
and livable cities.

safety will be integral or highly significant to achieving several SDGs, especially

SDGs 1, 2, and 3, while also contributing to achieving several other goals (box 1.1).1

UNDERSTANDING THE SOCIOECONOMIC IMPACTS OF

UNSAFE FOOD

To best understand the socioeconomic impact of enhancements in food safety

management systems, it is important to adopt a food system perspective. Food
systems encompass the entire range of activities and actors in the production,
processing, marketing, consumption, and disposal of food, including the inputs
needed and outputs generated at each stage. Food systems also encompass the

1
FBD was not given explicit attention in the formulation of the SDGs. This may reflect the poor
evidence base at the time, since the first global assessment of the burden of FBD was not published
until after 2015. This may also reflect the low awareness of the importance of food safety among
public health professionals and, especially, development practitioners. Considerable advances in
some areas of public health, including declines in the incidence of malaria and tuberculosis, mean
that the relative importance of food safety has increased, along with its growing share of the global
infectious disease burden.

Why Safe Food Matters to Economic Development 7

 institutions that define the social, economic, political, physical, and technologi-
cal environment in which these activities take place. A food system perspective
recognizes the physical transformation and movement of food, and the rules and
other institutions that organize and govern this system through the incentives
for actors at various stages of the agri-food chain to behave in particular ways.
The safety of food products can therefore be seen as an outcome of food systems,
which, in turn, reflects the capabilities and incentives for actors within the system
to adopt practices that enhance or maintain the safety of the end product.
The attention on food safety often focuses on specific agri-food value chains
and the institutional context in which they operate—and this, in turn, reflects the
wider social, economic, physical, and technological environment. Two c­ ritical
factors influence the performance of value chains in terms of food safety. The
first includes the capabilities of actors within value chains, both i­ndividually
and collectively, to undertake the functions needed to manage food safety, and
public and private sector actors outside value chains that provide necessary
regulatory services and support functions. And the second factor includes the
incentives for actors within and around value chains, again individually and
collectively, to undertake the practices needed to ensure the safety of the end
product. These incentives reflect the market demand of consumers and the reg-
ulatory actions of governments (which, themselves, may be influenced by mul-
tiple factors). A considerable body of theoretical and empirical evidence shows

BOX 1.2 Market Failures Associated with Food Safety

A well-functioning market provides incentives for food business operators to sup-

ply products that embody the characteristics of safety that consumers demand,
both because these operators derive greater profit from doing so and because their
reputation is essential for repeat sales. Under certain conditions, however, markets
may fail to provide the safety that consumers demand or that is socially desirable.
For example, consumers may be unable to judge the safety of a food product at
the point of purchase or before consumption. The safety of food is often impercep-
tible to the senses, and those consuming it may lack access to information on how
food was handled before reaching them. This problem becomes more pronounced
as supply chains become more impersonal. And in the event of food poisoning,
consumers often have no way of identifying the source of contamination. This
problem is called information asymmetry.
Because safety can increase costs for food business operators, this lack of infor-
mation may reduce their incentive to incur those costs. Operators that have more
information on the safety of the products they supply may be able to gain a strategic
advantage over consumers or their competitors, leading to inappropriate price sig-
nals or false product differentiation on the basis of safety.
This situation is compounded by the safety and quality characteristics associ-
ated with food being typically complex, and significant transaction costs can be
imposed on consumers searching for products that meet their particular demands

(Continued)

8 THE SAFE FOOD IMPERATIVE

BOX 1.2 Market Failures Associated with Food Safety (Continued)

and in assessing the actual characteristics of these products. These transaction costs
can impede market development.
Unsafe food not only imposes costs on the person eating it (for example, lost
income for time away from work) but also imposes broader costs on society through
the health care system. Normally, consumers do not take these costs—which econo-
mists call externalities—into account when choosing the food they buy, and so they
tend to demand a lower level of food safety than society would prefer. Externalities,
however, can also be positive. These are benefits that accrue to other parts of soci-
ety beyond consumers themselves; for example, the protection of the environment
when consumers buy safe food that is also environmentally friendly.
Governments can use food safety standards to try to tackle market failures to
achieve levels of safety that are socially desirable and to reduce the costs of unsafe
food. In extreme cases, this can take the form of product bans. More generally,
food safety standards specify the ways in which food products are produced and
their characteristics (for example, ingredients and storage conditions). Here, gov-
ernments may specify the safety characteristics of the end product, but leave food
business operators to choose the most appropriate way in which to grow or manu-
facture their products. In some cases, governments may also specify the informa-
tion that must be disclosed to consumers and the format for this information.
This market-failure perspective presents public standards as instruments that
correct inefficiencies in markets for food safety. But even a cursory observation of
the prevailing environment for food safety standards provides examples of public
standards that have been implemented in the absence of “market failure” or some
other action that may have been able to correct the failure at lower cost.
The political economy perspective on food safety standards acknowledges
that public authorities are influenced by the interest groups their actions affect—
whether businesses, consumers, or taxpayers—and that the standards they imple-
ment will reflect, at least in part, the power of these actors. It is widely recognized
that private interests can “capture” regulatory processes and steer them in directions
to their economic advantage. In these cases, public standards can aggravate market
failures and have considerable distributive impact.
Private standards are implemented by businesses and other entities, individually or
collectively, and these standards evolve for different reasons. They are often devised to
enhance economic efficiency by facilitating communication between buyers and sellers
or by ensuring the compatibility of product components or products that are consumed
jointly. Private standards can also be the basis of the competitive strategies of food busi-
ness operators to communicate with consumers and enhance their reputations.
Market signals are sufficient to induce the development of private standards; the
role of the government is to ensure that these standards do not constitute or conceal
anticompetitive practices.

that the incentives in markets, when markets are left to their own devices, tend
to be weak (box 1.2).
A focus on agri-food value chains also recognizes the distinct pathways
through which food safety hazards occur and the pathways to better public
health, economic, and social outcomes. Figure 1.1 shows that there are often

Why Safe Food Matters to Economic Development 9

10
FIGURE 1.1 Public Health, Economic, and Social Outcomes of Unsafe Food

Public health Economic outcomes Social outcomes

outcomes / Level of economic development
( ,∆) Diet transition Malnutrition
Environmental health factors
Exposure to Domestic market
hazard ∆– Food system and value chains expansion
∆– Domestic Domestic Food security
∆–
focused focused

THE SAFE FOOD IMPERATIVE

Export revenue
Informal Formal Export
Burden of
market market focused
illeness
Farm Farm
Government
∆+ Farm revenue
Processing Processing
Exporter Poverty
Systemwide Market
Market
Employment and
Consumer incomes
Consumer
Value chain Market and
specific investor
confidence
∆+ ∆+

Export product ∆+
Imports
quality

Source: World Bank.

distinctive value chains, both the informal and formal, focused on servicing
domestic consumers or export markets. Agricultural raw materials and food
can also be imported to service both the domestic market and export-oriented
businesses. These value chains operate in a broader food system that also
includes physical infrastructure and other institutions. This broader system is
also influenced by a country’s wider environmental health in terms of water
and air quality. A country’s level of economic development is a key determinant
of the structure of agri-food chains, the relative importance of informal and
formal distribution channels, and the state of the environment.
A distinction can be made between agri-food value chains focused on
exports and those directed at consumers in domestic markets, reflecting two
different pathways through which the economic and social outcomes of FBD
occur. The first is the impacts on domestic consumers through exposure to
food safety hazards that bring about FBD. This has economic consequences
through costs associated with morbidity and premature mortality in terms of
pain and suffering, and loss of income and productivity. The second pathway
is the impacts on the performance of businesses operating in agri-food value
chains, whether directed at domestic or export markets.
Importantly, the economic and social outcomes of FBD are seen at the micro
level (for example, on individual consumers and businesses) and in the overall
economy (for example, through economic growth, employment, and trade per-
formance). These economic and social outcomes can also differ (for example,
between poorer and richer consumers, and small and large businesses), result-
ing in considerable distributional consequences.
FBD can arise from environmental health conditions; for example, inade-
quate sanitation that leads to cross contamination in food handling. Many FBDs
can also arise at multiple points in agri-food value chains, thereby increasing
the level of contamination (table 1.1). FBDs can also be spread through the
comingling of food products, especially when food markets expand and food is
distributed over long distances. Importantly, agri-food chains exist and respond
to a dynamic environment (for example, in the foods eaten by rich and poor
alike, and the expected trajectory of diets in the future) (box 1.3).
For export-oriented value chains, food safety affects trade performance
through compliance with public and private standards. Impacts on domestic
food safety only occur to the extent that export-oriented value chains also sup-
ply local markets or there are capacity spillovers to value chains directed at local
markets. Thus, poor product quality in these value chains may hurt exports,
with consequences for business performance, employment, farm incomes, and
government revenues.
The exposure of domestic consumers to food safety hazards reflects the
food safety management capacity of agri-food value chains and the wider food
system in which they operate. Informal value chains are typified by the prepon-
derance of micro and small enterprises, a high rate of attrition of enterprises,
weak regulatory oversight, and weak links between actors both vertically and
horizontally within the chain. Conversely, value chains directed at formal food

Why Safe Food Matters to Economic Development 11

 TABLE 1.1 Food Safety Hazards on the Farm-to-Fork Pathway
Stage of Source of Examples of hazards
pathway contamination
Production Soil Sewage effluents; animal manure; soil-associated
microbial pathogens (Listeria spp., Clostridium spp.);
heavy metals; industrial chemicals
Freshwater Microbial contaminants, parasite eggs, heavy metals,
industrial chemicals
Salt water Marine toxins
Bacteria: Vibrio spp.
Fertilizer and soil Pellet manure and fish emulsion can contain biological
amendments hazards, inorganic fertilizers may contain hazardous
chemicals, and biosolids may contain heavy metals
Agricultural Pesticides, fungicides, herbicides, rodenticides,
chemicals antimicrobials, illegal growth promoters, disinfectants;
fertilizers
Fodder and Dioxins, mycotoxins, microbial pathogens (Listeria,
roughage Neospora, Clostridium botulinum, Salmonella spp.)
Animal feeds Microbes, mycotoxins, metals, processing aids,
antinutrients, veterinary drugs, persistent organic
pollutants, plant toxicants (alkaloids)
Agricultural Feces-associated pathogenic bacteria (Salmonella spp.,
workers Shigella spp., E. coli O157:H7, and others)
Pathogenic parasites (Cryptosporidium, Cyclospora)
Pathogenic viruses (hepatitis, enterovirus)
Plant Natural toxins: lectins, cyanogenic glycosides, oxalates,
trypsin inhibitors
Livestock Microbes: Salmonella spp., Campylobacter, toxigenic
E. coli, and others
Parasites: pork tapeworm, beef tapeworm, Trichinella
Commensals
Drugs: antimicrobials, hormones
Aquatic animals Pathogens: Vibrio spp.
Commensals: Clostridium
Parasites: trematodes, nematodes
Contaminants: Erysipelothrix, Listeria
Spoilage: histamine
Harvest Plant harvesting Physical hazards: stones, wood splinters
Machine lubricants, cleaning materials
Slaughter Contamination of meat with gut contents (common),
animal skins, workers, water source, cleaning chemicals,
cross contamination among animals from different
sources
(Continued)

12 THE SAFE FOOD IMPERATIVE

 TABLE 1.1 Food Safety Hazards on the Farm-to-Fork Pathway
(Continued)
Stage of Source of Examples of hazards
pathway contamination
Aquatic capture Infected workers
Processing Infected food Infected workers
handler
Adulteration Unauthorized dyes, melamine, formaldehyde (as
with harmful preservative)
substances
Processing and Lack of appropriate cold chain control, acrylamide
transportation
conditions
Packaging Packaging migrants, unfavourable conditions leading to
microbial growth
Peri-domestic Flies, rodents, birds
pests
Retail Infected handlers Infected workers
Fomites Equipment, surfaces, clothes
Peri-domestic Flies, rodents, birds
pests
Store conditions Lack of cold storage
Home Inappropriate Temperature
storage
Cross Use of nonfood-grade containers, lack of hygiene in
contamination handling
Insufficient Kitchen surfaces, lack of stove or fuel
heating
Source: Adapted from Grace 2017.

markets tend to be made up of a diversity of small, medium, and large enter-

prises with lower rates of attrition, more systematic inspection and reporting,
and more coherent links between actors within the chain. The capacity to man-
age food safety clearly differs across value chains, with consequences for the
exposure of the consumers they serve to foodborne hazards.
Consumers can also be exposed to foodborne hazards through imported
food that flows into domestic value chains. For this food, much of the value
chain lies beyond the importing country, such that the degree to which con-
sumers are exposed to food safety hazards is essentially an issue of preborder,
border, and postborder controls, whether applied by governments or busi-
nesses operating in the trade and distribution of food.
The exposure of domestic consumers to food safety hazards can have sig-
nificant economic and social outcomes. FBD contributes to the incidence
of malnutrition and erodes food security. The burden of FBD, including the

Why Safe Food Matters to Economic Development 13

 BOX 1.3 Dietary Changes in Low- and Middle-Income Countries

Many low- and middle-income countries, especially middle-income countries,

have seen profound and rapid changes to the structure of diets in recent decades.
Figure B1.3.1 shows the change in diet in urban Indonesia from 1998 to 2013. Over
this period, the expenditure share on cereals (mainly rice) declined appreciably,
while expenditures on prepared food and beverages more than doubled, from
13 percent to 31 percent.
More profound changes to the structure of diets in low- and middle-income
countries are expected. In Southeast Asia, for example, it is predicted that more
than half the daily calorie intake will continue to come from cereals in 2030, but
with much more diversified sources of food contributing to energy, protein, and
fat requirements (Jamora and Labaste 2015). While rice and beef consumption
are expected to decline in per capita terms, strong demand growth is expected in
fruit and vegetables, pork and poultry, dairy products, edible oils, and cereals. This
will be reflected in individual diets and in expected aggregate national volumes
(figure B1.3.2).
Similar patterns are expected among LMICs more generally. According to
IFPRI (2017), LMIC consumption of meat and of fruits and vegetables is expected
to grow by 24 and 25 percent, respectively, between 2010 and 2030.

FIGURE B1.3.1 Composition of Food Expenditures in Urban

Indonesia, 1998–2013
100

90

80

70

60
Percent

50

40

30

20

10

0
1998 2001 2004 2007 2010 2013
Prepared food and beverages Beverages, spices, tobacco, misc. Oils and fats
Vegetables, legumes, and fruits Fish, meat, eggs, and milk Cereals, tubers

Source: BPS-Statistics Indonesia.

(Continued)

14 THE SAFE FOOD IMPERATIVE

BOX 1.3 Dietary Changes in Low- and Middle-Income Countries
(Continued)

FIGURE B1.3.2 Estimated Food Demand in Southeast Asia, 2009

and 2030
180
160
Kilocalories per capita per day

140
120
100
80
60
40
20
0
ce

at

ls

ts

es

ls
y
rk

ilk
ui
tr
aiz

vin

Fis
ea

oi
ea
he

bl
Po
Ri

M
Fr
ul
er
M

ta
m
Bo

le
W

Po

ge

ib
C

er

Ed
Ve
th
O

2009 2030

Source: Based on Jamora and Labaste 2015.

costs associated with premature mortality and morbidity, erodes employment

and incomes, with consequences for the rate of economic growth and the inci-
dence of poverty. Furthermore, the performance of a­ gri-food businesses can be
affected; for example, through loss of consumer trust and the erosion of investor
confidence, with consequences for the flow of revenues to governments and sec-
ondary impacts on employment and incomes.

THE FOOD SAFETY LIFE CYCLE

While food safety is both a major challenge and an opportunity for all countries,
the prominence of food safety issues and their specificity varies significantly
among countries. The evidence generally shows that FBD and the incentives for
enhancing food safety management capacity vary systematically with the level
of economic development. Figure 1.2 presents an indicative profile, or life cycle,
of the burden of FBD and failures in relation to countries according to the
level of economic development. Four broad stages are presented, from lowest
to highest.2 It is important to note that not only does the scale of the burden of
2
The precise path of the life cycle will differ among countries in terms of the rate of the incline or
decline and the curvature of the turning points.

Why Safe Food Matters to Economic Development 15

 FIGURE 1.2 Food Safety Life Cycle with Levels of Economic
Development
Traditional Transitioning Modernizing Postmodern
Food safety economic burden

Level of economic development

Source: World Bank.

FBD differ quantitatively at these different stages, but the sources of foodborne
hazards also change, as summarized in table 1.2.

Traditional Stage
In most low-income countries where many food safety problems are emerging
(the traditional stage in figure 1.2), both the supply of and demand for safe food
remain underdeveloped, and traditional concerns about national and household
food security are paramount. Often, the process of diet transformation has barely
commenced or is found only in very isolated urban clusters. The diet predomi-
nantly consists of starchy staples produced domestically. A lot of food is pro-
duced close to the point of consumption and undergoes limited transformation
before reaching households. The predominant FBDs come from microbiologi-
cal pathogens resulting from low access to clean water and improved sanitation,
and naturally occurring toxins, such as mycotoxins. Domestic market drivers
or incentives for safer food are often weak. Food safety management systems in
low-income countries tend to be rudimentary, with instances of more developed
systems being usually geographically concentrated and focused; for example, on
high-income consumers (among whom the willingness to pay for safer or certi-
fied food might be strong). The agri-food exports of many low-income countries
either center on commodities considered to have modest food safety risks (bever-
age crops) or involve cross-border movements into countries with similarly lim-
ited food safety management capacities. For higher-value exports, oases of strong

16 THE SAFE FOOD IMPERATIVE

 TABLE 1.2 Sources of Foodborne Hazards by Stage of the Food
Safety Life Cycle
Foodborne Stage of food safety life cycle
hazard Traditional Transitioning Modernizing Postmodern
Naturally occurring Significant Significant Moderate Minimal
food toxins
Livestock Major Significant Significant Minimal
zoonoses
Microbial Moderate Major Significant Moderate
pathogens
Veterinary drug Minimal Moderate Moderate Minimal
residues
Pesticide residues Minimal Moderate Moderate Minimal
Industrial Minimal Moderate Moderate Minimal
contaminants
Food adulterants Minimal Moderate Moderate Minimal
Aquatic zoonoses, Moderate Significant Moderate Minimal
parasites, and
toxins
Contaminated or Moderate Significant Moderate Minimal
adulterated feed
Food additives Minimal Moderate Moderate Minimal
Heavy metals Minimal Moderate Significant Minimal
Source: World Bank.

food safety management capacity, usually built around a limited set of lead firms
and designated “competent authorities,” may emerge, but these tend to be sepa-
rated from domestic systems.
In terms of figure 1.1, the predominant outcome of FBD in low-income
countries may be through impacts on malnutrition, food security, and poverty.
These stem from widespread environmental health challenges and low levels of
food safety awareness and capacity in the predominant informal food distribu-
tion channels. While impacts on incomes and employment may be significant
within the informal economy, secondary consequences, in terms of govern-
ment revenue or investor confidence, are likely to be very limited.

Transitioning Stage
Countries reaching lower-middle-income status have a broader range of and steeply
accelerated exposure to food safety hazards. They fall within the transitioning stage
of the food safety burden life cycle shown in figure 1.2. For these countries, diets
are rapidly transforming beyond starchy staples toward a wider array of plant and
animal source foods. In addition, more foods are consumed in processed form and
outside the home. As populations become increasingly urbanized, the distances

Why Safe Food Matters to Economic Development 17

 between food production and consumption tend to increase; and as supply chains
elongate, they also tend to involve more processes and intermediaries. The intensi-
fication of farm production often involves the increased use of agrochemicals and
veterinary drugs. Food imports, including perishable foods, often increase, expos-
ing domestic consumers to new foodborne hazards of a microbiological, chemical,
and physical nature.
During the transitioning stage, as shown in figure 1.2, agri-food value
chains begin to evolve, although the emergence of the formal sector and more
organized value chains tend to be geographically concentrated, predominantly
in urban areas. Most domestic markets continue to be served by the informal
sector. The modern retail sector gradually emerges, but with a focus on urban
markets for packaged and processed foods (box 1.4). Overall, food safety man-
agement systems remain underdeveloped. Where centers of enhanced food
safety capacity exist, they predominantly serve export and urban middle-
class markets. Very quickly, the domestic regulatory apparatus becomes over-
whelmed by the rising range and incidence of FBD. And because government
administrative systems change slowly, it is common to see food safety manage-
ment capacity being ineffectively used at this stage.
The slow development of food safety management systems in the transitioning
stage reflects the weak incentives for investment in these systems in the public and

BOX 1.4 The Link between Supermarket Penetration and Income

per Capita

The rapid spread of modern food retailing in Europe and Latin America led to
predictions that this model of food distribution would soon predominate (Reardon
and Gulati 2008; Reardon, Timmer, and Minton 2012). Supermarkets and other
large format outlets have indeed experienced considerable growth in many emerg-
ing markets and low-and middle-income countries, reflecting the fairly strong
relationship between income per capita and the penetration of more modern food
retail formats.
More traditional modes of food distribution remain the predominant outlet
in many low- and middle-income countries, especially for fresh produce, meat,
and fish. Small convenience stores, meanwhile, have often undergone some of the
most rapid growth in the “modern” food retailing segment, as seen in Indonesia
(Minot et al. 2015). Here, modern retailing accounts for more than half of urban
food spending for many processed foods, yet for less than 5 percent of spending
on rice, fish, poultry, tofu, and most vegetables. Shopping in modern food outlets
is highly correlated with incomes. It accounts for one-third of food expenditures
among the highest-income decile, yet only 8 ­percent in the fifth decile and 4 percent
in the poorest decile. Ironically, there is also a tendency to return to more direct
food sourcing at high incomes; for example, through farmers’ markets, home deliv-
ery, and direct purchases from farms. Moreover, e-commerce is beginning to make
inroads into retail food markets.

(Continued)

18 THE SAFE FOOD IMPERATIVE

BOX 1.4 The Link between Supermarket Penetration and Income
per Capita (Continued)

FIGURE B1.4.1 Link between Supermarket Penetration and per

Capita Income
100 Canada United States
Supermarket share of retail food sales (%)

Japan
New Zealand
80
Malaysia Chile Hong Kong SAR, China
Taiwan, China
Mexico Australia
60
Thailand
Ecuador Colombia
40
Indonesia Korea, Rep.
20 Philippines
Peru
China R2 = 0.67
Vietnam

0 $10,000 $20,000 $30,000 $40,000

GDP per capita, 2004 (PPP)

Source: Pacific Economic Cooperation Council 2007.

Note: PPP = purchasing power parity.

private sectors. The polity is slow to respond to the growing burden of FBDs, largely
reflecting the inadequacy of surveillance systems, such that the scale and rate of
change in the prevalence of FBDs is largely unknown. There is little incentive to
allocate scarce public resources to tackle a problem whose impact is largely invis-
ible and predominantly affects the politically weak, such as the poor. Furthermore,
market-based incentives are largely missing, except among urban elites. Consumer
awareness and concerns about food safety grow (along with increased social media
attention), and some consumers are willing to pay extra for food they perceive to
be safer (box 1.4). But most consumers continue to focus on value rather than
quality in the food they buy. This, and the credibility of “safe food” claims, inhibit
private investment in enhanced food safety management systems.
First movers are not always rewarded, especially in circumstances where
lower cost and an agile informal sector are prominent, if not dominant. Even so,
larger branded food companies will increasingly recognize the business case for
investing in improved food safety in their operations and supply chains. But it
could take a long time before incentives emerge for investing in enhanced food
safety management systems directed at markets serving the poor. So, although
levels of investment in enhanced food safety management systems begin to be
observed, these tend to be predominately focused on oases that have little or no
impact on the broad population.
Lower-middle-income countries often experience an expansion and
diversification in their agri-food exports that target both high-income and

Why Safe Food Matters to Economic Development 19

 regional-peer countries. Safety-sensitive, high-value foods may feature more
prominently, and many more actors of varying sizes and capabilities test their
skills and luck to compete in this trade. This may be reflected in a mixed picture
of quality management and compliance with trade-partner regulatory or pri-
vate standards. Concerns about compliance costs, unfair treatment, and other
real or alleged problems tend to come to the fore in these emergent industries.
Figure 1.2 reflects the expectation that countries will experience the highest
economic burden of FBD when they transition from lower-middle- to upper-­
middle-income status. In these countries, consumers will be exposed to a wide
range of foodborne hazards as the coexistence of formal and informal markets
sends mixed signals to public and private actors to invest in food safety con-
trols. But eventually, as political pressure for change intensifies and awareness
and capacity begin to catch up with underlying needs, this burden will peak
and start to decline.
During the transitioning stage, food imports often become more prominent,
as do exports of higher-value products that are food-safety-sensitive. The eco-
nomic and social outcomes of FBD begin to multiply and extend across the net-
work of links shown in figure 1.1. Thus, the burden of FBD increases in terms of
the costs of medical care and loss of productivity associated with morbidity and
premature death. The impact on businesses of food safety failures becomes more
significant, both through the erosion of consumer and investor confidence and
interruptions in trade flows. Secondary impacts may be more significant through
the loss of employment and incomes and lower government revenues. At the
same time, the direct impacts on malnutrition and food security may decline,
reflecting more powerful and broad-based processes of economic development.

Modernizing Stage
The modernizing stage shown in figure 1.2 is characterized by the increasingly
rapid upgrading of food safety management systems in the public and private
sectors. Because of administrative change and public investment, regulatory
systems become more effective at establishing and enforcing minimum food
safety standards, and at promoting and facilitating upgrades in food safety
management systems in the private sector. More effective surveillance systems
also highlight the burden of FBD, helping the problem gain recognition and
making the benefits of upgrading food safety management systems more appar-
ent. Simultaneously, the public administration of food safety becomes more
efficient, and is able to respond to the needs and demands of s­takeholders.3
All these changes foster greater public trust in the ability of the agri-food sys-
tem to deliver safe food (box 1.6).

3
By improving tax revenue, governments have access to more of the resources needed to invest
in enhancing food safety management systems in the public sector, and to provide incentives for
private investment (or to defray the risks that private investors face). Internationally, government
institutions are becoming more involved—and to greater effect—in food safety governance, includ-
ing through the Codex Alimentarius and the World Trade Organization.

20 THE SAFE FOOD IMPERATIVE

BOX 1.5 Consumer Willingness to Pay for Food Safety

Many consumers in low- and middle-income countries value food safety and,
hypothetically at least, show a willingness to pay (WTP) a premium for what they
perceive to be safer food. And there is evidence for this, with studies in Asia on
WTP for food safety showing the following:

• Studies in China found that consumers were willing to pay a premium for foods
with a “safe food” label (multiple sources in Yan 2011). Tian, Yu, and Holst
(2011) found that Chinese consumers were willing to pay a premium of 25–50
percent for “green food.” Revell (2016) found that consumers in Beijing were
willing to pay 20–40 percent more for certified chemical-residue-free products,
and many other studies have likewise found that Chinese consumers are pre-
pared to pay more for certified foods, including for food safety reasons.
• Studies in Vietnam found that consumers were willing to pay 10–15 percent
more for “safety-labeled free-range chicken” (Ifft, Roland‐Holst, Zilberman
2012), and an average of 60 percent more for certified chemical-residue-free
greens (Mergenthaler, Weinberger, and Qaim 2009).
• Wongprawmas, Canavari, and Waisarayutt (2014) found that Thai consumers
were willing to pay 117–180 percent more for food with safety labels.
• Birol et al. (2015) found that Mumbai consumers were willing to pay more for
grapes described to them as having safe-food certification.
In all these studies, trust in labels is a key contributing factor. The actual behav-
ior of consumers often diverges from their stated WTP, and many of the higher pre-
miums reported in these studies are unlikely to be realized. The WTP is estimated
more precisely when real alternatives are presented, and consumers make decisions
under their usual budget constraints.
Shogren et al. (1999) compared the WTP for food safety across different valu-
ation methodologies, including a direct market experiment for safer poultry meat
in the United States. Their results were similar across methods, but actual market
behavior revealed the smallest premium for food safety, suggesting that nonmarket
methods, such as surveys, may overestimate the potential WTP. In that experiment,
the lowest market premium was still greater than the cost of providing safer food,
so the certified process was profitable. Even if some of the larger WTP premiums
found in the Asian studies could be obtained in the marketplace, they would be
competed away over time since they are probably greater than the cost of producing
safer food products.
The gap between stated and actual WTP may be explained by multiple factors,
including poor study design. Even so, some generalizations are possible from the
literature on this issue. Consumers consistently express a desire for safer food and
place a positive value on this. The WTP increases with income and varies with
socioeconomic factors, such as education and gender. This willingness also depends
on the credibility of safe food claims and on consumers’ perceived subjective risk,
which may differ from objective risk. Leveraging the WTP by providing consistent
and credible certification can be one approach to incentivize food safety improve-
ments, and this is discussed in chapter 4.

(Continued)

Why Safe Food Matters to Economic Development 21

 BOX 1.5 Consumer Willingness to Pay for Food Safety (Continued)

As markets develop, consumers begin to expect safe food as a matter of course,

and thus market incentives more often punish food safety failures rather than
reward safer food. Negative market incentives after these failures take the form of
lost sales or brand reputation, as well as lost equity value for larger firms. These
negative incentives are more important in modernizing economies than in tradi-
tional ones.

The modernizing stage is also characterized by a profound and often rapid

restructuring of agri-food value chains. Formal sector enterprises come to
dominate in both urban and rural areas, and the modern retail sector expands
and extends into smaller urban centers and rural areas. Modern retail comes to
play a more dominant role beyond processed packaged foods, including in the
fresh produce and fresh and semiprocessed animal product sectors. The food
service sector begins to emerge and, at later phases of modernization, expands
rapidly in urban areas. The branding of food becomes more widespread and
even becoming the dominant basis of food marketing and consumer choice.
As businesses become better organized, both as individual enterprises and col-
lectively across sectors, they are able to exert greater pressure on government to
take actions to enhance public food safety management systems.4
Overall in the modernizing stage, the significant enhancement of food safety
management systems translates into a lower FBD burden. The rate of decline
will reflect the appropriateness, efficacy, and efficiency of the enhancement of
food safety management systems. The direction of investments in these systems
will reflect the size of market-based and political incentives. Everything else
being equal, the role of market-based incentives will probably become more
important as consumers are more aware of the potential hazards associated
with the food they eat. Furthermore, the “voice” of middle-income consumers
and eventually low-income ones will get louder through both market and polit-
ical channels, such that more investment in the enhancement of food safety
capacity will be directed at the supply of foods to poorer parts of the popula-
tion. Among countries at the modernizing stage, either advanced food safety
management systems are adopted by smaller exporting enterprises or exports
become consolidated among a limited pool of larger companies with modern
facilities that broadly apply international standards.
At this stage, the economic and social outcomes of FBD result predominantly
from failures in managing food safety risks in the formal sector directed at domestic
and external consumers. The direct burden of FBD, through medical care costs and
4
Businesses also face market pressure to improve the safety of their products, as consumers
become more aware of FBDs and are increasingly able and willing to pay for food they judge to be
safer—and suppliers begin to differentiate their products in the eyes of the consumer on the basis
of food safety. Thus, broader applications of good agricultural and manufacturing practices, hazard
analysis, and critical control points are observed, driven by proactive businesses that yield the pri-
vate gains necessary to incentivize innovation in their food safety management systems.

22 THE SAFE FOOD IMPERATIVE

BOX 1.6 Personal and Institutional Trust in Food Safety Systems

Trust is an intangible yet vitally important element of a food safety system. The range
and depth of trust affect relationships among multiple stakeholders and strongly
influence their behavior. The degree of trust strongly influences the relationships
between, for example, (1) consumers and food vendors, (2) food manufacturers and
their raw material suppliers, (3) consumers and food business operators and public
regulatory authorities, (4) exporters and overseas buyers, and (5) public regulatory
agencies in different countries. Important attributes of a trustworthy food safety
system include competency, transparency, and accountability (WHO 2018).
In traditional and localized food systems, trust tends to be highly personal-
ized. Transactions tend to be repetitive among individuals with whom there may
be wider social ties and a sense of moral obligation. As food systems become more
complex, trust becomes more institutionalized as interactions increasingly occur
among formal institutions, including producing firms, labeling schemes, state agen-
cies, and scientific establishments.
Institutionalized trust relies on, among other things, formal regulations, pack-
aging, brands, and labels. Repeated interactions of the same individuals may hap-
pen less frequently, or repeated interactions may become less personal because
consumers know that providers are acting as representatives of their institution.
Institutionalized trust is more conditional and hence more vulnerable than per-
sonalized trust.
Public organizations gain consumer trust by applying results from scientific
research, and by involving various types of experts (legal, scientific, and adminis-
trative, for example). Private organizations gain trust through brand development,
marketing practices, participation in certification schemes, and corporate social
responsibility programs, where they try to show that human interest is not subser-
vient to short-term profit considerations. Trust in nongovernment and consumer
organizations comes from their absence of commercial interests and expertise in
developing standards, information campaigns, and consumer guides. Trust in food
is generally stable because food consumption behavior is highly routinized (that
is, people buy the same food from the same places). But this can be disrupted by
lifestyle changes and food safety scares that cause routines to be changed (Kjaernes,
Harvey, and Warde 2007; Zhang et al. 2016).

productivity loses, are high, even though the overall incidence of disease may be
declining. Likewise, the costs of consumer market or trade disruptions and product
recalls may be considerable. Secondary outcomes on businesses and the economy
may also be high, although links between FBD, malnutrition, and food security will
generally weaken among countries in the modernizing stage.

Postmodern Stage
Eventually, the burden of FBD declines to much lower and relatively stable lev-
els in the postmodern stage, as figure 1.2 shows, at which point any further
improvements in the safety of food occur in smaller increments. While differ-
ences persist in the prevalence of particular FBDs across high-income counties,
improvements in the aggregate and for particular hazards are slow, especially

Why Safe Food Matters to Economic Development 23

 compared with those observed among a rising number of middle-income
countries. This new equilibrium reflects the fact that both market-based and
political incentives for improved food safety management capacity remain high
and that agri-food value chains are complex. Also reflected in the new equilib-
rium is that a significant proportion of food is imported, and that “easy wins”
from improved capacity will be few. In the postmodern stage, periodic food
safety lapses will occur and FBD outbreaks will attract a lot of attention. But the
high quality of health services in most high-income countries leads to a situa-
tion in which deaths attributable to FBD are comparatively rare.
Table 1.3 summarizes the conditions associated with the different stages of
the food safety life cycle, as shown in figure 1.2. The table highlights the degree
to which the agri-food sector has transitioned from the informal to the for-
mal sector, and the degree of dietary transformation beyond traditional staples.
The level and nature of market-based and political incentives for upgrading
food safety management capacity—which underlies the shape of the life cycle
in ­figure 1.2—is not only the level and nature of foodborne hazards but also the
extent to which there are incentives for investment in food safety management

TABLE 1.3 Structural Change and Incentives for Enhanced Food

Safety Action
Stage Agri-food Diet trans- Market- Political Level and direction
(income sector formation based incentives of investment
level) formaliza- incentives in food safety
tion capacity
Traditional Very low Very low, Very low Low Low, with exceptions
(low) except in, of islands or
relation to corridors of capacity
trade for export
Transitional Low Moderate Generally Medium Low but increasing,
(lower but low, but and with a focus on
middle) accelerating with market major exports and
fast segment urban high-income
exceptions consumers
and in relation
to trade
Modernizing Medium Medium Medium and High Medium and rapidly
(upper accelerating increasing, both for
middle) fast the domestic market
and a broader set of
export industries.

Postmodern High High High High High and stable,

(high) with a predominant
focus on domestic
consumers overall

Source: World Bank.

24 THE SAFE FOOD IMPERATIVE

systems in response to changes in these hazards. This points to the gap that
opens between prevailing capacity and the food safety burden faced by certain
countries, especially at the transitional and modernizing stages.

SUMMARY

This chapter has shown how safer food supports economic development and
the SDGs by improving health and economic opportunity. The specific chal-
lenges of tackling food safety in the process of economic development come
from the market failures associated with providing safer food and the need
to work with all food value chain actors to achieve solutions. This chapter has
outlined a model of a food safety life cycle that creates a gap between need and
capacity as economies develop. The transformation of the food system dur-
ing the process of economic development leads to a food safety life cycle for
LMICs in which the socioeconomic burden of food safety increases as coun-
tries pass from the low- to middle-income stage. As part of this life cycle, there
is a lag in the public and private response to emerging food safety challenges.
Understanding the evolution of food safety needs during economic develop-
ment sets the stage for examining the costs of food safety and the state of man-
agement capacity in the following chapters.

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the United States of America 109 (31): 12332–37. https://doi.org/10.1073/pnas.1003 160108.
Revell, B. 2016. “Urban Consumer Attitudes to Fresh Produce Safety in China.” Journal of
Food Science and Engineering 6 (1).
Shogren, J. F., J. A. Fox, D. J. Hayes, and J. Roosen. 1999. “Observed Choices for Food Safety
in Retail, Survey, and Auction Markets.” American Journal of Agricultural Economics
81 (5): 1192–99.
Tian, Xu, Xiaohua Yu, and Rainer Holst. 2011. “Applying the Payment Card Approach to
Estimate the WTP For Green Food in China.” IAMO Forum No. 23, Leibniz Institut
für Agrarentwicklung in Mittel- und Osteuropa, Halle, Germany. http://hdl.handle​
.net/10419/50786.
Wongprawmas, Rungsaran, Maurizio Canavari, and Chutima Waisarayutt. 2014. “Are Thai
Consumers Willing to Pay for Food Safety Labels? Choice Experiment on Fresh Produce.”
Presentation at the European Association of Agricultural Economists Congress, “Agri-
Food and Rural Innovations for Healthier Societies,” Ljubljana, Slovenia.
WHO (World Health Organization). 2018. Regional Framework for Action on Food Safety in
the Western Pacific. Manila: WHO.
Yan, Y. 2011. “Willingness to Pay for Safer Dairy Products in China: Evidence from Shanghai
Customers’ Purchasing Decision of Bright Dairy’s Baby Cheese.” Nanjing Agricultural
University. https://getd.libs.uga.edu/pdfs/yan_yiwei_201408_ms.pdf.
Zhang, Lei, Yunan Xu, Peter Oosterveer, and Arthur P. J. Mol. 2016. “Consumer Trust in
Different Food Provisioning Schemes: Evidence from Beijing, China.” Journal of Cleaner
Production, Special volume: Transitions to Sustainable Consumption and Production in
Cities 134 (October): 269–79.

26 THE SAFE FOOD IMPERATIVE

 C H A P T E R T WO

Evidence on the Burden of

Unsafe Food in Low- and
Middle-Income Countries

INTRODUCTION

A
large body of literature provides evidence of the considerable
­economic costs associated with foodborne disease (FBD) (for exam-
ple, Hoffmann, Maculloch, and Batz 2015; Thomas et al. 2013; Mangen
et al. 2014). While most of this literature relates to high-income countries, rec-
ognition is growing that the costs of FBD in low- and middle-income countries
(LMICs) are also significant (Grace 2015). As the life cycle concept introduced
in chapter 1 suggests, the costs associated with FBD vary both quantitatively
and qualitatively according to a country’s stage of economic development.
In countries at lower levels of economic development, the economic costs of
FBD tend to focus on informal domestic food markets. As countries grow and
transform, food safety comes to play an important role in the performance of
businesses in the formal sector, especially for agri-food exports. And here the
costs associated with FBD become more visible, in line with growing economic
development. Critically, the degree to which these costs change over time
depends on how well emerging food safety challenges are managed.
FBD involves two distinct categories of costs. The first is associated with
the public health impacts of unsafe food, including the costs of medical care
and productivity losses from ill-health and premature death. The second is the
economic and social impacts of food safety failures on consumers, businesses,
and the economy as a whole. Examples of economic impacts include reductions
in agri-food exports and the deleterious effects on business performance. This
chapter examines both categories of costs in LMICs.

27
 THE PUBLIC HEALTH BURDEN OF FOODBORNE DISEASES

The starting point for an analysis of the economic costs of FBD is to examine
the associated burden of illness—how many people get sick, how often, and
how seriously.1 Until recently, data on the incidence of FBD and its associated
costs were limited to high-income countries and regions, including Canada,
parts of Europe, and the United States (Scallan et al. 2011; Thomas et al. 2013;
Havelaar et al. 2012; Adak et al. 2005). To address this gap, the World Health
Organization’s (WHO) Foodborne Disease Burden Epidemiology Reference
Group (FERG) has been working since 2006 on global estimates of the inci-
dence of FBD.2 These estimates cover 31 foodborne hazards in 14 regions,
and are expressed in disability-adjusted life years (DALYs) associated with
ill-health and premature death, with 2010 as the base year.3 To prepare this
report, the authors had access to FERG estimates of the DALYs associated with
FBD for regions and for selected countries, with distinctions made between
persons ages above and below five.
The total global burden of FBD in 2010 is estimated at 33 million DALYs,
the result of 600 million illnesses and 420,000 premature deaths (table 2.1). As
a basis for comparison, in 2015 the estimated global burden of tuberculosis was
40 ­million DALYs, and of malaria, 66 million DALYS. These estimates starkly
illustrate the magnitude of the burden associated with FBD—a finding that is
given further credence because FERG estimates are conservative.4
Of the total global burden due to FBDs, over 90 percent of illnesses are
estimated to be related to diarrheal disease. These cases, however, account
for a much smaller proportion of premature deaths due to FBDs (55 percent)
and of the total loss of DALYs (54 percent). Invasive disease accounts for only
6 ­percent of cases of illness due to FBD, but 28 percent of premature deaths.

1
Many LMICs lack robust data on the incidence of FBD. While the most reliable data are derived
from systems of active surveillance, these are lacking in most LMICs, especially in low- and lower-
middle-income countries. Passive systems for reporting FBD cases and outbreaks can provide an
indication of incidence, but these are typically a small proportion of the total cases, the majority of
which occur sporadically within a population. And even these systems of case reporting tend to be
underdeveloped in many LMICs.
2
Other sources of global disease-burden estimates include WHO’s Global Health Estimates and
its Childhood Epidemiology Reference Group, and the Institute of Health Metrics and Evaluation.
A direct comparison of FERG results with these sources is difficult because of differences in meth-
ods and assumptions that may have an important effect on FBD-burden estimates.
3
One DALY can be thought of as one lost year of “healthy” life. The sum of DALYs across a popu-
lation is a measure of the burden of disease, and can be thought of as a measurement of the gap
between current health status and an ideal health situation where the entire population lives to an
advanced age, free of disease and disability. Estimates of DALYS encompass losses due to prema-
ture death and the loss of health status due to illness. For how DALYs are calculated, see http://
www.who.int/healthinfo/global_burden_disease/metrics_daly/en/.
4
For example, the incidence of illness associated with chemical hazards was underestimated in
earlier FERG work. Because of data limitations, only four chemicals (aflatoxin, dioxin, cassava
cyanide, and peanut allergens) were included in the FERG study. New estimates have been made
and are expected to be published in late 2018.

28 THE SAFE FOOD IMPERATIVE

 TABLE 2.1 Estimated Global Burden of Disease by Food-Related
Hazards
Hazard group Illnesses Deaths DALYs
(millions) (thousands) (millions)
Food- All Food- All Food- All
borne pathways borne pathways borne pathways
All hazards 600 2,050 420 1,170 33 83
Diarrheal disease 549 1,910 230 780 18 59
Invasive disease 36 98 117 380 8 21
Helminths 13 28 45 53 6 7
Chemicals 0.2 0.2 19 19 0.9 0.9
Source: Havelaar et al. 2015.
Note: DALY = disability-adjusted life year.

FIGURE 2.1 The Global Burden of Foodborne Disease by Hazard

Group and Region, 2010
20

18

16
Number of incidents (millions)

14

12

10

0
Asia Africa Other developing Developed
Other toxins Aflatoxins Helminths Microbial

Source: Derived from Foodborne Disease Burden Epidemiology Reference Group estimates.

Globally, Asia and Sub-Saharan Africa have the highest incidence of FBD,
along with the highest rate of deaths due to FBDs and the greatest loss of
DALYs. LMICs in South Asia, Southeast Asia, and Sub-Saharan Africa are esti-
mated to account for 53 percent of all illnesses due to FBD, 75 percent of deaths,
and 72 percent of DALYs related to FBD (figure 2.1). To put these estimates

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 29

 into context, these countries account for 41 percent of the global population.
Diarrheal disease accounts for a large proportion of the total burden of FBD in
these countries.
Children under five years bear a disproportionate share of the burden of
FBD, accounting for 9 percent of the global population, but 38 percent of all
cases of illness and 40 percent of DALYs. An estimated 30 percent of premature
deaths due to FBD are of children under age five. Children are more exposed to
foodborne hazards because of their lack of control over food preparation and
a propensity to behaviors that increase the risk of FBD. Children are more vul-
nerable to the consequences of infection because of their developing immune
systems, small body size, and lower levels of stomach acid, among other fac-
tors.5 Geographically, children are most likely to die from FBD in Sub-Saharan
Africa, followed by South Asia.
An important question is whether vulnerable consumers, and especially the
poor, can reduce their exposure to food safety risks since, as just discussed,
the burden of FBD falls disproportionately on the poor and the young. Many
studies have found that the poor underinvest in preventive health care (for
example, Lucas 2010 and Ozier 2014), and that those who stand to benefit most
from preventive action, including avoiding food with high food safety risks, are
excluded by higher prices. Thus, consumers who are more susceptible to FBD
tend to take on a higher level of risk than is optimal. Furthermore, a differenti-
ated market may lead to hazardous food being concentrated in markets for the
poor. This is an important challenge for market-incentive efforts to improve
food safety.
Almost 80 percent of the burden of FBD is associated with microbial patho-
gens. These are estimated to account for 580 million cases of illness, 450,000
premature deaths, and the yearly loss of over 25 million DALYs. The most
important microbial pathogens are Salmonella spp., toxigenic E. coli, norovirus,
and Campylobacter spp. Foodborne macroparasites are also a significant cause
of disease, notably in LMICs. These include tapeworms (particularly pork tape-
worm, a cause of epilepsy), fish-associated fluke, and roundworms.
For risk management, it is important to have detailed information on which
foods are involved in the transmission of FBD. Unfortunately, very little infor-
mation on this is available for most countries and regions. A FERG expert
elicitation process sought to attribute the FBD burden to different product
categories, although that study involved only 11 of the 31 foodborne hazards
included in FERG’s assessment (Hoffmann et al. 2017). These hazards, how-
ever, account for less than half (43%) of the total estimated DALYs. The analy-
sis concluded that several hazards are predominantly attributable to vegetables
and fruit, typically with a two-thirds and one-third weighting, respectively.

5
The elderly are also more vulnerable to FBD because of deteriorating immune systems and chronic
conditions. People with primary immune deficiencies, such as a low production of antibodies, are
prone to foodborne infections. Patients treated with radiation or with immunosuppressive drugs
for cancer and other diseases have a higher vulnerability to FBD.

30 THE SAFE FOOD IMPERATIVE

For several other hazards, attribution was split across several animal product
lines (for example, beef, pork, dairy, poultry, and eggs). On the basis of the
scientific literature, FERG identified nine other hazards as being completely
transmitted by only one food category for each of the hazards.
Because of data limitations and the complexities of tracking the pathways of
FBD, the picture of FBD attribution to different product groups is incomplete.
In some Organisation for Economic Co-operation and Development countries,
animal products were estimated to account for half or more of the burden of
FBD, as in studies of the United States (Painter et al. 2013) and the United
Kingdom (Tam et al. 2012). Feltes, Arisseto-Bragotto, and Block (2017) esti-
mated that animal products account for more than half of the FBD burden in
Brazil. Yet, the pattern for this is likely to vary considerably among countries,
given differences in diets, industry structures, environmental health condi-
tions, and other factors. That said, the evidence suggests that animal products,
and fruit and vegetables, account for most FBD. In parts of Asia, the burden
of FBD from fish is likely to be significant.6 Current estimates attribute very
little of the global burden of FBD to cereals, although the understanding of this
may change with the ongoing FERG analysis of chemical hazards. Especially in
Africa but also elsewhere, there are widespread concerns over the short- and
long-term health effects of aflatoxin exposure (box 2.1).
In collaboration with this report, FERG researchers undertook further
detailed analyses of FBDs that can be attributed to animal source foods. The
FERG team determined that 14 hazards are closely linked to FBD from animal
source foods. Based on the available data, estimates for loss of DALYs from
this source were made for more than 100 countries (figure 2.2). While FERG’s
FBD estimates are for the year 2010, countries are mapped according to average
income levels in 2016 because this better reflects today’s situation.
The enormous variation among countries, including within regions, is
immediately evident from figure 2.2. For this sample of countries, there is
very little difference in the unweighted average share of animal source foods
in total DALYs among regions. The regional averages range from 40 percent
in the Middle East and North Africa, and in Eastern Europe, to 49 percent in
Latin America and the Caribbean. The difference is even less in group aver-
ages among low- (43.6%), lower-middle- (42.5%), and upper-middle-income
(43.2%) countries. Intercountry comparisons, however, show large differences.
Within Sub-Saharan Africa, Ethiopia, Kenya, and Nigeria have similar levels of
meat consumption per capita, but the DALYs attributed to animal source foods
differ by nearly a factor of three. As a result, the shares of animal source foods
in the total DALYs for these countries are estimated at 21 percent (Ethiopia),
40 percent (Kenya), and 43 percent (Nigeria).

6
Throughout Southeast Asia and China, eating raw or partially cooked cyprinid fish is common
and an important source of hazards from fish-borne zoonotic trematodes. Seafood poisoning from
marine toxins is also a significant and increasing problem in Asia, resulting in tens of thousands of
cases of illness annually.

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 31

 BOX 2.1 Aflatoxins, Staple Crops, and Public Health

Aflatoxins are naturally occurring toxins produced by certain fungi, most impor-
tantly Aspergillus flavus and Aspergillus parasiticus. In high doses, aflatoxins can lead
to serious illness and even death in humans and animals. Aflatoxins mainly accu-
mulate on crops and grains in tropical regions and contaminate a wide variety of
food crops and products, including maize (corn), sorghum, cassava, macadamia nuts,
paprika, melon seed, sesame, rice, yam chips, and chili. Aflatoxin-contaminated feed
in dairy rations can result in aflatoxin-contaminated livestock products. Children can
be affected by aflatoxin through breast milk or from the direct consumption of wean-
ing foods (Mahdavi et al. 2010). The Food and Agriculture Organization estimates
that 25 ­percent of the world crop area is affected by aflatoxins; the U.S. Centers for
Disease Control and Prevention estimate that 4.5 billion people in the developing
world are exposed to aflatoxins.
Aflatoxins occur most frequently in dry weather when crops are near maturity,
when high moisture is present during harvest, and when crop drying and storage
are inadequate. Countries in latitudes between 40° north and 40° south are affected
by aflatoxins. Thus, Sub-Saharan Africa, South Asia, and Southeast Asia are regions
of high potential exposure to aflatoxins. Parts of the Americas also have a high
intake of mycotoxins; for example, countries with high maize daily intake, such as
Central American countries. The outbreak of aflatoxins in milk in the European
Union in 2013, traced to contaminated maize from Serbia and Romania, is an indi-
cation of the effects of drought on higher levels of aflatoxin contamination. Climate
variability and changes in climate patterns are expected to have implications for
aflatoxin production—and ongoing research is trying to understand these implica-
tions. The health impacts of aflatoxins are a result of exposure, which is determined
by consumption patterns and the incidence of contamination; they are also influ-
enced by an individual’s weight and nutritional condition.
Acute exposure to mycotoxins can be lethal. More than 150 deaths were caused
by aflatoxin poisoning in Kenya in 2004 and 2005. Chronic exposure, however, is
more pervasive. Epidemiological studies carried out in China, Kenya, Mozambique,
the Philippines, Swaziland, Thailand, and South Africa showed a strong positive cor-
relation between aflatoxin levels in the diet and cancer (Wu, Groopman, and Pestka
2014). The synergy between exposure to aflatoxins and infection with the hepatitis
B virus substantially increases the risk of carcinoma. Every year, about 100,000 new
cases of hepatocellular carcinoma, usually always fatal, are attributable to aflatoxin
exposure (Liu and Wu 2010; Liu et al. 2012). Aflatoxins are associated with growth
retardation and immunosuppression, especially in children (Gong et al. 2002;
Khlangwiset, Shephard, and Wu 2011). Even low levels of aflatoxin in animal feed
have been found to have significant animal health implications, from reduced pro-
ductivity and fertility, liver damage, and higher susceptibility to infectious diseases.
A growing set of technological and management solutions have emerged to con-
trol aflatoxins. These include using resistant and tolerant crop varieties; applying
soil amendments; changing crop densities and the timing of planting and harvest-
ing; biological controls; and using different technologies and practices for drying,
storing, and processing crops. Other interventions may affect exposure through
dietary diversification and treatments to prevent consumers from absorbing the
toxic effects of aflatoxins. There are differential knowledge, cost, institutional, and
other constraints on adopting these solutions.

32 THE SAFE FOOD IMPERATIVE

 FIGURE 2.2 Foodborne Disease Burden Attributable to Animal Source Foods by Region
100
Region
Asia
90
Latin America and the Caribbean
Honduras Middle East and North Africa, and Eastern Europe
80
Bolivia
Sub-Saharan Africa
Liberia Kyrgyz Republic
70
Niger
Paraguay Albania
Central Turkmenistan
African Republic Azerbaijan
60 China Panama
Chad Uzbekistan
Cameroon Bosnia and Belarus
Benin Philippines Herzegovina
50 Madagascar Cambodia Colombia Brazil
Nicaragua
Congo Ghana Serbia
Dem. Rep. Côte d'Ivoire Jamaica Kazakhstan
Burundi Afghanistan Nigeria Angola Thailand
40 Kenya Belize
Tanzania Morocco Argentina
Vietnam Jordan Costa Rica
Uganda Yemen, Rep. Iran, Islamic Rep.
Lesotho Libya
Zimbabwe Sudan Egypt, Tunisia South Africa
30 Pakistan Arab Rep. Algeria Suriname
Senegal
Ethiopia Mauritania
20 India
Myanmar
Indonesia
Comoros Bangladesh Malaysia

Share of animal source food in total FBD DALYs, 2010 (%)

10 Botswana

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000 11,000 12,000 13,000
Gross national income per capita, 2016

EVIDENCE ON THE BURDEN OF UNSAFE FOOD

Source: Based on Foodborne Disease Burden Epidemiology Reference Group estimates.

33
 In Asia, Indonesia, Thailand, and Vietnam have similar levels of meat
consumption per capita, which is about three times higher than for the three
African countries. The share of animal source foods in the total FBD DALYs
for the three Asian countries also varies significantly, ranging from 17 ­percent
in Indonesia to 42 percent in Thailand. The picture for India and China appears
to be significantly different, with animal source foods estimated to account for
only 21 percent of India’s FBD burden yet nearly 59 percent of China’s. The
aggregate burden of FBD in upper-middle-income countries in Latin America
is relatively low, but the share of animal source foods in FBD appears to be
­significant—at 50 percent in Brazil and Colombia. Thus, different country cir-
cumstances need to be carefully considered when prioritizing risk manage-
ment measures, including toward different value chains.
Although FERG estimates give a snapshot of the burden of FBD globally,
they do not indicate the extent to which the burden has been changing over
time. Data from the Institute of Health Metrics and Evaluation show that
the global burden of diarrheal disease declined by 40 percent over 2006–16
(GBD 2017a). This is almost entirely due to a marked reduction in deaths
related to diarrheal disease from oral rehydration therapy and other interven-
tions, and reductions in the underlying causes of death, such as malnutrition
(GBD 2017b).
Global data on changes in the burden of FBD specifically are not avail-
able. Most high-income countries and regions, such as the United States and
European Union (EU), have not seen reductions in the incidence of most
FBDs (EFSA 2012; CDC 2018). But there is evidence that targeted interven-
tions have achieved marked reductions in the number of cases of certain FBDs;
for example, salmonellosis in the EU (EFSA 2017) and campylobacteriosis in
New Zealand (Sears et al. 2011). Against this trend, new foodborne ­hazards
have emerged, such as foodborne cases of norovirus. And the number of
reported FBD outbreaks has continued to increase in some Organisation for
Economic Co-operation and Development countries, although this probably
has more to do with improved surveillance than more outbreaks.
A key factor in the evolution of FBD in LMICs is the change in dietary
­patterns in populations and related changes in the way food is bought, pre-
pared, and consumed. Thus, the shift from starchy staples toward animal-based
foods, for example, leads to qualitative and quantitative changes in exposure to
foodborne hazards. Likewise, the degree to which consumer beliefs and norms
on food and its safety, and the extent to which these persist or change as diets
evolve, can be critical vis-à-vis the extent to which consumers expose them-
selves to foodborne hazards (box 2.2).
Climate change is another important yet less well understood long-term
factor for the spread of FBD. Changing weather patterns will affect pathogens
and their hosts in land and aquatic environments, as well as the m ­ obility of
food contaminants (Uyttendaele, Liu, and Hofstra 2015; Tirado et al. 2010;
Miraglia et al. 2009). For example, shifts in average temperatures, rain-
fall concentration, and plant geography may change the range of latitudes

34 THE SAFE FOOD IMPERATIVE

BOX 2.2 The “Good” and “Bad” Food Safety Practices of Consumers

It is important to recognize that consumers can be at risk from the food they choose
to consume and the way in which they source, store, and prepare food. And as diets
change, consumers can expose themselves to greater and different food safety risks.
Eating raw animal source foods is one of the riskiest food safety practices. Fish
and seafood products are much more likely to be eaten raw than meat (with a few
exceptions, such as beef in Ethiopia). Throughout Southeast Asia and China, eating
raw or partially cooked cyprinid fish can cause liver disease and cancer from fish-
borne zoonotic trematodes. In high-income countries, the boom in consumption of
sushi has reportedly caused a rapid rise in tapeworm infections.
Most new human diseases originate in wildlife. Creating opportunities for
humans to interact with and eat wild animals is a high risk for the emergence of
novel diseases, as well as being a risk for the transmission of known pathogens.
The most devastating pandemics in human history—the Black Death, Spanish
influenza, and HIV/AIDS—were all caused by zoonoses from wildlife, and the
emergence of major human pandemics is regularly ranked among the top existen-
tial threats to humanity.
Consumers can take measures to mitigate the potential food safety hazards they
face—for example, by properly cooking food and storing food in a way that reduces
cross contamination (for instance, between cooked and uncooked foods)—and
the rate of replication of microbial pathogens (for example, through refrigeration).
Many traditional eating practices serve this function, and often rapid changes in
diet can mean the loss of these practices and the exposure of consumers to potential
harm from foodborne disease.

at which certain strains of mycotoxin-producing fungi are able to compete

and create opportunities for new fungal toxins to emerge as a public health
concern. Climate-related changes in soil properties may favor the build-up in
crops of toxic heavy metals, such as arsenic and cadmium. Ocean warming
and changes in salinity are affecting the incidence of aquatic microorgan-
isms, such as pathogenic vibrios and harmful algal blooms that cause toxins
in consumed shellfish.
Climate change will also influence the efficacy of adaptive farming and sup-
ply chain practices, including those related to soil fertility, pests, animal disease,
and product quality management. Longer grazing seasons from a warming cli-
mate could increase the exposure of livestock to wildlife and outdoor vectors
of disease. And moving animals indoors to temperature-controlled facilities
could increase the risk of disease transmission. This, in turn, could increase
the dependence of farmers on antibiotics and other chemicals, which could
find their way into the food system (box 2.3). The disruptive effects of climate
change on agroecosystems may favor the emergence or resurgence of certain
pests, causing farmers to resort to more and harsher chemicals to control them.
This kind of “arms race” could prove problematic from a food safety perspective.
As well as the direct impacts of FBD accounted for in FERG estimates,
these diseases can have adverse impacts on nutrition. In LMICs, FBD and

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 35

 BOX 2.3 Antimicrobial Resistance and Links to Food

Antimicrobial resistance arises when potentially infectious microorganisms—­

bacteria, viruses, protozoa, and fungi—acquire the capacity to resist the antimi-
crobial agents used to treat infectious diseases. This occurs through a process of
natural selection when antimicrobials are used to prevent or treat infections, even
when these drugs are correctly used. Microorganisms with antimicrobial resistance
occur in people and animals but also in contaminated food, water sources, and,
more broadly, the environment.
Microorganisms with antimicrobial resistance can be transmitted through
various pathways, such as person-to-person contact, person-to-animal contact,
and contact with human and agricultural wastes. Food plays an important role in
the emergence and spread of antimicrobial resistance, especially in the excessive
or inappropriate use of antimicrobials in food production systems, including live-
stock, aquaculture, and crop production. The use of sanitizers and biocides may
further exacerbate this resistance.
Foodborne infections caused by resistant bacteria, such as Salmonella spp.
and Campylobacter spp., pose a particular risk to humans because of possible
treatment failure. In Europe, resistance to ciprofloxacin, an antimicrobial that is
important for treating human infections, is very high in Campylobacter spp. As
well as antimicrobial resistance in pathogens, microorganisms with this resis-
tance that do not directly pose a health risk may transmit antimicrobial-resistant
genes to microorganisms that are more serious human and animal pathogens.
For example, resistant commensal bacteria, such as E. coli and Enterococcus spp.,
can pose a risk when they carry resistance genes that can be further transferred
to pathogens.
The increasing emergence of antimicrobial resistance is creating a global public
health threat from its impacts on humans, animals, and the global economy. The
toll attributable to drug-resistant microbes is estimated at 700,000 annual human
deaths. Microorganisms with antimicrobial resistance in food are an economic risk,
because of the potential to affect market access, consumer behavior, and the cost
involved in adapting or changing farming practices to reduce the presence of resis-
tant microorganisms.
Managing the risks of antimicrobial resistance in food is complex and requires
good practices, from primary production and throughout the food chain to con-
sumption. In practice, managing the emergence and spread of microorganisms
with antimicrobial resistance through food is similar to managing other foodborne
hazards. But it requires awareness of antimicrobial resistance measures to control
microbial populations that harbor resistance determinants, and the risk factors that
exacerbate its emergence and spread. Because the use of antimicrobials is key to
resistance, the responsible use of antimicrobials is central to the management of
related risks.
Large quantities of antimicrobials are being used globally in animal production.
One study predicts that consumption could rise by 67 percent by 2030, and nearly
double in BRICS countries, essentially driven by the growing consumer demand for
animal source foods in middle-income countries and a shift to intensive production
systems where antimicrobials are used routinely (van Boekel et al. 2015).

(Continued)

36 THE SAFE FOOD IMPERATIVE

BOX 2.3 Antimicrobial Resistance and Links to Food (Continued)

In Vietnam, which uses these systems, antimicrobials are used to prevent infec-
tions and increase productivity. Because requirements for a withdrawal period are
not being complied with in Vietnam, antimicrobial residues are increasingly found
in marketed meat, which can cause allergic and other reactions and gastrointestinal
problems. For example, Nguyen et al. (2018) detected residues of sulfonamides,
tetracyclines, and macrolides in meat samples from supermarkets and traditional
wet markets, with 9.6 percent of samples from wet markets containing residues.
The improper use of antimicrobials on farms in Vietnam appears to be giv-
ing rise to multidrug resistance against major foodborne pathogens, such as
Salmonella. spp. Nguyen et al. (2018) found high levels of resistance against
quinolones and β-lactams, with the highest prevalence of multidrug resistance
detected in chicken and pork meat. Vietnam is taking steps to tackle this. It has
developed a national action plan against antimicrobial resistance, and in 2017
adopted a new regulation aimed at greatly reducing the nontherapeutic use of
antimicrobials in livestock.

undernutrition are bidirectionally related.7 Infectious FBD often manifests

as diarrhea, which is strongly associated with child stunting and vice versa
(Checkley et al. 2008; Guerrant et al. 2013; Richard et al. 2014).8 One multi-
country study found that 25 percent of the stunting burden was attributable to
repeated episodes of diarrhea (Checkley et al. 2008). Each additional diarrhea
episode in the first 24 months of life increases the risk of stunting by roughly
5 percent (Black et al. 2008). Studies find a strong peak in diarrhea after the
introduction of supplementary foods, with some weaning foods having high
levels of microbial contamination (Kumi et al. 2014). About half the burden
of infectious disease results from nongastrointestinal manifestations, which
can also cause undernutrition through reduced appetite and increased nutri-
ent requirements resulting from inflammation, infection, or other conditions
(Tappenden et al. 2013). Environmental enteric dysfunction is estimated to
contribute to 40 percent of all global cases of stunting. This has been linked to
the ingestion of fecal bacteria in food, as well as zoonotic infections (George
et al. 2015).
Aflatoxins are among the most worrying food safety hazards affecting
staple food crops and animal source food if livestock feed is contaminated.
7
See Hasler et al. (2017) for insights into the complexity of food safety and nutrition relationships,
and the differences in approaches and foci in food safety and nutritional assessments.
8
Stunting, or extreme shortness (very low height for age), is the result of a combination of chronic
poor dietary intake, both in terms of food quality and quantity, and repeated infectious disease epi-
sodes. While stunting is preventable, its impacts are largely irreversible when it occurs within the
first 1,000 days of life, a period which is critical for the physical and mental development of infants.
Long-term effects of stunting include reduced cognitive and physical development, increased mor-
bidity and mortality from common illnesses, poorer educational outcomes, and decreased produc-
tive capacity. Globally, stunting affects some 155 million children ages under five.

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 37

 These natural toxins are estimated to cause some 90,000 cases of liver cancer
each year. A growing body of research shows that high levels of aflatoxin inges-
tion is strongly associated with stunting and immune suppression in children,
although it is not yet possible to attribute causation. Grace et al. (2015) discuss
recent studies and the challenges in attributing stunting to aflatoxin. The 83rd
Meeting of the Joint Expert Committee on Food Additives of the WHO and
Food and Agriculture Organization concluded that “epidemiological data have
become available to support the hypothesis that aflatoxin exposure in utero and
during early life has negative effects on growth. . . . The available data did not
provide evidence for an exposure level at which there is a significant risk for
growth faltering” (JECFA 2017). A careful study of doctor-diagnosed children
with the most severe stunting (kwashiorkor, marasmus) suggested that daily
dietary exposures of 400–1,000 nanograms of aflatoxin per kilogram of body
weight leads to stunting (McMillan et al. 2018). Exposure at this range is not
uncommon in Sub-Saharan Africa (JECFA 2017; Wild, Miller, and Groopman
2015). For example, evidence shows that diarrheal disease is a significant factor
in the high incidence of stunting among the poor in this region. The implica-
tions are that FBD has even wider and longer-term development implications
for LMICs, and, therefore, for achieving the Sustainable Development Goals.

ECONOMIC COSTS OF FOODBORNE DISEASE

A range of potential economic costs are associated with FBD. These include the
harm caused by the disease (for example, lost productivity) and several types
of responses (for example, medical treatment and food recalls). These costs are
incurred by various economic actors, including consumers, health care pro-
viders, agri-food businesses, and governments (McLinden et al. 2014). Food
safety failures can also affect export performance, which is discussed later in
the chapter.
Valuing the costs associated with FBD is far from easy. Valuation methods
are demanding in their data requirements and subject to recognized limitations.
This is particularly the case for LMICs, where data are lacking or of poor qual-
ity. Indeed, few studies capture national data and those that do often depend on
broad assumptions or extrapolations. Despite these challenges, estimates of the
cost of FBD can provide valuable insights into the overall economic burden and
how this is distributed across society.
The approach used to estimate the economic burden of FBD is summarized
in box 2.4. Intuitively, DALYs represent years lost to illness, disability, or death,
and this loss to the economy can be crudely represented by gross national
income per capita. Using this measure, the total productivity loss associated
with FBD in LMICs is estimated at US$95.2 billion. Of this, upper-­middle-
income countries account for US$50.8 billion, or 53 percent (­figure 2.3).
Lower-middle-income countries account for US$40.6 billion of the burden,

38 THE SAFE FOOD IMPERATIVE

BOX 2.4 Estimating the Economic Burden of Foodborne Disease

The valuation of health costs using a human capital approach starts with
­estimated disability-adjusted life years (DALYs). These include years of life
lost and years lost to disability, which distinguish between lives lost (­mortality)
and illness (morbidity). Loss of life typically accounts for the biggest share
of the estimated health costs. Narain and Sall (2016) review health valuation
methods.
Loss of life can be valued in two ways. The first is the forgone output from the
life lost; that is, what a person would have produced if premature death had not
occurred. And the second is the value of a statistical life derived from the “willing-
ness to pay” to avoid death. The willingness-to-pay approach typically yields much
higher estimates than the forgone-output approach, since the willingness to pay to
avoid death is typically higher than income.
Illness or morbidity costs include the direct costs of care and treatment,
forgone productivity from days or years of work lost, and the cost of suffering.
Because most illnesses have multiple outcomes depending on individual char-
acteristics, tracing these various costs is a challenge for estimating costs from
morbidity. For any disease, the number of hospitalizations and days lost from
work need to be derived for both mild and more serious infections. Typically,
such estimates result in a lower value for years lost to disability than years of
life lost.
Given this economic framework, generalizations can be made about the rela-
tive economic costs of different diseases. First, those resulting in a higher ratio of
years of life lost to years lost to disability are a greater economic burden. Second,
illnesses that are a greater burden on children are a greater economic burden, since
the premature death of a child results in more years of life lost than the premature
death of an adult.
It is difficult in practice to make detailed estimates for the value of either years
of life lost or years lost to disability. A frequent shortcut is to use gross national
income (GNI) per capita as a measure of lost productivity. Intuitively, for each year
lost to illness, disability, or premature death, the economy loses the economic out-
put associated with that year. In this report, we make an approximate estimate of
the economic burden of FBD based on this simple measure of lost productivity.
While these estimates are crude, they provide insights into the relative economic
importance of foodborne disease in low- and middle-income countries and across
different levels of development.
The Foodborne Disease Burden Epidemiology Reference Group’s 2010 esti-
mates of DALYs per 100,000 people associated with FBD within each region (and
by country, where available) are used. Total DALYs for a region and country are
calculated by multiplying this estimate by the population in 2016. The economic
cost associated with the total DALY burden is then estimated as the value of pro-
ductivity loss from FBD. This is measured by simply multiplying 2016’s GNI per
capita by the number of DALYs. The estimate is VPi = Bi × Yi where VPi is the value
of the productivity losses associated with foodborne illness in country i; B is the
total DALY burden from foodborne illness in country i; and Yi is the GNI per capita
for country i.

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 39

 FIGURE 2.3 Productivity Loss from Foodborne Disease by LMIC
Income Group and Region, 2016
a. Country income group b. Region
Low Sub-Saharan
4% Africa
18%

Middle East and

North Africa and
Europe and
Central Asia
8% Asia
Upper- 66%
middle
53%
Lower- Latin America and
middle the Caribbean
43% 8%
2016 human capital loss
Income 2016 human capital loss Region
(current US$, billions)
group (current US$, billions)
Asia 63.1

Low 3.8
Latin America and
7.4
the Caribbean

Low Middle 40.6 Middle East and North

Africa and Europe and 7.9
Central Asia

Upper Middle 50.8 Sub-Saharan Africa 16.7

Total 95.2 Total 95.2

Source: World Bank.

and low-income countries account for US$3.8 billion, or 4 percent of the total.
The small share of low-income countries is attributable to changes in the World
Bank’s country categorization. In 2000, 63 countries were classified as low
income and accounted for 40 percent of the world’s population. By 2016, only
31 countries accounted for less than 9 percent of world’s population.
By region, LMICs in Asia account for US$63.1 billion, while those in Sub-
Saharan Africa have an economic burden of US$16.7 billion. China alone
accounts for over US$30 billion of the total burden of FBD in LMICs, and India
for US$15 billion, with these two countries accounting for 49 percent of the
total economic burden of FBD in LMICs and for 71 percent of the total burden
in Asia. Fifteen LMIC countries have an FBD burden exceeding US$1 ­billion a
year—seven of which are in Asia and three in Sub-Saharan Africa (­ figure 2.4).
While these economies are generally large (for example, China, India,
Indonesia, and Nigeria), they include smaller economies (for example, Angola,

40 THE SAFE FOOD IMPERATIVE

FIGURE 2.4 Productivity Loss from Foodborne Disease by Country,
2016
33
30
27
24
21
18
15
12
9.0
US$ (billions)

6.0
3.5

3.0
2.5
2.0
1.5
1.0
0.5
0
ail ia

a
Isl Me esh

pi la
lad n

ss ne ietn ya

i L na

Pe a
do ia

R a
N sia

Pa ep.

ic ico

K ria
na

Ph An p.

Fe ela m
ra B

Ar nza a

S u
ol n
s

Al sia

Sr enti a
Et tion
M Iraq
Eg So B and
t, h zil

bi
k
ab ric

Ta iopi
ne
ng sta

g ni

r
C uda
Th iger

de , R
ilip go
In Ind

Re

ian zu a
Ru Ve V en

an
hi

ne

ge

om
y
yp ut ra

am x
Ar Af

ala
Ba ki
C

h
n,
Ira

Asia Latin America and the Caribbean

Middle East and North Africa, and Europe and Central Asia Sub-Saharan Africa

Source: World Bank calculations.

Note: Calculated by multiplying unpublished 2010 Foodborne Disease Burden Epidemiology
Reference Group country estimates for foodborne disease disability-adjusted life years by 2016
gross national income per capita estimates of the World Bank’s World Development Indicators
Database.

Iraq, and South Africa). All countries with an FBD burden exceeding US$1
billion a year are lower- or upper-middle-income countries. A further thirteen
countries have a burden of between US$500 million and US$1 billion, with all
regions included in this group of countries.
To get a better sense of the burden of FBD in LMICs by level of economic
development, figure 2.5 plots the loss of productivity as a proportion of total
national food expenditures against income per capita. This ratio makes it pos-
sible to compare the economic burden of FBD across countries with different
population sizes. The ratio was computed for 2010 since data on national food
expenditures were not readily available for later years in many low-income
countries. While countries, are quite widely scattered in figure 2.5, it is pos-
sible to discern a broad pattern in which the relative burden of FBD is high-
est in middle-income countries, where the processes of market transformation
and diet transition are in full swing. The FBD burden is lower in countries
with higher levels of income per capita, which is broadly in line with the food

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 41

42
FIGURE 2.5 Relative Burden of Foodborne Disease by per Capita Income, 2010
6.0
Region
5.5 South Africa Asia
Latin America and the Caribbean
5.0 Middle East and North Africa, and
Nigeria
Europe and Central Asia
4.5
Ghana Sub-Saharan Africa
Congo Rep.
Côte d’Ivoire
Thailand

THE SAFE FOOD IMPERATIVE

4.0 Lesotho
India
Kenya
3.5 Mauritania
Sri Lanka
Chad
3.0 Senegal
Niger Indonesia
Iran, Islamic Rep.
Bangladesh
2.5 Malawi China
Nepal Malaysia
Congo, Dem. Rep. Bolivia
2.0 Burundi Algeria
Sudan
Tunisia Ecuador
Pakistan Egypt, Arab Rep.
1.5 Jordan Peru
Ethiopia Morocco
Vietnam Colombia
Philippines Brazil
1.0 Mexico

Productivity loss as a percentage of food expenditures

El Salvador
Jamaica Costa Rica
Guatemala
Cambodia Turkmenistan Bulgaria
0.5 Azerbaijan Turkey
Uzbekistan Ukraine Belarus Argentina
Honduras Macedonia, FYR
Georgia Bosnia and Herzegovina Serbia Kazakhstan Romania Russian Federation

0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 5,500 6,000 6,500 7,000 7,500 8,000 8,500 9,000 9,500 10,000 10,500
Gross national income per capita (US$)

Source: World Bank calculations.

safety life cycle described earlier. Figure 2.5 does not show the relative burden
of FBD in high-income countries, which tends to be 1 percent or smaller. For
example, the estimated ratio is 0.96 percent for the United States, 0.88 percent
for Canada, and 0.48 percent for Japan.
Beyond the broad estimates of productivity loss associated with FBD
­presented here, there are few estimates of the burden on LMICs. Notable excep-
tions include more in-depth economic analyses of specific countries, includ-
ing India (Kristkova, Grace, and Kuiper 2017) and Indonesia (On 2016). In
the analysis of India, 100 million cases of FBD were estimated in 2011. The
total impact on gross domestic product of avoiding these cases of FBD in
India is estimated at 0.5 percent, equivalent to an annual recurring benefit of
US$28 ­billion. This amounts to about US$160 per case.9
A small number of cost-of-illness studies that aim to document the actual
costs incurred—for example, medical treatment and out-of-pocket expenses—
also provide evidence on the economic burden of FBD. Kristkova, Grace, and
Kuiper (2017), in a study of FBD in India, estimate these costs at US$20 per
case, implying a total cost of US$2 billion. Other cost-of-illness estimates
include ILRI (2011) for diarrhea attributable to food in Nigeria (US$10 per
case) and Ethiopia (US$40 per case) (Grace et al. 2018). For shigellosis in
China, Guh et al. (2008) estimate US$28 per case. Although these studies use
different methods and provide differing estimates, there is a convergence at
about US$27 per case. This can be used to derive a very approximate cost-of-
illness estimate for FBD in LMICs of US$15.1 billion, using FERG’s estimate
of 558 million cases for these countries in 2010. If the “human capital loss”
estimate is added to this, the estimate for the public health burden of FBD for
LMICs is $110.2 billion.

FOOD SAFETY RISKS IN LMIC DOMESTIC MARKETS

The data just presented give a picture of the aggregate burden of FBD in LMICs
for regional and country income groupings and for individual countries. FBD
is clearly a heavy burden on LMICs, though the nature and magnitude of this
burden varies significantly among countries, most notably with the level of a
country’s economic development. Such broad trends, however, reflect—and
can act to obscure—variations in food safety risks within countries. For exam-
ple, there are variations across different foods, between rural and urban areas,
and within informal and formal agri-food sectors. Identifying where major
food safety problems exist in LMICs, and how these vary over time in line with
economic development, is essential for developing and implementing strategies
to reduce the burden of FBD.
The agri-food systems of LMICs, and especially middle-income coun-
tries, are characterized by the rapid evolution of businesses operating in the
9
Importantly, these benefits are based on a general equilibrium model that takes account of the
multiplier effects of the various economic flows created by the avoidance of FBD.

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 43

 production, processing, and marketing of food and the structure and modus
operandi of value chains. Such changes are closely aligned and interrelated with
the progressive diversification of diets and with the increased consumption of
animal-based foods, fruit and vegetables, and processed foods. Systems for the
management of food safety also evolve, although, as chapter 3 shows, these are
typically outpaced by the transformation of agri-food systems. This amalgam of
changes is a critical driver of the incidence of FBD and the associated economic
burden on LMICs.
Despite the progressive modernization of agri-food systems in LMICs,
traditional sectors in many of these countries continue to predominate in the
production, processing, and marketing of food (Gomez and Ricketts 2013),
especially fresh food. In Sub-Saharan Africa, for example, 85–95 percent of the
market demand for food is serviced by informal markets (Tschirley et al. 2010).
In Vietnam, 97 percent of pork is bought in traditional wet markets; and in
Malaysia, where the supermarket sector is much more developed, most meat is
sourced from traditional markets (Chamhuri and Batt 2013). Indeed, in many
low- and lower-middle-income countries, traditional marketing systems will
likely remain the norm for years (Minot et al. 2015; World Bank 2016; Ortega
and Tschirley 2017). For Sub-Saharan Africa, the proportion of food bought
through the informal sector is expected only to decline to 50–70 percent by
2040 (Tschirley et al. 2014).
Street food is a dominant facet of traditional informal food markets in
LMICs. This is food prepared and/or sold by vendors in public places that
requires no further preparation before consumption. In many Sub-Saharan
Africa, street food accounts for over 50 percent of food intake (Steyn et al.
2014), and it is estimated that 2.5 billion people in LMICs eat street food
daily (Fellows and Hilmi 2011). The preparation and sale of street food are
also a significant source of employment, especially among the poor and for
women.
Street food is typically prepared and sold around places of work, schools,
hospitals, and transportation hubs, and in local markets. This raises concerns
about the safety of street food, reflecting the insanitary conditions in which it
is often prepared and sold. The literature on risk factors associated with street
food includes Choudhury et al. 2011, Ababio and Lowatt 2015, Sezgin and
Şanlıer 2016, and Johnson et al. 2015. The risk factors include:

• Inappropriate and unhygienic locations and surroundings, as vendors target

high human-traffic areas that may be exposed to airborne chemicals in dust
and vehicle exhaust fumes.
• Low-quality raw materials being bought in open air markets.
• Methods of transportation of food and ingredients, especially inner-city
movements of meat and animal carcasses by carts, motor bikes, and on bus
rooftops.
• Poor design and construction of street food carts, especially the work sur-
faces, which inhibit cleanliness and thereby harbor microorganisms.

44 THE SAFE FOOD IMPERATIVE

• Unclean places of preparation—including surfaces, equipment, and
­utensils—whether at the vending site or in the home, where condiments
may be prepared ahead of time.
• Use of contaminated water and ice when noncontaminated sources are
not available.
• Use of nondisposable plates, cups, and cutlery.
• Lack of knowledge on temperature control; this is especially problematic
when time gaps between food preparation and consumption are long.
• Poor storage practices, including the disposal of leftovers and waste man-
agement (most street vendors do not have access to refrigeration).
• Poor personal hygiene practices, either due to a lack of knowledge or a lack
of nearby hygienic facilities.
• Low awareness of chemical and microbial contamination.

Comprehensive national or multicountry studies of the safety of street

foods are lacking. But the evidence from small-scale studies of street food
suggest worryingly high bacterial contamination levels in ready-to-eat food
in LMICs (Paudyal et al. 2017; Alimi 2016).10 Certain street foods are lower
risk; for example, those fried immediately before consumption or food that is
very salty, sweet, or acidic. Bacterial growth is also minimized when the time
between preparation and consumption is short. These exceptions notwith-
standing, studies show that street food vendors in LMICs are typified by poor
food safety conditions and practices.
In Brazil, Cortese et al. (2016) found that 100 percent of street food vendors
in Florianopolis had no access to a water supply, and 12 percent lacked proper
cold holding during transport. Twelve percent did not provide ice, 95 percent
did not wash their hands, and 91 percent did not have hair covering. Alves da
Silva et al. (2014) found that only 38 percent of street vendors in Bahia, Brazil,
kept perishable foods in cooling containers, 23 percent did not sanitize their
hands, and 80 percent handled food and money simultaneously. In Uganda,
Muyanja et al. (2011) found that street food vendors operated in locations with
poor hygiene and that, although they tended to be aware of hygienic practices,
they did not follow them. The authors concluded that the provision of sanitary
facilities at vending sites and vendor education was needed to improve the food
safety conditions at the sites under study. Gadaga et al. (2008) found hygienic
practices of food vendors in Harare were lacking, and that facilities at vending
sites were typically inadequate for safe food handling operations.
Traditional food markets in LMICs extend, of course, well beyond street
food to include wet markets for fresh produce, and informal and formal
micro and small enterprises engaged in animal slaughtering and processing

10
The findings include high levels of microbial pathogens in street-vended salads and gravies in
Johannesburg (Kubheka, Mosupye, and Holy 2001); salads and traditional fermented foods in
Ghana (Mensah et al. 2002); and chicken in Guatemala (Jarquin, Alvaraz, and Morales 2015) and
Vietnam (Ta et al. 2012; Nguyen et al. 2018).

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 45

 animal- and plant-based foods. The safety of this food is potentially a very
significant issue for LMICs because much of it is associated with recog-
nized microbiological and other food-based hazards (for example, meat,
fish, and milk-based foods). While the literature is not conclusive on this
subject, there is evidence that food safety practices in these areas tend to
be weak (Macheka et al. 2013; Wambui et al. 2016), and that the incidence
of foodborne pathogens can be significant (Chahed et al. 2006; Beneduce
et al. 2008; Elgroud et al. 2009; Grace et al. 2011; Nguyen-Viet et al. 2013;
Doyle et al. 2015).
Some of these risks can be mitigated by the food preparation and consump-
tion practices of consumers. For example, milk bought from informal vendors
is generally boiled before consumption, which minimizes exposure to micro-
bial pathogens (Grace et al. 2008; Makita et al. 2010). Pork from traditional
markets in Vietnam is generally cooked very soon after being bought, with time
enough to kill most foodborne pathogens (Lapar et al. 2014). In other cases,
consumer preparation practices may not be effective in mitigating food safety
risks, as in India and parts of Sub-Saharan Africa, where milk is fermented
before consumption (Johnson et al. 2015).
It is reasonable to expect that, everything else being equal, the progres-
sive formalization of the agri-food sector will bring about improvements in
food safety management practices and capacity. Formal enterprises will tend
to process and handle foods in better physical condition, have access to a reli-
able supply of safe drinking water, and use refrigeration (and have a reliable
supply of electricity for this). Furthermore, as food businesses begin to pack-
age and brand their products, there are growing market-based incentives to
manage food safety effectively. Formalization will make the agri-food system
more amenable to regulation. And formal sector and larger businesses should
be able to have access to the financial and technical resources to implement and
upgrade food safety management systems.
Formalization, however, does not automatically translate into better food
safety outcomes.11 Changes in supply chains, larger facilities, and more modern
production techniques must be accompanied by the appropriate management
of risks, which will change as supply chains evolve. Investments in physical and
human capital will also be needed to manage these risks. Even in more advanced
food safety systems, lapses and high-profile outbreaks occur, as illustrated by the
outbreak of listeriosis in South Africa in 201712 and the publication of studies

11
Several studies highlight circumstances where food sold though formal sector marketing chan-
nels was no safer than food sold in the informal sector. Roesel and Grace (2014) report that in
Mozambique, levels of microbial pathogens were lower in poultry bought from live bird markets
than from formal sector abattoirs; in Kenya, the microbiological quality of beef from a typical local
slaughterhouse was no greater than in beef from an improved slaughterhouse selling to supermar-
kets; and in Assam, India, little or no difference was found in rates of compliance with food safety
standards in formal and informal milk value chains.
12
For a report on the listeriosis outbreak, see https://www.reuters.com/article/us-listeria-tiger​
-brands/south-africa -blames-food-firms-for-worlds-worst-listeria-outbreak-idUSKBN1GH0S9.

46 THE SAFE FOOD IMPERATIVE

showing a much higher rate of product recalls in recent years in the United
States and other Organisation for Economic Cooperation and Development
countries.13 But it is not clear whether the rise in product recalls stems from
more frequent lapses or—quite the opposite—from improved laws, hazard
detection, and product traceability; in other words, from enhanced capacities.
A key characteristic of the transformation of agri-food systems in LMICs is
the extension of value chains, both geographically and in the number of par-
ticipants. These changes reflect the growing distance between the locations of
production and consumption, accompanying progressive urbanization and the
increasing transformation of food that goes with the rising consumption of
processed foods. Many modern value chains involve a “bulking” step, whereby
foods are aggregated for transportation, storage, and processing. Examples
include chilling tanks for milk, abattoirs for meat, and mills for cereals. Several
studies from LMICs indicate that bulking steps in value chains can be a source
of contamination.14 In this way, the transformation of the agri-food system in
line with economic development presents new food safety problems. And if
these are not effectively managed, the burden of FBD can grow, as in the rapid
upward slope of the food safety life cycle in the transitioning stage depicted in
figure 1.2 in chapter 1.
Food fraud is a particular food safety problem associated with the modern-
ization of agri-food systems in LMICs, especially adulteration and ­tampering.15
Zhang and Xue (2016) suggest that economically motivated food fraud and
adulteration is a growing problem in China. There is also evidence of food
adulteration in other LMICs. Handford, Campbell, and Elliott (2016) show
how milk is frequently the target of adulteration and other forms of fraud in
many LMIC because of its high value and the rapid growth in demand for milk.
Souza et al. (2011) found that all samples of UHT milk examined in their study
in Brazil contained at least one adulterant; 44 percent of samples, for example,
were found to contain formaldehyde. Adulteration is not only linked to food
produced domestically but also imports. Six percent of milk powder sampled
in Dar-es-Salaam, Tanzania, was found to be contaminated with melamine
(Schoder 2010). Food can also be contaminated with ingredients that are used

13
For more information on these recalls, see http://www.foodsafetynews.com/2018/04/better​
-tests-stronger-laws-more-foods-add-up-to-more-recalls/ and https://www.ncbi.nlm.nih.gov/pmc​
/articles /PMC5201 359/.
14
For Burkina Faso, Millogo et al. (2010) found that the total bacteria count of milk is lower at
the point of production than further along the value chain, suggesting that contamination occurs
post-farm-gate and further along the distribution system. A study in Ghana examining the safety
of tomatoes before and after milling found that milling increased contamination (Sinayobye and
Saalia 2011).
15
There are many different types of food fraud, and some do not affect food safety, although they
have potentially serious impacts on commercial activity. For example, about 20 percent of all fish
sold worldwide is estimated to be mislabeled. This often involves less-valuable fish as the fraud is
often difficult to detect after filleting. A more specific example is the horsemeat scandal in 2013,
when beef sold in Ireland, Germany, and the United Kingdom was found to contain horsemeat
from Romania.

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 47

 purposefully—including food additives, pesticides, and veterinary drugs—but
are found at levels that can be injurious to human health. For example, a meta-
analysis of studies of acute food poisoning in China found that 10 percent of
incidents were related to food additives, accounting for only 3 percent of ill-
nesses but 12 percent of deaths (Xue and Zhang 2013).

COSTS OF DOMESTIC FOOD SAFETY FAILURES

Appreciable costs can be imposed on consumers, food businesses, and govern-

ments when large-scale food failures occur, and especially where these result
in significant cases of FBD as part of an outbreak (table 2.2). In the aggregate,
these costs can also be considerable for the economy. The findings from stud-
ies of food safety failures in developing countries are in line with the many
studies in high-income countries that show how consumers avoid products
involved in safety failures. Estimates of the effect of media reports on bacterial
contamination of meat in the United States show a modest impact on consumer
demand of 1–3 percent of total sales (Lusk and Schroeder 2002; Piggott and
Marsh 2004). Similar modest effects were found for the widely publicized recall
of peanut butter in the United States in 2007 (Bakhtavoryan, Capps, and Salin
2014). So, while consumer responses to food safety incidents can be dramatic
in the short term, the impact on demand tends to taper off over time (Burton,
Young, and Cromb 1999; Piggott and Marsh 2004).
In settings where regulatory capacity and associated consumer confidence
are high, this is arguably a rational response to the belief that corrective action
will be taken and the hazard quickly brought under control. In some cases,
however, consumer responses to food safety failures are more dramatic and
longer term. Examples of this include the effect on U.S. consumer demand for
fresh spinach after an outbreak of E. coli in 2005 (Arnade, Calvin, and Kuchler
2009) and U.K. consumer demand for beef after an outbreak of bovine spongi-
form encephalopathy in the 1990s (Burton, Young, and Cromb 1999). In these
and similar cases, consumers clearly lacked trust in food safety management
systems and the outbreak was enough to erode any trust that hitherto existed.16
Food safety failures can impose significant costs on businesses and indus-
tries. These include loss of sales as consumers eliminate foods perceived to
be risky and substitute for alternatives, erosion of firm equity, and even the
complete loss of business at the firm or market level. Businesses can also face
the risk and associated costs of legal action by regulators and private litigation

16
Risk perception often drives consumer response. In contrast to experts, who tend to base their
judgments of risk on the number of mortalities or years lost to illness for a given level of exposure
to a hazard, the assessments of the general public are driven by a complex array of factors, includ-
ing how familiar the hazard is, the level of perceived control, and how potentially catastrophic the
consequences might be—no matter how low the probability of these consequences (Slovic 1987).
For example, consumers tend to be more concerned about genetically modified organisms and
hormones and less concerned about microbial pathogens, even though the objective risks from the
latter are much greater (Lusk and Murray 2014).

48 THE SAFE FOOD IMPERATIVE

 TABLE 2.2 Potential Market and Economy Costs from Food Safety Problems
Economic Types of costs incurred when food Distribution of costs Market incentives or regulatory Variations by development level
unit affected safety failures occur enforcement for food safety
Consumer Consumers seek substitutes, limit Foodborne illness is a greater burden Consumers may not always identify source Consumer awareness and access to good
consumption. May pay higher food prices on poor people and children. Both of hazard and, as a result, may not be able information about hazard avoidance will be limited
or incur avoidance costs. May influence acute and chronic illnesses will reduce to avoid them. Consumers will look to in low-income countries. Information improves
dietary patterns with negative nutritional labor productivity and incomes. certification, media reports, public sector for with urbanization, but this may not always be
consequences. guidance. reliable. Good evidence for public health burden;
mixed evidence on willingness to pay.
Firm Lower price for products, loss of both Small firms may evade detection and Consumers shun firm or accept product Unlikely to be detected at low-income levels,
domestic and export markets, loss of impact more likely for larger firms. only with lower price. Export markets may except in limited way in informal markets. Buyer
firm equity and brand reputation, firm Per unit costs of mitigation likely be closed. Formal sector buyers require incentives more likely as markets urbanize. Export
failure. Mitigation may require new higher for small firms. certification. Regulators impose fines or market failures can occur at any income level. Firm
investments and recurring costs, including recall products. Equity prices decline. equity impacts only in high-income countries with
certification. larger firms.
Industry Loss of product reputation is a cost Firm failure for those unable to Consumers shun domestic product, make More likely as markets develop and regulators
to all firms, even good actors. Lower comply leads to change in industry substitutions, or accept only at lower discover problems, which are then reported in
price or loss of market share relative to structure as smallholders more price. Export markets may require special the media. More likely if product is also exported,
substitute products or import suppliers. likely to have higher costs of certification or approval. Regulators may as problems in meeting high-income standards
Loss of export markets or diversion to compliance. impose new requirements for entire industry become known.
lower-price markets. Limited market with additional costs. Formal sector may
expansion. impose certification requirements.
Food sector Limited expansion of supply for products May bias sector development Incentives are subtler at this level, and More likely to be experienced as countries pass
associated with failures, with resulting toward processed or imported these effects would only appear over time. through the middle-income stage of market
losses for producers. products. May bias food safety development.
investments toward high-value
exports with little spillover for
domestic quality.
Economy Limited food sector development, May limit opportunity for Incentives subtler and shift toward fewer Public health burden hidden but likely more
especially processing and high-value smallholders, women in food high-risk commodities in production and significant at low-income levels. Consequences
exports. Burden of foodborne illness processing. May skew direction consumption would occur over a long time. for structural transformation emerge as countries
reduces labor productivity and output of structural transformation in Food trade balance impacts also likely to pass through the middle-income stage.

EVIDENCE ON THE BURDEN OF UNSAFE FOOD

across all sectors. Increased food agriculture and food with possible accrue slowly over time. Burden of foodborne
imports and/or reduced exports negative consequences for income illness often hidden and impacts of better
reduce government revenues. distribution. health on productivity are hard to measure.

49
Source: World Bank.
 by victims and their families. Importantly, the costs of food scares unravel in
unpredictable ways as the facts surface and different patterns of organizational
and consumer behavior occur. In some cases, the distribution costs of food
safety failures are poorly aligned with those who are primarily responsible.
While incidents of food safety failure are relatively common in LMICs, their
costs and broader ramifications are much less well understood than compara-
ble failures in industrial countries.17 The best documented cases tend to involve
multinational food businesses; examples include sales of outdated Yum Brand
meat in China (2012) and high levels of lead in Maggi noodles in India (2015).
The Chinese melamine milk scandal of 2008 is also well documented (Wang
and Saghaian 2013; Xiu and Klein 2010; Pei et al. 2011), a reflection in part
that milk products contaminated with melamine entered international trade.
Indeed, some of the better documented cases of more generalized food safety
failures in LMICs are in the context of agri-food exports (boxes 2.5 and 2.6)
Impacts of food safety failures by sector or economy are less well docu-
mented, even in industrial countries. The limited evidence that exists, how-
ever, suggests there are often long-term structural outcomes from persistent
food safety failures. The lack of quality certification for infant weaning foods in
West Africa, for example, biased consumers toward imported products despite
the availability of nutritious and less expensive local substitutes (Masters and
Sanogo 2002). Conversely, evidence shows that the contamination of milk
products with melamine in China did not drive consumers toward imported
products in the longer term (Qiao, Guo, and Klein 2010).
Some evidence of persistent and more generalized structural change in
the growing middle-class demand for food safety is found in China. The dairy
industry provides insights into the extensive market changes in response to the
milk contamination scandal in 2008, and subsequent incidents in 2010. The gov-
ernment reacted to the scandal by instituting new marketing regulations for the
industry and promoting centralized dairy production facilities (Jia et al. 2014).
These efforts, as well as slumping consumer demand, reshaped marketing chan-
nels, with roughly half of milk collection centers going out of business and many
smallholders left without market outlets. From this, new models for organiz-
ing production and processing emerged, which provided greater oversight and
quality control through strengthened vertical coordination (Wang, Chen, and
Klein 2015; Jia et al 2014). Another dimension of the market response was the
growth in demand for UHT milk, which is seen as providing more reliable qual-
ity and safety (Ortega et al. 2012). As a processed branded product, UHT milk
allows firms to develop brand reputation and capture returns to better and more
reliable quality, but this requires reliable product certification. The dairy market
changes adopted in China show how food safety can shape market development
and concentration, as well as certified product demand.

17
Green (2016) reviewed some 900 news articles and other publications on 30 food scares in
LMICs from 2000 to 2016 and found only four to be of high quality in terms of providing rigorous
evidence of impacts.

50 THE SAFE FOOD IMPERATIVE

BOX 2.5 Sudan Red Dye in Chili Powder from India

The 2005 Sudan Red scandal illustrates the broad ramifications that a food contam-
ination incident can have when food is exported for use as an ingredient in a variety
of processed foods. The scandal was triggered when an industrial dye known as
Sudan Red was discovered in a batch of Crosse & Blackwell Worcestershire Sauce,
then a brand of British food manufacturer Premier Foods.
The industrial dye—normally used in waxes, solvents, polishes, leathers, and
fabrics—proved to be carcinogenic when ingested in large or chronic doses in
animal studies. Its discovery in a range of branded food products led the British
food safety agency to recall several hundred products, which included prepared
sausages, noodles, salad dressings, and sauces, many of which used Worcestershire
Sauce as an ingredient.
The dye’s presence in these food products was traced back to chili powder from
India. Unscrupulous spice producers looking to cut production costs allegedly used
the dye to restore their chili powder to its characteristically red color after bulking
it up with light-colored adulterants, such as stems, seeds, and light-colored pods.
In fact, the dye had already been detected in spice imports to Europe in 2001
(Tarantelli 2017). In 2003, Sudan Red was found in consignments of chili powder
sent to France, prompting a much smaller-scale recall that led the Spices Board of
India to temporarily suspend the export-registration certificates of five companies
(Jaffee 2005). In the same year, the European Union (EU) issued a directive requir-
ing all dried and crushed chili entering the EU to be certified free of Sudan Red,
which had been prohibited in food since 1997. As the story unfolded it became
clear that what had initially seemed like the misdeeds of a few rogue producers was
a widespread problem. Indeed, over 2003–04, the dye was discovered in a growing
number of shipments from numerous countries, including China, India, Pakistan,
South Africa, the Syrian Arab Republic, and Turkey (Jaffee 2005).
Between 2001 and 2017, the discovery of Sudan Red dye in herbs and spices
resulted in at least 429 notifications to the EU’s Rapid Alert System for Food and
Feed (Tarantelli 2017), though the number of notifications declined in the after-
math of the scandal (ranging from none to three a year since 2012).
In 2005, the widespread use of chilies—and Worcestershire Sauce—as ingre-
dients in processed foods led to a surge in recalls of both, forcing a multitude of
businesses across many countries, including restaurant chains with thousands of
outlets, to withdraw products that likely contained trace amounts of the dye in
sauce packets.
In China, 1,200 KFC outlets suspend menu items sold with affected sauces con-
taining Sudan Red. Beijing’s food safety office banned all flavoring products manu-
factured by the Heinz-Meiweiyuan Food Company after Sudan Red was detected
in its pepper sauce (Xinhua News Agency 2005). A wholly owned subsidiary of the
South African restaurant chain Nando’s Chickenland claimed that it had suffered
about US$1 million in costs and damages when its bottled sauces were found to
contain Sudan Red, leading to a worldwide recall in 2004.
In all, the recall was estimated to have cost US$150 million (Peter 2012). Overall,
costs to the food industry worldwide were estimated to over US$220 ­million in
lost sales, inventory destruction, management and consultants’ time, and brand
damage.

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 51

 BOX 2.6 Brazil’s Tainted Meat Scandal

A scandal involving some of largest meat processors in Brazil and the world, includ-
ing JBS and BRF, erupted in 2017, when a federal police investigation pointed to
employees of these companies bribing ministry inspectors to approve outdated and
adulted products for sale and export. In all, 21 companies were involved in Brazil’s
tainted meant scandal.
No cases of poisoning were linked to the scandal, despite police reports that
flour and cardboard were added to sausages and cold cuts and that the smell of
spoilage was masked by chemicals in some cases. The two-year investigation, trig-
gered by a whistleblower, led to hundreds of raids across six Brazilian states and
Brasília as part of Operation Weak Meat. Brazil’s Ministry of Agriculture, which
suspended 33 officials as part of the affair, regarded the incidents as isolated.
The fallout on Brazil’s meat exports and reputation was significant. Brazil annu-
ally exports over US$12 billion in meat to about 150 countries, accounting for
40 percent of world chicken exports and 20 percent of beef exports. The tainted
meat scandal resulted in importers and authorities in Chile, China, the European
Union, Japan, Mexico, the Republic of Korea, and South Africa, among other coun-
tries, rejecting Brazilian meat shipments and temporarily suspending meat imports
from the country, putting perishable products in jeopardy.
According to Bloomberg News (2017), “Chilled meat needs to get from meat-
packer to consumer in about 70 days and meat shipped from Brazil uses more than
half that time at sea, according to Asian shippers. Inspection times at the receiving
port are usually four or five days, but can take two weeks for a thorough exami-
nation. Agricultural products that do not pass customs inspections are typically
burned at the port, the shippers said.”
The full economic impact of the scandal has yet to be determined. One estimate
of the cost for Brazil’s meat processing industry is US$3.5 billion in lost export rev-
enues, equivalent to 0.2 percent of the country’s gross domestic product.

Source: This account of Brazil’s tainted meat scandal draws on Reeves 2017; Freitas
and Batista 2017; Freitas, Singh, and Gilber t 2017; Freitas and Freitas 2017; Associated
Press 2017; and Bloomberg News 2017.

THE COSTS OF FOOD SAFETY FAILURES IN TRADE

Beyond the burden of FBD, food safety is a critical factor affecting the agri-food
trade performance of LMICs, with important consequences for formal sector
businesses, employment, and incomes. A significant body of literature shows
the influence of food safety requirements on agri-food exports. While much of
this literature focuses on exports from industrial countries, a growing body of
research shows the importance of compliance with food safety regulations and
standards for the trade performance of LMICs.
Broadly, these studies show that effectively competing in international
agri-food trade may entail considerable compliance costs for the ­public
and private sectors to meet the requirements of food safety regulations or

52 THE SAFE FOOD IMPERATIVE

standards in export markets. While this is a well-established issue with
exports to industrial countries, compliance with food safety requirements is
also becoming the norm for trade between LMICs. The size of these costs is
clearly an issue for export competitiveness and is affected by multiple factors,
including firm and industry size, the gap between food safety management
capacity and the capacity required for compliance with export market require-
ments, and levels of collective action between exporting firms (World Bank
2005). Such a consolidation occurred in the Indian fish processing industry
in the early 2000s after the EU imposed restrictions on the industry’s exports.
The fixed costs of meeting stricter food safety requirements in export mar-
kets tend to favor established exporters (Anders and Caswell 2009). Food
safety challenges generally reenforce or accentuate the broader set of competi-
tive strengths and weaknesses of industries and firms. In some cases, “trade
losses” attributed to noncompliance with more stringent standards are more
accurately attributable to more entrenched and longer-term competitiveness
issues within businesses and sectors (Diaz Rios and Jaffee 2008).
Countries, and businesses and sectors within countries, with lower levels of
food safety management capacity often struggle to get into potentially lucrative
high-value exports markets. And then there is the specter of exclusion from
these markets as food safety requirements are enhanced or when food safety
failures occur (Beghin and Orden 2012).18 Stricter food safety regulations and
standards are often portrayed as nontariff barriers to trade. But these can act as
powerful catalysts for investments in improved food safety management sys-
tems, especially when incentives for these investments are lacking in domestic
markets (Jaffee and Henson 2004). The economic returns from these invest-
ments, however, are sensitive to the way in which they are made. Significant
benefits can come from upgrading food safety management capacity as part of
longer-term and strategic efforts to enhance export performance. But they tend
to be less beneficial when made as a reaction to immediate crises, such as the
loss of a key export market (World Bank 2005).19
Some studies have examined the impact of specific and highly publicized
food safety events on LMICs export markets. Examples include restrictions on
fish and fishery products imported into the EU imposed on Bangladesh, China,
and Kenya, among other countries; and U.S. restrictions on raspberry imports

18
For agri-food products, it is more commonly the case that binding make-or-break constraints
are associated with phytosanitary and animal disease issues rather than food safety compliance.
It is common for countries to apply absolute restrictions on imports of fresh fruit and vegetables,
plants, animal products, and live animals on the basis of the presence of quarantine plant pests and
animal diseases, and the absence of adequate information on or effective controls for these pests
and diseases. For example, only 28 non–EU member countries are permitted to supply meat prod-
ucts to the EU. Of these, 12 are high-income countries, 15 are upper-middle-income countries, and
one is a lower middle-income country.
19
For example, through case studies on the aquatic products and horticultural sectors, Henson
and Jaffee (2008) show that while many LMICs (and export businesses in these countries) tend to
upgrade food safety capacity in a reactive mode, those that benefit most make these investments
preemptively and as market leaders.

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 53

 from Guatemala. There is evidence that significant losses were incurred by
the sectors affected by these restrictions (Cato and Subasinge 2003; Henson
and Mitullah 2004; Calvin et al. 2002; Alavi 2009). In each of these cases, sig-
nificant investments to upgrade food safety management systems were made
in response. Although these investments were successful at regaining mar-
ket access, not all export businesses survived, and the value of trade took a
considerable time to recover. In general, businesses and sectors caught up in
high-profile food safety failures, when trade is banned or restricted and strict
timelines are set for upgrading food safety management systems, tend to see a
heavy consolidation of exports as smaller and less-established actors struggle to
upgrade. Such a consolidation followed the EU’s restrictions on the industry’s
exports (Henson, Saqib, and Rajasenan 2004).
Compliance with export market food safety regulations and standards can
also bring about changes in the structure and modus operandi of agri-food
value chains. In some cases, these changes are a direct and necessary part
of upgrading food safety management systems to achieve compliance. For
example, for Indian shrimp exporters to comply with EU hygiene require-
ments, the outsourcing of shrimp peeling was prohibited, resulting in this
step being centralized in industrial fish-processing operations (Henson,
Saqib, and Rajasenan 2004). In other cases, value chains are restructured
because compliance with food safety requirements is easier to achieve and
less costly with more consolidated systems of production, processing, and
distribution. Concerns have been raised that compliance with stricter food
safety requirements might exclude smallholder farmers from value chains for
high-value agri-food exports, such as fresh fruit and vegetables. These con-
cerns and the broader issue of smallholder farmer compliance with standards
are discussed in chapter 3.
It is probably not possible to know with any certainty the degree to which
agri-food exports from LMICs are adversely affected by the challenges of com-
pliance with food safety requirements for export markets or by food safety fail-
ures. While the degree to which exports decline because of these factors can
be estimated, a nontrivial impact is the loss of potential trade from unrealized
exports as a result of firms being deterred from entering a market on concerns
that they cannot comply with food safety requirements or that the costs of com-
pliance would erode their competitiveness. In other words, there are certainly
cases in which food safety requirements act as a “barrier” to potential trade. It
is reasonable to expect that this scenario most commonly applies to smaller and
less established enterprises. This then raises the question of whether food safety
requirements are really the binding constraint or whether broader competitive-
ness challenges are the real issue.
The most commonly observed impact on trade from food safety require-
ments is the rejection of consignments of agri-food products during border
inspections at destination export markets (Unnevehr 2007; Buzby. Unnevehr,
and Roberts 2008; Baylis, Nogueira, and Pace 2010). While data on border
rejections have several limitations, they do provide a picture of recurring issues

54 THE SAFE FOOD IMPERATIVE

on compliance with food safety requirements and how compliance issues vary
across exporting countries and destinations, and over time.20 For example, the
United Nations Industrial Development Organization provides an analysis of
food import rejections for Australia, the EU, Japan, and the United States from
2002 to 2013 (UNIDO 2015, 2017). This analysis has been updated for this
report for the EU by examining border rejection data for 2014–16.
Most border rejections in industrial country markets are accounted for by
a small number of countries and for recurring reasons. For example, U.S. bor-
der rejections are dominated by fresh fruit and vegetables from Mexico due to
pesticide residues or adulteration, fish and seafood from China due to micro-
bial pathogens or toxins, and spices from India due to microbial pathogens or
toxins. U.S. border rejections of fish and seafood from LMICs due to microbial
pathogens have been a persistent problem, but rejections due to veterinary drug
residues have declined. Rejections of spices have increased, but rejections of fruit
and vegetables from Mexico due to adulteration have declined (Bovay 2016).
A similar pattern of border rejections being dominated by a small number
of countries and for recurring reasons can be seen in the EU. A notable recur-
ring reason is the high level of rejections of nuts and nut products and dried
fruit due to aflatoxin contamination, especially from the Islamic Republic of
Iran (which has an ongoing problem controlling levels of aflatoxins in pista-
chios). Rejections of fish and fishery products have also been high in the EU,
although rejection rates vary widely across exporting countries (figure 2.6).
These rejections were due to noncompliance with hygiene requirements in the
capture and processing of fish, and restrictions on antibiotic residues, predomi-
nantly in fish from aquaculture production. Rejection rates tend to be quite low
for countries with income per capita below US$2,000, but the rates rise among
countries with income per capita of US$3,000–US$6,000. Border rejections for
fresh fruit and vegetables show a similar pattern, where the predominant issue
is compliance with EU requirements for pesticide residues (figure 2.7).
A range of factors can explain the patterns of border rejections seen in
­figures 2.6 and 2.7. At lower income levels, exports from LMICs tend to be domi-
nated by a small number of lead firms that find it easier to comply with strict
export food safety requirements. Indeed, the ease and lower cost with which they
can comply can be essential to their competitive advantage. As exports increase,
however, new exporting firms emerge, many of which struggle to achieve com-
pliance requirements, and they experience rejections of consignments in target
export markets. These firms either achieve compliance or are excluded over time,
and the sector in which they operate increasingly acts collectively to upgrade
standards to achieve a reputation for food safety management. And because of
these interventions, levels of border rejections decline.

20
For example, border rejections only provide an indication of compliance challenges where trade
occurs, and where compliance is assessed in the destination export market through the inspection
of consignments at the point of entry. Furthermore, these data provide no indication of the chal-
lenges faced in complying with voluntary public or private standards.

EVIDENCE ON THE BURDEN OF UNSAFE FOOD 55

56
FIGURE 2.6 Rejection Rates of Fish and Fishery Product Imports to the EU by Lower-Middle-Income Countries,
2014–16
1.2
Tunisia Income group
1.1 Algeria Low income
Lower-middle income
1.0
Upper-middle income
0.9

0.8 Mozambique
Iran, Islamic Rep.
Pakistan

THE SAFE FOOD IMPERATIVE

0.7 Sri Lanka
Serbia Brazil
0.6 Belize

0.5 Vietnam
Ukraine
Panama
Bosnia and Herzegovina
0.4 Senegal Jamaica Malaysia
Cabo Verde
Suriname
0.3
Ghana Mexico
India Papua New Guinea
0.2 Mauritania Thailand
Kenya Namibia
Myanmar Nigeria Indonesia South Africa
0.1 Honduras Morocco El Salvador Peru China Russian Maldives
Tanzania Albania Argentina
Côte d’Ivoire Bangladesh Philippines Ecuador Federation Mauritius Turkey
Uganda Nicaragua Jordan Belarus Kazakhstan Costa Rica
0
Cameroon Moldova Georgia Colombia Dominican Lebanon
Ethiopia Macedonia, FYR

Rejection rate of high-value fish per US$10 million in EU imports

Repub.

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000 11,000 12,000 13,000
GDP per income 2016 (current US$)

Source: World Bank based on EU Rapid Alert System for Food and Feed and United Nations Comtrade data.
Note: EU = European Union; GDP = gross domestic product. Rejection rate by country calculated as the three-year sum of EU notifications for 2014–16 divided by
the three-year sum of fish and fishery products exports to the EU (in US$10 million) over the same period. Includes LMICs with exports of US$25 million or more.
Excludes the Arab Republic of Egypt and Zimbabwe with rejection rates of 3.9 and 18.9, respectively.
 FIGURE 2.7 Rejection Rates of Fresh Fruit and Vegetable Imports to the EU by Low- and Middle-Income Countries,
2014–16
5.0 Bangladesh
4.5 Income group
4.0 Low income
3.5 Uzbekistan
Low-middle income
3.0
2.5 Upper-middle income
Thailand
2.0
1.5
1.0
1.0
Malaysia
0.9 Uganda
0.8 India

0.7 Jordan
Sri Lanka
0.6
Egypt,
0.5 Arab Rep.
Kenya Albania
0.4 Serbia
Pakistan Tunisia Turkey
Bosnia and

Rejection rate for fresh fruit and vegetable trade

0.3 Mozambique Nicaragua Iran, Colombia
Morocco Herzegovina
Myanmar Vietnam Islamic Dominican Repub.
0.2 Ethiopia Algeria Rep. Suriname
Honduras Belize China
Zimbabwe Ghana Ukraine Azerbaijan Peru
0.1 Senegal Namibia Brazil Argentina
Cameroon Indonesia Belarus Ecuador
Tanzania Costa Rica
Mexico Russian Federation
0 South Africa
Philippines Georgia Jamaica
Madagascar Burkina Côte Moldova
Faso d’Ivoire Bolivia Guatemala Macedonia, FYR

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000 11,000 12,000 13,000
GDP per capita 2016 (current US$)

Source: World Bank based on EU Rapid Alert System for Food and Feed and United Nations Comtrade data.

EVIDENCE ON THE BURDEN OF UNSAFE FOOD

Note: EU = European Union; GDP = gross domestic product. Rejection rate by country calculated as the three-year sum of EU notifications for 2014–16 divided by
the three-year sum of fresh fruit and vegetable exports to the EU (in US$10 million) over the same period. Includes LMICs with exports valued at US$25 million or
more.

57
 Beyond this general pattern, it is evident from rejections of fish and
f­ishery products, and fresh fruit and vegetables, that some countries
are ­outliers, which have much higher or lower levels of rejections than
most countries at a similar level of development. These countries include
Tunisia, which has had a much higher level of rejections of fish and fishery
products than most lower-middle-income countries; and Thailand, which
has had a much higher level of rejections of fresh fruit and vegetables than
most upper-middle-income countries. Clearly, countries face local issues
in trying to comply with export food safety requirements that may relate
to sector size and structure, degree of cooperation between firms, and
food safety management capacity within and across the public and private
sectors.
The prominence of many leading LMIC exporters of high-value agri-
food products in the border rejection data of the EU and United States sug-
gests that these rejections are merely a bump in the road—or the cost of
doing b­ usiness—in these markets and their export businesses and sectors.
Thus, these LMIC countries maintain access to these markets and continue
to expand their exports—and, to an extent, that they command dominant
market shares in some cases. Each of the top ten LMIC suppliers of high-
value foods to the EU experienced a reduction in their rate of rejections
between 2010 and 2016. Overall, the proportion of LMIC food trade now
impacted by border rejections is likely to be in the range of 0.5 to 1 percent
in value terms—or about US$2 ­billion in aggregate (given that LMIC total
food exports and higher-value food safety-sensitive exports were US$475 bil-
lion and US$220 billion, respectively, in 2016). For some of the businesses
and smaller industries that incur rejections, the costs (and reputation effects)
can certainly be considerable—and, in extreme cases, catastrophic. But for
many leading industries and larger businesses, the financial and commercial
impacts of having some consignments destroyed, reconditioned, or rerouted
are much less significant.
As noted earlier, these are not the full trade–related costs or losses asso-
ciated with unsafe food. Concerns about the ability to comply with regula-
tory requirements and private standards, together with the financial risks
of undertaking significant upfront investments in order to comply, may
deter food manufacturers or trading companies from initiating exports in
the first place. This deterrent effect probably affects more LMIC trade than
actual consignment rejections. Yet, this is primarily a distributional issue
rather than one of lost trade for LMICs in aggregate. Some smaller industries
and businesses are deterred from exports, while others go ahead and cap-
ture those market opportunities. This seems to be what we are witnessing in
global LMIC food trade. Food safety (and other sanitary and phytosanitary)
challenges are accentuating underlying competitive advantages and disad-
vantages and contributing to the further consolidation of the LMIC trade in
high-value foods.

58 THE SAFE FOOD IMPERATIVE

SUMMARY

This chapter has provided evidence on the costs of food safety for public health,
consumer welfare, industry viability, and market growth. Countries today have
a better understanding of the public health burden and the nature of food safety
risks in transforming food systems, and this is allowing estimates to be made of
the productivity costs associated with food safety. Globally, these are annually at
least $95 billion, with 28 countries having losses exceeding $500 million. In line
with the food safety life cycle trajectory outlined in chapter 1, food safety costs
are greatest as a share of food expenditures for lower-middle-income countries,
showing the lag in food system capabilities during food market transformation
in line with economic development.
In addition to this overall cost to developing counties, evidence is strong
that food safety imposes costs on food consumers and the food industry, with
possible consequences for market development. Consumers shift their con-
sumption patterns in response to real or perceived risks, thereby increasing
their own food costs or changing product selection, which has consequences
for food producers. In international markets, potential losses of international
sales—or the diversion of sales to lower-value markets—are also evident when
food safety is inadequate, and these effects have persisted even as global trade
has expanded. Taken together, domestic and international market forces in
turn shape structural changes in the food sector, as consolidation takes place in
response to perceived needs for better food safety management.
This analysis of costs shows that a lack of capacity to address food safety
places burdens on public health, the food sector, and the economy as a whole.
The next chapter examines the state of the public capacity to facilitate improved
food safety management on several levels.

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EVIDENCE ON THE BURDEN OF UNSAFE FOOD 67

 CHAPTER THREE

The Status of Food Safety

Management in Developing
Countries

FOOD SAFETY CAPACITY

T
he foregoing discussion highlights how the prevalence of food safety
hazards reflects the actions, both individually and collectively, of actors
along agri-food value chains, as well as actors that are outside value
chains but are part of the wider food system. This reflects the level of food safety
capacity within specific value chains and the wider food system.
This perspective shows how food safety capacity is positioned at three ­levels
within food systems. First, it is positioned within the system itself; for example,
in the capacity of regulatory agencies and of testing, inspection, and certifi-
cation ­services. Second, it is positioned within value chain actors, including
input suppliers, producers, ­processors, distributors, retailers and caterers. And
third, it is positioned within individuals handling food products and operating
within the wider food system; for example, in the form of knowledge and skills
relating to food hygiene.
Integral to this broad definition of food safety capacity is the ability to
perform the various functions needed to manage the safety of the food end
product. These functions can be thought of as an interdependent and itera-
tive hierarchy of capabilities, as shown in figure 3.1: Food Safety Management
Capacities and Functions. At the most basic level, they include awareness and
recognition of the importance of food safety, the sources and consequences of
food hazards, and the nature and need for food safety practices. The next level is
the application of basic good hygiene practices along the value chain to prevent
contamination and to eradicate or manage food hazards along the value chain.

69
 FIGURE 3.1 Food Safety Management Capacities and Functions
Capacities Food safety management functions

Strategic
management

Risk-based systems

Human capital
Use of prevention or
Physical infrastructure controls of
Management systems food safety management

Institutional norms and systems

Basic hygiene practices

Awareness and recognition

Source: World Bank.

Simple examples include handwashing, cleaning processing tools or machines

after use, thorough cooking where needed, and keeping raw and cooked foods
separate to avoid cross contamination. These basic functions at the lower level
of the hierarchy are often missing in many informal food markets.
The middle of the hierarchy represents the progression to more advanced
and technically challenging elements of food safety management, entailing
the use of prevention or control measures in informed and purposive ways.
For example, in a food-processing plant this means adopting basic sanitary
controls, including monitoring incoming ingredients for hazards; monitor-
ing control processes to ensure they are effective (minimum temperatures,
for example); and sampling to ensure that basic standards are met. For farm
production, this can mean following good agricultural practices—GAPs—for
using chemicals and veterinary drugs, and applying manure.1

1
Good agricultural practices are a collection of principles for applying on-farm production and
­ ostproduction processes. They are aimed at promoting safe and healthy food and nonfood
p
­agricultural products, while taking into account economic, social, and environmental sustain-
ability. There are GAPs related to soil, water, animal husbandry/health, pest management, and
other e­lements of farm production. GAP applications have been developed by governments,
­nongovernmental organizations, the private sector, and international organizations. GLOBALG.A.P.
is an international private sector membership body, which develops and promotes the adoption of
a set of specific farm assurance standards involving GAP principles. Farms or businesses a­ pplying
GLOBALG.A.P. standards can obtain certification.

70 THE SAFE FOOD IMPERATIVE

 The top two segments of the hierarchy shown in figure 3.1 involve risk-
based and more sophisticated approaches to food safety management. This
includes using deliberate steps and procedures to identify sources of hazards
and critical control points, and using sampling and testing to verify controls.
The approaches also include setting up procedures for handling contaminated
or substandard products by destroying or diverting them to lower-risk uses.
Within a value chain, risk-based management can mean food value chain
actors verifying production processes for raw products, ensuring cold chain
control, and providing information to retailers and consumers about control
measures taken. Adopting risk-based systems is often accompanied by certifi-
cation to verify management practices.
Strategic management involves taking a forward-looking perspective
on potential and emerging risks, so that proactive measures can be taken to
develop control and surveillance. For modernizing economies, new risks may
appear with changes in production and marketing practices, as well as changes
in diets and consumer expectations. Here, food producers and firms need to
be strategic to avoid risks to brand reputation, and public agencies need to be
strategic in monitoring risks and carrying out public education.
Achieving the food safety functions shown in figure 3.1 requires establish-
ing, operating, and maintaining a portfolio of four key capacities. The first
is human capital across all those involved in the handling of food, as all are
potential food safety managers. This has various layers: basic knowledge of
food safety hazards and hygiene, appropriate food-handling techniques, and
specialized and technically sophisticated expertise in prevention and control.
Management and leadership skills are important human capital elements in an
effective food safety management system, which often requires coordination
along the supply chain. The second capacity is the necessary physical infra-
structure, which also has various layers: hygienic market places and distribu-
tion centers, food-processing facilities, and laboratory testing and research
facilities. Infrastructure to provide clean water, electricity, and sanitation is
vital for safe food.
The third and fourth capacities are less tangible than the first two, and often
less recognized. The management systems within enterprises handling food—
including record-keeping systems, procedures for staff training, methods of
verification, and procedures for recalling products—are the third capacity. This
also covers institutions involved in food safety controls, such as laboratories
and inspection and certification bodies, that require internal management sys-
tems for the use of their information to be effective. For example, laboratories
can be part of a broader system of surveillance, but this requires an informa-
tion management system. The fourth capacity is the broader institutional and
cultural norms and systems that inform the actions of food system participants.
These include regulations and their enforcement, standardization, enterprise
and brand reputation, social cues and pressures, and the professionalization of
food safety managers. These norms influence the strength (or otherwise) of a
food safety culture (box 3.1).

The Status of Food Safety Management in Developing Countries 71

 BOX 3.1 Food Safety Culture: What Happens When No
One Is Looking

The concept of a food safety culture is gaining ground to explain differences in

food safety performance across organizations, as well as the variable effectiveness
of training programs. Indeed, the recognition that training and, as a result, food
safety knowledge and awareness are poor predictors of safe food handling led
researchers to look for other explanatory factors. Some have gravitated toward the
concept of food safety culture, which has been described as “what happens when
no one is looking.”
How does a food safety culture develop, and how can a culture of producing
safe food be deliberately fostered? To answer these questions, it is necessary to
recognize that a food safety culture is multidimensional. The U.K. Food Standards
Agency’s work in these areas offers guidance. In 2013, the agency issued an
assessment tool for measuring food safety culture in food service organizations,
and recommendations on how food safety inspectors can most constructively
approach organizations given their prevailing food safety culture.
The tool is structured around eight dimensions: (1) priorities and attitudes
(a company’s attitudes toward food safety and how much it is prioritized), (2) risk
perceptions and knowledge, (3) confidence in food safety systems (including the
perceived validity and effectiveness of food hygiene regulations), (4) ownership
(whether food hygiene is seen as the responsibility of the firm or the regulator),
(5) competence (knowledge and understanding the risks and subsequent risk
management), (6) leadership (the extent of a clear commitment from management
for food safety), (7) employee involvement, and (8) communications (including the
freedom to challenge and discuss practices).
This way of breaking down the concept of a food safety culture suggests multiple
entry points for fostering a culture of safe food. It certainly upholds the relevance
of training programs. Indeed, training can not only be used to develop knowledge
and competence but also to shape attitudes and behaviors, and to show leadership.
It also shows staff that food safety is of central importance to a business, thereby
increasing their motivation to take food safety seriously. Here, the frequency of
training and how it is presented to staff can matter. The level of attendance of
training sessions and learning lessons reinforced by managers can also be key.

The hierarchy of food safety capacities shown in figure 3.1 encompasses

functions undertaken within agri-food value chains and by other actors, most
notably regulators and other the public sector bodies. Recognizing the locus
of food safety capacity is important to understand the factors influencing the
prevalence of food safety hazards, and for identifying potential points of entry
for investment or inducing behavioral change. Understanding the complemen-
tarities and interdependencies of these elements of capacity is critical to the
design and implementation of efforts to reduce food safety hazards. Thus, many
elements of capacity will not work effectively unless they coexist with other ele-
ments of capacity.

72 THE SAFE FOOD IMPERATIVE

 For example, regulatory limits on microbiological and chemical contami-
nants in food cannot be enforced unless reliable testing can be done. And this,
in turn, requires that laboratory facilities are available and laboratory quality
assurance schemes are in place. In some circumstances, capacity weaknesses
can be offset by capacity strengths—or at least the ability to tap capacity else-
where. Laboratory testing capacity in the public and private sectors is an exam-
ple of how exporting firms can either do their own testing or use private sector
providers if public sector capacity is weak (Henson and Jaffee 2008). In the
latter case, there are options for where capacity is best situated. Some form of
cost-benefit assessment is needed to determine where investments can be best
focused given the status of preexisting food safety capacity.

FACTORS THAT MOTIVATE FOOD SAFETY CAPACITY AND

BEHAVIORAL CHANGE

Investments in safe food management systems in the public and private sectors,
and safe food production and handling practices, are both motivated actions,
which can be induced by ethical, commercial, social, political, or other consid-
erations. When accounting for current gaps or lapses, and when considering
possible solutions, it is necessary to consider the underlying incentives, drivers,
or other motivating factors that apply to specific contexts, and how these are
changing or are amenable to change. The motivation for this can come from
various sources:

• Primary farm producers can be motivated to change their production

­practices because this can protect their households against disease and
enable them to tap more remunerative markets. Changing production prac-
tices can also come from family and social pressure from the community,
and whether these producers can use public support programs.
• Businesses may be motivated to invest in enhanced food safety capacity
because of fears of the consequences of noncompliance with regulations,
to avoid recalls and reputational losses, to reap competitive gains, out of
a sense of corporate social responsibility, and from pressure from political
leaders.
• Political leaders may be motivated to invest in enhanced food safety capac-
ity in the public and private sectors because of pressure from influential
­constituencies, such as large firms or vocal urban consumers, and oppor-
tunities to tap into additional funding from bilateral or multilateral donors.
Other motivations include gaining political advantage and reputation. In
some countries, political leaders have business interests in agricultural pro-
duction, and food production and distribution.

The nature of these incentives and their magnitude in particular con-

texts need to be explained, as do the reasons why these incentives might be

The Status of Food Safety Management in Developing Countries 73

 missing or weak in the first place. Effective ways need to be found to enhance
these incentives. These include the use of signaling mechanisms in retail food
markets that engender consumer demand for safer food, and efforts to raise
awareness among exporters of the importance of food safety capacity for inter-
national competitiveness. For simplicity, these incentives can be grouped into
two types:

• Market-based incentives through the demands of domestic consumers for

the safety of the food they buy and consume, the practices of food suppliers,
and the commercial requirements in overseas markets that exporters need
to comply with. Critical here is the role of value chains through which mar-
ket signals are transmitted from end-product markets to food processors,
traders, intermediaries, and primary producers.
• Political incentives through the demands put on governments by citizens,
advocacy groups, and businesses domestically; and by trading partners and
international agreements for investments in enhanced food safety capacity
and for more effective institutions for laying down and applying food safety
regulations and norms.

Importantly, these incentives vary both qualitatively and quantitatively,

depending on the level of economic of development. It is through changes in
the nature and level of these incentives that changes are seen in the level of
food safety capacity and, in turn, any variation in the burden of unsafe food
across countries. The potential to augment these incentives, individually and
collectively, and the degree to which they are complements or substitutes for
one another, varies with the level of economic development.
It is also important to recognize the role of a wide range of actors and insti-
tutions in creating and transmitting incentives for investment in enhanced food
safety capacity. The state of food safety capacity itself is important; indeed, there
is a cyclical interdependence—and possibly even a virtuous circle—between
food safety capacity across the public and private sectors and the incentives
that engender its creation in the first place (figure 3.2). For example, the abil-
ity to detect and monitor the prevalence of foodborne illness is a key driver of
market-based and political incentives to enhance capacity. Perhaps unsurpris-
ingly, many of the poorest countries are caught in a low-level capacity trap in
which incentives to build capacity are weak. This is because many of the critical
capabilities that generate and support these incentives, including effective food
safety risk assessment and public health reporting, are missing. But actors and
institutions well beyond the direct terrain of food safety also play a key role
in creating or refining incentives. These actors include the media, consumer
organizations, chambers of commerce and other business organizations, and
the courts and other aspects of the legal system.
While incentives are important as drivers of the overall level of investment
in enhanced food safety capacity, they also steer the direction of investments.

74 THE SAFE FOOD IMPERATIVE

FIGURE 3.2 Cyclical Relationship between Incentives and Level of
Capacity

Food safety capacity

Public and private incentives

Source: World Bank.

If, for example, the “voice” of exporters or rich consumers is loudest, whether
through market or political routes, it is likely that investments directed at the
food safety capacity needs of export value chains and formal urban market seg-
ments catering to elites will predominate. Likewise, if the “voice” of the poor
is muted or weak, there will probably be little political or market-based incen-
tives to invest in enhancing food safety capacity directed at markets catering
to them, as in informal food distribution channels. Hence, a “silent” burden
of foodborne illness exists among poor and rural populations more generally.
There is an evident need for training food handlers in informal markets and
informing consumers to induce incentives for behavioral change for improved
food safety (box 3.2).
Recognizing the role of incentives can be important to bring about sus-
tained improvements in food safety capacity, and understanding the nature
of choice behavior can make regulatory action and other interventions more
effective. People often think fast and respond automatically and decisively
to social incentives, and use mental models or specific worldviews to inter-
pret information and perceptions. Reflexive methodologies like nudging are
gaining attention as a way of triggering desired behavioral outcomes. Instead
of changing the conscious decision-making process, nudges alter the envi-
ronmental context in which a decision or behavior is completed (Marteau
et al. 2011). Nudges can take many forms, including environmental cues
that engage automatic decision-making processes that are quick and uncon-
scious rather than self-aware, goal-oriented, and controlled decision making.
Successful nudges have reduced food waste by 30–50 percent by not offering
trays in cafeterias (Thaler et al. 2009), increased positive recycling behav-
ior by 46 percent when footprints led individuals to recycling bins (Hansen
2010), and reduced portion size by serving food in smaller bowls (16 per-
cent) while increasing perceived food intake (7 percent) (Wansink and van
Ittersum 2006).

The Status of Food Safety Management in Developing Countries 75

 BOX 3.2 Food Handlers,Training, and Behavioral Change

Studies point to low levels of food safety awareness and unsafe food handling
practices, including among food handlers in formal and informal micro and small
enterprises across a variety of contexts and among consumers. This research often
finds that training, education, and information campaigns are needed to increase
the food safety knowledge and awareness of both consumers and food suppliers.
Training is one of the most common interventions used to improve food handling
and related food safety outcomes, but evidence suggests this has a weak record
of durably changing food handling attitudes and behavior, let alone food safety
outcomes.
The limitations of training in achieving behavior change is not a surprise, at least
to the extent that the main purpose of training is to remediate gaps in knowledge
and know-how, on the assumption that information is central to behavioral failure
and essential to remedying it. Training programs often fail to address what is
understood about human behavior. A literature review yields several insights that
are now discussed.
Done right, training can enhance knowledge and awareness of food safety
risks and risk mitigation practices. Many studies show that trained food handlers
have greater knowledge of food safety risks and mitigation practices. For example,
improvements in food handlers’ post-training knowledge were found in studies by
da Cunha, Stedefeldt, and de Rosso (2014) for food handlers in Santos City, Brazil;
by McIntyre et al. (2013) for food handlers in British Columbia, Canada; by Baş,
Ersun, and Kıvanç (2006) for food handlers in Turkey; by Al-Shabib, Mosilhey, and
Husain (2016) for food handlers at a university in Saudi Arabia; by Park, Kwak, and
Chang (2010) for restaurant workers in the Republic of Korea; by Soon and Baines
(2012) for farm workers in the United Kingdom; by Campbell (2011) for street food
vendors in Johannesburg; by Brannon et al. (2009) for food service workers in the
United States; and by Choudhury et al. (2011) for street food vendors in Assam,
India—to name just some of these studies.
Improved knowledge, however, does not always translate into safer practices
among food handlers. Some studies find statistically significant—yet still minor,
partial, or time-bound changes in behavior—demonstrating the limitations of
training. Singh et al. 2016, in a study of street food vendors in India, showed that
training resulted in only partial behavior change, but was not enough for vendors to
meet standards. Acikel et al. (2008), in a study of hospital food workers in Turkey,
found that wearing jewelry and watches declined after training (self-reported), but
that other hygienic behavior remained the same, as did the level of enteric colonies
growing on the hands of participants after training. In another study, food handlers
in the United Kingdom perceived the effects of training on behavior to be positive
yet time-bound and limited (Seaman and Eves 2010).
Some studies find no significant change in behavior. A review of 253 studies
showed half of them found “no proper translation of knowledge” into attitudes or
attitudes into practices after training (Zanin et al. 2017). Most of the studies were
conducted in developing economies.

(Continued)

76 THE SAFE FOOD IMPERATIVE

BOX 3.2 Food Handlers,Training, and Behavioral Change (Continued)

The obvious conclusion from this literature review is that training is a necessary
but insufficient condition for behavioral change among food handlers. But this
requires much more than providing them with knowledge or know-how; it
requires attention to economic incentives as well as social norms. Insights from
the behavioral sciences—from social psychology, marketing, and behavioral
economics—are potentially relevant for designing food safety training programs
and other interventions.
Many of these directions are consistent with what are known as social marketing
techniques. These often appeal to emotions and social motivations to increase the
salience of information, as well as the likelihood that it will be acted on. Social
marketing techniques also attempt to harness the power of automatic behavior by
providing people with new mental models and behavioral scripts, and by inserting
behavioral triggers into their environment.
Given the power of social incentives to change behavior, one promising
approach to improving food safety may be to involve consumers and peers in
monitoring the behavior of food handlers. One way to do this is to raise awareness
among consumers and empower them to make demands on food handlers, thereby
shifting social norms surrounding a given behavior.

BENCHMARKING FOOD SAFETY CAPACITY

Benchmarking provides important signals about institutional performance

and helps motivate improvements. It can point to specific reform or investment
needs and help set and monitor targets. Examples of influential benchmark-
ing abound, including the World Bank’s long-standing Doing Business Index,
the Enabling Business of Agriculture Index, Transparency International’s
Corruption Perceptions Index, the Economist Intelligence Unit’s Global
Food Security Index, and the Barilla Center for Food and Nutrition’s Food
Sustainability Index.
But no representative and comprehensive benchmark exists for food safety
in low- and middle- income countries (LMICs). While detailed assessments
have been done on the status of primarily public food control systems in many
of these countries, the findings are generally not conducive to quantification
and thus comparison. And many of these studies are not in the public domain
because of the sensitivity surrounding public food control systems, and per-
haps because of concerns about how the media or public would react to docu-
mented shortcomings in current systems. Much of the detailed information
on food safety management capacity and performance is found in the “gray”
literature, which cannot be directly quoted. This situation, together with the
underlying weaknesses in the data on food safety hazards and foodborne dis-
ease (FBD), exacerbates the inadequate public dialogue on food safety priori-
ties in many LMICs. This is manifested in two separate public dialogues: one

The Status of Food Safety Management in Developing Countries 77

 involving experts with lead agencies and private companies; the other playing
out in social media, informed by a combination of facts, rumors, and myths.
Reviews of food safety technical assessments across countries at similar
levels of economic development tend to show many common strengths and
weaknesses. For example, a series of food control assessments carried out
by the Food and Agriculture Organization in South Asia and Southeast Asia
(FAO 2015a, 2015b, 2016) found quite common situations in terms of:

• The lack of a comprehensive national policy, translating into a lack of priori-

tization of key elements of food safety management capacity.
• Progress on food law modernization, but less on regulations to enable
enforcement of the law.
• Food safety laws frequently not being risk-based and covering the whole
food chain.
• The presence of many standards, yet lack of clarity on their voluntary versus
mandatory nature.
• The absence of effective mechanisms for the accreditation and certification
of businesses.
• The categorization of food-processing and -handling enterprises being more
frequently based on size and domestic or export market orientation and not
on risk considerations. Because of this, inspections of enterprises and facili-
ties were generally not risk-based.
• The fragmentation of institutional responsibilities among lead agencies and
ministries with often weak coordination due to overlapping mandates or
gaps (these entities also tended to resist giving up their roles so that reforms
required policy decisions at higher levels).
• The lack of coordination in monitoring hazards, risks, and illness outcomes.
• Fragmented systems for laboratory testing that do not function as a network
and do not yield inferences on food safety.
• Most laboratories not being fully accredited.
• The lack of reliable data to assess the scale and distribution of many food
safety problems. Research from different disciplines used different sam-
ples and methods that could not be easily analyzed in an integrated way.
Although there are some in-depth studies of specific industries or hazards,
research tends not to link up with broader changes in the food system and
therefore cannot inform forward-looking policy making.

The single dedicated tool for benchmarking food safety management

c­ apacities—the Food Safety Performance World Ranking—has been applied
only to 17 Organisation for Economic Co-operation and Development coun-
tries (Le Vallée and Charlebois 2014). This tool takes a systematic approach to
identify and evaluate the elements of food safety management systems related
to risk assessment, risk management, and risk communication. Importantly,
many of the tool’s indicators may not be directly applicable to LMICs.

78 THE SAFE FOOD IMPERATIVE

Other examples of benchmarking or comparative tools in which LMICs are
included or are the foci include:

• The World Health Organization’s International Health Regulations core

competency framework. This entails self-reporting related to various laws or
institutions. For food safety, however, the “yes” or “no” responses it encom-
passes often do not give an accurate picture of underlying institutional
functionality.
• The Economist Intelligence Unit’s Global Food Security Index. This includes
ratings for food quality and safety, but it puts more emphasis on dietary
quality and diversity indicators, while its three food safety indicators give
little information on food safety management capacity.2
• The Inter-American Institute for Cooperation in Agriculture’s performance
of veterinary service (PVS) tool. This covers multiple dimensions of food
safety, but it is based on self-reporting and has been systematically applied
to only six Latin American and Caribbean countries (and the results are not
publicly available).
• The United Nations Industrial Development Organization. It has done a
one-time survey of 28 Asian and African countries to gauge the quality of
management infrastructure and institutions; coverage included metrology,
standardization, certification, and testing.
• Several attempts to use trade rejection data to gauge food safety and wider
sanitary and phytosanitary performance. Perhaps the most comprehen-
sive of these being UNIDO (2015); results from this work are cited in
chapter 2.
• The International Livestock Research Institute’s food safety performance
assessment tool. Its first application was in countries in Sub-Saharan
Africa, and it shows considerable promise (Grace et al. 2018). But because
it relies on secondary data, it only gauges food safety management capaci-
ties to a limited extent. Still, it uses other indicators—related to physical,
social, and human capital—which would be expected to improve food
safety outcomes.

This report took several approaches to gauge levels of food safety manage-
ment capacity and compare them across countries in different regions and at
­different levels of economic development. Several restricted databases were
used to discern some broad patterns, supplemented by literature reviews on
capacity dimensions for which national or comparative data are not generally
available. The results, while interesting and suggestive, are not enough, given

2
These are access to potable water, the presence of modern food retailing, and a dedicated food
safety control agency.

The Status of Food Safety Management in Developing Countries 79

 the importance of having an accurate reading of food safety management
capacity and performance.3

THE PUBLIC SECTOR’S CAPACITIES FOR MANAGING

DOMESTIC FOOD SAFETY RISKS

A major source of data for this report is the assessment results of the World
Organisation for Animal Health–led Evaluation of Performance of Veterinary
Services. This is relevant because veterinary services are normally responsible
for the safety of animal source foods, typically the riskiest commodities. The
organization’s PVS tool is used to gauge the status of a broad set of critical
­competencies associated with national veterinary services. The fundamen-
tal components of the assessment pertain to human, physical, and financial
resources; technical authority and capability; interaction with interested
­parties; and measures to ensure market access. The tool’s 6th and most recent
version covers 38 critical competencies. World Organisation for Animal Health
member countries request the organization to undertake evaluations, and
expert teams are used for this purpose. The evaluations are often supplemented
by gap analyses, in which progress is gauged from the time of earlier analyses.
These assessments include a rating system for each competency, ranging from
1 (little or no capacity) to 5 (a very high level of competence or application of
best international practice).
The PVS tool has been used in over 100 countries across all country income
categories. Most assessments and gap analyses are not public documents, and
some have highly restricted access. Development partners, including the World
Bank, are being given selective access to many of these assessments because of
their role in potentially financing new investments to strengthen service capac-
ities. But there are still limitations on what information from these assessments
can be made public, and this includes specific capability assessment ratings for
individual countries. Because of this, the information in this report is aggre-
gated or clustered across types of countries.
The relevance of the PVS tool for this report is twofold. First, a subset of
the 38 assessment criteria is either directly associated with the food safety of
animal products or is likely to influence how well food safety is performed.
This report uses the ratings for 18 criteria, including two associated with
­funding adequacy (operational funding and capital investment); 11 associ-
ated with technical capacities and regulatory functions (that is, those related
to inspections, veterinary drug regulation, residue testing, the identification

3
Future work should seek to develop more comprehensive and comparable benchmarks. The
authors of this report believe the Inter-American Institute for Cooperation in Agriculture’s assess-
ment tool provides a promising start from which adjustments could be made to several of the core
criteria. It is important that any comparative tool involve disinterested and expert assessments
(rather than self-reporting), and that the results, or at least a stylized summary of those results, be
put in the public domain.

80 THE SAFE FOOD IMPERATIVE

and traceability of animals and animal products, laboratory infrastructure,
quality assurance, quarantine, border controls, and emergency response);
and four related to international market access. Because of the prominence
of animal source foods in the incidence of foodborne disease globally and
in LMICs, this report’s coverage of this more specialized dimension of
food safety management is highly relevant and likely indicative of broader
patterns.
PVS assessment ratings were obtained for 93 countries where these assess-
ments and gap analyses had been done since 2010. The 93 comprised 20
low-income countries, 35 lower-middle-income countries, 39 upper-middle-
income countries, and nine high-income countries. This report focuses on the
LMICs.
Table 3.1 highlights the ratings in the PVS assessments for the adequacy of
public spending on national veterinary services for operational funding and
capital investment. For simplicity, the ratings of 3, 4, and 5 denote adequate
funding; ratings of 1 or 2 denote inadequate funding. Spending more of course
does not necessarily translate into an effective capacity to perform key func-
tions. Yet, the absence of adequate funding will surely translate into problems
for the delivery of regulatory and technical services. Low operational funding
restricts the mobility of veterinary and inspectorate staff and their ability to
carry out functions, while low capital investment may result in dilapidated or
antiquated core infrastructure. The assessed situation is quite serious. Public
funding is inadequate across much of the LMIC sample. Only in 15 of the
84 LMICs is funding for operations and capital investment adequate. The situa-
tion is much better among upper-middle-income countries (more than a third
have adequate funding) than among low- and lower-­middle-income countries.4

TABLE 3.1 Adequacy of the Finance for National Veterinary

Services
Income Countries Countries with Countries Countries
category for which adequate levels with adequate with adequate
data were of operational levels of capital levels of both
sourced funding investment
Low 20 2 3 2
Lower-middle 35 5 4 3
Upper-middle 29 14 18 10
High 9 8 8 8
Total 93 29 33 23
Source: Based on World Organisation for Animal Health performance of veterinary services
assessments.

4
Many of the PVS reports provide detailed estimates on the levels of funding that are needed for
effective veterinary system performance.

The Status of Food Safety Management in Developing Countries 81

 Figure 3.3 summarizes the frequency of adequate ratings across 13 indica-
tors for different categories of LMICs. Not included are the results for high-
income countries, where, almost universally, the ratings are high, except where
the capacity is not relevant given some dimension of a country’s agriculture
or food system. Again, an adequate capacity is one in which the rating is either
a 3, 4, or 5. Even in the absence of a detailed breakdown, the broad picture is a
concern because it points to considerable underinvestment in capacities, espe-
cially in low- and lower-middle-income countries. For example:

• Across most LMICs, capacities for disease and food safety surveillance, and
production and facility inspections, are very low. This makes risk assess-
ment problematic and, in turn, means that risk management is not readily
undertaken.
• Traceability systems for animals and animal products, which are prominent
features of disease control and food safety management systems in high-
income countries, are virtually absent in LMICs.
• A somewhat larger proportion of LMICs have adequate laboratory infra-
structure, but laboratory quality assurance systems are generally weak.
• A much larger proportion of upper-middle-income countries have ­adequate
capacities across most functional areas considered here. But most upper-­
middle-income countries have strong capacity only for a minority of functions.

FIGURE 3.3 Indications of Underinvestment in Animal Product Food

Safety Capacity
80
Proportion of countries with

70
adequate capacity (%)

60
50
40
30
20
10
0
es ir i ora tion

dr lati spe strib es

nd f v ate n

An sid ical y

im ntifi g

to ra du n
in ab s ID

re

en enc tro er

e
on

uc ls,
in
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an anc

tifi of l ons
s a o r tio

o
g a pe s
gu in di rat

tu

rg con ord
bi ete s

u s

qu stru y

tio y re ls

od a
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ts
st
te

at
t

pr anim
t c

ug on cto u

ry ce ct
fra ili
c

ur
al e te

sp
Pr at pec odu

o r
nd to

tio gist
b
ss
c

e
ra d t ro

ra ty a
in Pr

of
e
sin ns

n
e
i
i
s

l
in
a

n
nt
im

ca
oc to

e
An

ta
Em
b
La

ua
Ab

er
Q
Re

em

C
La

pl
Im

Low income Lower-middle income Upper-middle income

Source: Based on World Organisation for Animal Health country performance of veterinary
service assessments and gap analyses.

82 THE SAFE FOOD IMPERATIVE

 The ratings for capacities relevant to the management of food safety related
to animals and animal products are brought together to develop a simple
unweighted Animal Products–Related Food Safety Capacity Index. Figure 3.4
shows the comparative results by country and region. Several observations can
be made. The highest capacities tend to be clustered among countries in Latin
America, several of which are major exporters of animal products. For these
countries, market position has undoubtedly been a major driver of invest-
ments in veterinary controls and food safety. Animal products–related food
safety capacity is also generally stronger among countries in North Africa,
the Middle East, and Eastern Europe, either stemming from their existing or
aspired trading relations with the European Union (EU) or Russian Federation,
or because of the importance of commercial livestock production in these
countries. Capacity patterns vary considerably in Asia and Sub-Saharan Africa,
with some better-performing outliers (for example, Botswana, Malaysia, South
Africa, Thailand, and Uganda); yet many other countries in these regions have
comparatively low capacities.
The capacity to manage the food safety risks associated with animal prod-
ucts needs to be considered in relation to the need to do so. Livestock and
animal products are vital to the agricultural economies of some countries, yet
not to others. The importance of animal products in diets also varies widely.
Some countries are prominent or at least minor exporters of livestock and
animal products, while others are not. Exporting countries tend to have more
advanced capacities to oversee external trade in animal products, yet this may
not spill over to improved risk management for these products in domestic
markets. Demographic factors, such as level of urbanization, might be expected
to influence the need for effective food safety management, given its impact on
the length of animal product distribution channels or the greater possibility of
disease transmission in densely populated areas. Taking these factors into con-
sideration, a Food Safety Management Capacity Need Index was constructed.5
Figure 3.5 maps the Animal Products–Related Food Safety Capacity Index
against the Food Safety Management Capacity Need Index for countries for
which data are available. Countries in the top right quadrant have high capac-
ity needs and high-rated capacities. Those in the bottom left quadrant have
low capacity needs given their dietary, agricultural structure, and demographic
conditions. Countries in the lower right quadrant have high capacity needs
relative to capacity and, consequently, are those of greatest concern.
It is the relationship between need and capacity that should influence
food safety outcomes. Figure 3.6 ranks countries according to their apparent

5
This is based on a series of the following proxies: (1) the economic importance of the livestock sec-
tor measured by livestock production as a proportion of the value of agricultural output (35 percent
weighting), (2) level of consumption of animal-based foods measured as the proportion of total food
consumption accounted for by these foods (35 percent weighting), (3) importance of exports measured
by the value of livestock and meat exports as a proportion of total agri-food exports (15 percent weight-
ing), and (4) the extent of supply chain restructuring and degree of separation of production and con-
sumption measured by the proportion of the population living in urban areas (15 percent weighting).

The Status of Food Safety Management in Developing Countries 83

 FIGURE 3.4 Animal Products–Related Food Safety Capacity Index by
Country and Region
Chile
Argentina
Uruguay
Serbia
Brazil
South Africa
Colombia
Morocco
Algeria
Thailand
Botswana
Bosnia and Herzegovina
Iran, Islamic Rep.
Uganda
Belarus
Malaysia
Panama
Paraguay
Philippines
Sudan
Dominican Republic
Tunisia
Belize
Eswatini
Congo, Dem. Rep.
Ethiopia
Fiji
Zimbabwe
Bolivia
Vietnam
Barbados
Nigeria
Kazakhstan
Senegal
Trinidad and Tobago
Jordan
Kyrgyz Republic
Bhutan
Seychelles
Vanuatu
Kenya
Uzbekistan
Indonesia
Suriname
Egypt, Arab Rep.
Albania
Papua New Guinea
Venezuela, RB
Côte d’Ivoire
Tanzania
Guinea
Honduras
Myanmar
Pakistan
Angola
Ecuador
Nicaragua
Cabo Verde
Jamaica
Yemen, Rep.
Togo
Afghanistan
Benin
Ghana
Madagascar
Mauritania
São Tomé and Príncipe
United Arab Emirates
Azerbaijan
Cameroon
Niger
Turkmenistan
Costa Rica
Gabon
Lesotho
Mongolia
Central African Republic
Lao PDR
Burundi
Chad
Guinea-Bissau
Libya Region
Maldives Asia
Cambodia
Haiti Latin America and the Caribbean
Liberia
Timor-Leste Middle East and North Africa, Eastern Europe
Bangladesh
Comoros Sub-Saharan Africa
Sierra Leone
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
Animal-Products Related Food Safety Capacity Index

Source: Based on World Organisation for Animal Health country performance of veterinary
service assessments and gap analyses.

84 THE SAFE FOOD IMPERATIVE

 FIGURE 3.5 Animal Products–Related Food Safety Capacity Index versus Food Safety Management Capacity Need
Index by Income Group
85
Income group
80 Low income Chile
Argentina Uruguay
Lower-middle income
75 Serbia
Upper-middle income Brazil
70 High income
Colombia South Africa
65 Thailand Algeria
Iran, Islamic Rep. Botswana
Uganda Belarus
60 Malaysia
Paraguay Panama
Philippines Dominican Republic
55 Sudan
Tunisia
Eswatini Belize
50 Congo, Dem. Rep. Ethiopia Bolivia
Zimbabwe Trinidad and Tobago Barbados
Vietnam Kazakhstan
45 Nigeria Senegal Kyrgyz Republic Jordan
Bhutan Kenya
Seychelles
40 Vanuatu Uzbekistan
Papua New Guinea Indonesia Egypt, Arab Rep. Suriname Venezuela, RB
Honduras Albania
35 Guinea United Arab
Tanzania Myanmar
Cabo verde
Angloa Pakistan
Togo Emirates Yemen, Rep. Jamaica Nicaragua
Madagascar Niger Afghanistan
30 Benin Costa Rica Turkmenistan
São Tomé and Lesotho Mauritania
Cameroon Gabon Príncipe Azerbaijan Mongolia
Burundi Guinea-Bissau Central Africa
Chad Maldives Libya

Animal Products–Related Food Safety Capacity Index

25 Bangladesh Republic
Cambodia Haiti
Liberia Timor-Leste
Comoros
20 Sierra Leone

15
15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95
Food Safety Management Capacity Need Index

The Status of Food Safety Management in Developing Countries

Source: Based on World Organisation for Animal Health country performance of veterinary service assessments and gap analyses; FAOSTAT; World Bank, World
Development Indicators.

85
 FIGURE 3.6 Gap between Animal-Based Food Safety Need and
Capacity by Country and Income Group
Mongolia Income group
Mauritania
Nicaragua Low income
Libya
Venezuela, RB Lower-middle income
Albania
Pakistan Upper-middle income
Azerbaijan High income
Turkmenistan
Jamaica
Congo, Dem. Rep.
Central African Republic
Maldives
Yemen, Rep.
Kazakhstan
Seychelles
Jordan
Cabo Verde
Kyrgyz Republic
Suriname
Ecuador
Barbados
Lesotho
Timor-Leste
Afghanistan
Guinea-Bissau
Bolivia
Belarus
Honduras
Trinidad and Tobago
Haiti
Bosnia and Herzegovina
United Arab Emirates
Uzbekistan
Sierra Leone
Lao PDR
Chad
Panama
Myanmar
Bangladesh
Cambodia
Niger
Vietnam
Kenya
Uruguay
Brazil
Costa Rica
Egypt, Arab Rep.
Tanzania
Tunisia
South Africa
Botswana
Comoros
Colombia
Ethiopia
Madagascar
Malaysia
Gabon
São Tomé and Príncipe
Vanuatu
Angola
Uganda
Liberia
Chile
Senegal
Indonesia
Belize
Sudan
Fiji
Zimbabwe
Serbia
Algeria
Philippines
Morocco
Paraguay
Bhutan
Cameroon
Argentina
Benin
Ghana
Togo
Thailand
Iran, Islamic Rep.
Eswatini
Burundi
Côte d’Ivoire
Papua New Guinea
Guinea
Nigeria
Dominican Republic
–30 –25 –20 –15 –10 –5 0 5 10 15 20 25 30 35 40 45 50 55 60 65
xxxx

Sources: Based on World Organisation for Animal Health country performance of veterinary
service assessments and gap analyses; FAOSTAT; World Bank, World Development Indicators.

86 THE SAFE FOOD IMPERATIVE

“capacity gap” in managing animal-based food safety—that is, the gap between
need and capacity as shown by the relative position of the two indexes. Most of
the countries with especially high gaps are middle-income countries, a pattern
consistent with the life cycle concept highlighted in chapter 1. The largest gaps
appear to be for Mauritania, Mongolia, and Nicaragua. Countries having more
than adequate capacity are either those with very strong animal-based food
safety management systems (for example, Argentina, the Islamic Republic of
Iran, and Thailand) or those not yet requiring strong capacities because of their
position on the agricultural and dietary transformation pathway. An example
of efforts to address this gap in food safety management capacity for animal-
based foods is given in box 3.3.
Multiple factors contribute to FBD from animal-based foods. Among bad
conditions and practices are poor husbandry practices, inappropriately adminis-
tered veterinary drugs, mishandled animals during transport, insanitary slaugh-
ter facilities and inappropriate slaughtering methods, and recontaminated meat
during storage and distribution. Weak capacities to regulate and deliver technical
support services undoubtedly exacerbate the widespread nature and persistence
of these conditions and practices.

BOX 3.3 Tackling Risks from Animal-Based Foods in Vietnam

The World Bank–supported Livestock Competitiveness and Food Safety Project

aims to increase the competitiveness of livestock production in 12 provinces in
Vietnam, while reducing the environmental footprint of livestock and enhancing
food safety along the entire value chain.
The project supports disease-free livestock production and the adoption of
good animal husbandry practices, combined with the collective action of livestock
farmers, the modernization of slaughterhouses to comply with environmental and
food safety standards, and upgrading traditional wet markets, where most fresh
food in Vietnam is bought. The project also aims to strengthen the capacities
of central and local governments to undertake disease and food safety control
measures.
The project has already effectively applied a One Health approach on a fairly
large scale. Significant attention has been given to upgrading slaughterhouse
and market infrastructure, as well as influencing the behavior of farmers, food
operators, and consumers toward safer animal husbandry, food handling, and food
preparation practices.
The project has been instrumental in changing the minds of policy makers
about the role and ability of smallholders and small and medium-sized enterprises
to participate in modern agri-food value chains, and in demonstrating practical
examples of how to improve the management of food safety in the context of a
relatively fragmented farm sector, informal trade practices, and consumers’
preference for buying fresh meat in wet markets. The prevailing thinking had
been that production and distribution channels must be consolidated to realize
improved food safety.

The Status of Food Safety Management in Developing Countries 87

 Everything else being equal, countries with more adequate levels of food
safety management capacity will likely have a lower incidence of FBD. To test
this assumption, the burden of FBD attributable to animal source foods, as esti-
mated by the Foodborne Disease Burden Epidemiology Reference Group, was
examined in relation to the Animal Products–Related Food Safety Capacity
Index. Countries with a higher value on the index have a lower burden of
­animal-based FBD.6 For particular elements of the index, capacities for inspec-
tion and the regulation of veterinary drugs and residue testing have the stron-
gest negative correlation with the burden of animal-based FBD.7 The status of
laboratory infrastructure is the element of animal-based food safety capacity
that is least strongly correlated with the burden of animal-based FBD.8
An especially noteworthy finding is the enormous difference among low-
and lower-middle-income countries in the apparent FBD burden between
countries that are and are not adequately funding their veterinary services.
This is summarized in table 3.2. Only seven of the 55 low- or lower-middle-
income countries in the sample were rated in the World Organisation for
Animal Health’s PVS assessments as providing adequate operational funding
for their veterinary services. For the seven countries, the average disability-
adjusted life years (DALYs) burden of FBD from animal source foods is 192

TABLE 3.2 Average Animal Source Food DALYs Burden by Country

Category and Funding Adequacy
Income Countries Countries Average animal Average animal
category in sample with source food source food
adequate DALYs per DALYs per
levels of 100,000 people 100,000 people
veterinary for countries for countries
service with adequate with inadequate
operational funding funding
funding

Low 20 2 228.1 597.7

Lower middle 35 5 177.1 293.2
Upper middle 29 14 116.1 81.0
High 9 8 46.0 41.9
Total 93 29 115.1 333.0
Sources: Based on World Organisation for Animal Health performance of veterinary services
assessments and Foodborne Disease Burden Epidemiology Reference Group estimates.
Note: DALY = disability-adjusted life year.

6
Correlation coefficient is −0.57.
7
Correlation coefficients are inspection and regulation of veterinary drugs = −0.52, residue
­testing = −0.51.
8
Correlation coefficient is = −0.37.

88 THE SAFE FOOD IMPERATIVE

 per 100,000 people. For the 48 countries using inadequate public resources, the
estimated DALYs burden is 407 per 100,000. The difference between the two is
equivalent to four or five times the total FBD DALYs from animal source foods
per 100,000 people in most high-income countries.
Figure 3.7 shows the diverse pattern of estimated FBD DALYs from ani-
mal source foods among several Sub-Saharan African countries. Countries
are split between those with adequate and inadequate levels of operational
funding for veterinary services. The averages for the former are a loss of 208
DALYs per 100,000 of the population; for the latter, the average is 569. For
an indicative country of 20 million people that has a gross national income of
US$2,000 per capita with adequate funding, the annual productivity loss would
be US$83.2 million. The loss for inadequate funding using the same mea-
sure would be US$227.6 million. For Nigeria, a large country, the difference
between having adequate and inadequate finance implies a productivity loss of
US$749 million rather than US$2.05 billion. Conversely, by adequately invest-
ing in veterinary services, a country the size of Ethiopia would have a burden of
US$415 million rather than US$1.1 billion. These results provide a compelling
case that moderate levels of investment in enhancing food safety management
capacity—and specifically for animal-based FBD—can have significant public
health and economic benefits.

FIGURE 3.7 Foodborne Disease Attributable to Animal-Based Foods

among Sub-Saharan African Countries with Adequate
vs. Inadequate Veterinary Service Funding
1,000
900
DALYs per 100,000 of the population

800
700
600
500
400
300
200
100
0
Inadequate Adequate

Central Africa Eastern Africa Southern Africa Western Africa

Sources: DALY estimates by Foodborne Disease Burden Epidemiology Reference Group; fund-
ing adequacy based on the World Organisation for Animal Health performance of veterinary
services assessments.
Note: Country-specific burden of disease estimates are not published by the WHO and hence
the countries are not individually labeled in this graph. DALY = disability-adjusted life year.
Inadequate and adequate refers to the adequacy of animal product food safety financing.

The Status of Food Safety Management in Developing Countries 89

 THE ALTERNATIVES TO PUBLIC REGULATION

Because public food safety management capacity tends to be inadequate in LMICs,

interest is growing in alternative approaches to regulation envisaging a new rela-
tionship between the private sector as the “regulated” and the government as “regu-
lator” (box 3.4). Thus, co-regulatory approaches and other forms of public-private
partnerships are seen to provide opportunities to achieve greater efficiency in the
management of food safety through the adoption of approaches that are practica-
ble and more amenable to available resources, prevailing capacities, and incentives
within agri-food value chains (Martinez et al. 2007; Narrod et al. 2009).
For alternatives to direct regulation, the public sector can support the
­development and application of voluntary codes of practice or private ­standards,
provide information to businesses and consumers about risk management, and
engender market-based incentives for better risk management. Regulatory
approaches can be made more flexible to allow businesses to comply in ways
that are more efficient and effective. Initiatives for this include industry inputs
to the design of regulatory standards, flexibility in applying and enforcing pro-
cess standards, and industry collaboration on enforcement.

BOX 3.4 Shifting Paradigms and Responsibilities in Food

Safety Regulation

Regulatory systems for delivering public goods have traditionally been aimed at
changing or controlling the behavior of businesses in a way that will either avoid
damage or help create desired public goods, including the protection of public
health. The trend toward a new regulatory paradigm, most notably in industrial
countries—such as Australia, New Zealand, the United Kingdom, and the United
States—involves establishing a partnership between the public and private sectors,
and moving away from the strict policing function of government. The aim is to
ensure that regulatory systems are effective in what they aim to deliver (in other
words, how they perform in terms of desired outcomes), rather than in how they
are designed and the enforcement functions applied.
For food safety, there is a strong link between this trend and the more preventive
approach. Rather than ex post sanctioning for a food safety failure, the focus has
progressively shifted to ex ante identification of a hazard, and measures are then
taken to prevent potential damage. Thus, the focus is essentially on managing
risk. For example, the European Union adopted a preventive approach through
its General Food Law Regulation of 2002. In 2011, the United States adopted a
preventive approach through its Food Safety Modernization Act, and spent six
years developing the implementing regulations and preparing staff, businesses, and
markets for this new approach to food safety regulation.
The United Kingdom has perhaps advanced farthest, with the Food Standards
Agency actively promoting the concept of “regulated self-assurance and earned
recognition” through its Regulating Our Future proposal. This includes measures

(Continued)

90 THE SAFE FOOD IMPERATIVE

BOX 3.4 Shifting Paradigms and Responsibilities in Food
Safety Regulation (Continued)

to (1) develop an enhanced registration system to gather more data on food

businesses and to try to ensure that each business is sufficiently compliant
from the start; (2) develop the agency’s segmentation model of food businesses,
which is still based on risk but is moving most of the sector into regulated self-
assurance; (3) develop a system of regulated self-assurance for businesses that have
demonstrated their compliance; (4) maintain inspection and enforcement systems
at the local government level; (5) maintain a surveillance system for emerging
risks; and (6) aim for full cost recovery of regulatory activities, including the Food
Standards Agency’s running costs and the costs of intervention.
A key element of co-regulatory approaches to food safety regulation is the
recognition of private assurance systems. These involve food safety standards
that are established by private entities, which have compliance with regulatory
requirements as their starting point and compliance ascertained through private
auditing systems. In the United Kingdom, the Red Tractor Scheme is an on-farm
assurance facility with separate standards for different agricultural commodities.
Red Tractor, run by the nonprofit company Assured Food Standards, sets standards
and assesses compliance with these standards at various points on the value chain.
Certificates of conformity permit products to display the Red Tractor logo at the
point of sale. For organic foods in the United Kingdom, the charity Soil Association
certifies food products against its own organic standards, which comply with
European Union norms.
Co-regulatory approaches to food safety have progressed most dramatically in
industrial countries, though there are signs of a shift toward this approach in low-
and middle-income countries. China uses the preventive model at the legislative
level through its Food Safety Law of 2015, although the country has a long way
to go to implementing this approach. The Association of Southeast Asian Nations,
also in in 2015, adopted the Food Safety Policy and Regulatory Framework for its
member states, which has proactive prevention at its core. And India is striving to
engage consumers in raising food safety standards as an alternative and supplement
to conventional enforcement.

Because of the weak regulatory capacity of many LMICs, especially low- and
lower-middle-income countries, considerable interest is growing in the role of
co-regulatory approaches and other forms of public-private partnerships for
food safety. These approaches offer opportunities to offset weaknesses in public
systems in promulgating and enforcing food safety regulations by leveraging
private incentives for safe food. This, however, greatly contrasts with the strict
regulatory function of government in LMICs and will require a significant cul-
tural shift by regulatory agencies and their personnel.
Importantly, adopting co-regulatory approaches does not imply that
­governments simply stand back and let agri-food markets function unimpeded.
Active engagement is needed between the public and private sectors, and explicit
recognition of where private food safety governance mechanisms do or do not

The Status of Food Safety Management in Developing Countries 91

 accord with regulatory requirements. Indeed, a role remains for more traditional
modes of regulatory enforcement where private mechanisms of food safety
assurance are too weak or market-based incentives for businesses to upgrade
their food safety management capacity are missing. Co-regulatory approaches
also require capabilities within businesses and across sectors, including the abil-
ity and willingness of value chain actors to coordinate their activities for food
safety management. In nascent and rapidly evolving sectors, and in the informal
sector, it is unlikely that conditions will be conducive to this approach.
In industrial countries, markets have emerged for foods on the basis of food
safety, either through the branding of food (for example, many retailers’ brands
are marketed on their safety and quality) and labels attached to systems of certi-
fication with voluntary public or private standards, especially the latter. In prin-
ciple, market-based initiatives might offer potential for the private governance
of food safety in LMICs, but these countries face various constraints that are
likely to limit their role in practice.
Market-based incentives for compliance with voluntary food safety
­standards are highly reliant on consumer demand for certified foods. There
is evidence that consumers in LMICs are unable or unwilling to pay for these
foods because of a lack of awareness or poor understanding of what certifica-
tion represents. Yin et al. (2010) found that low awareness of organic food was
one of the main reasons for the lack of consumer demand for these products
in China. A study carried out in urban centers of southern Vietnam found that
consumer familiarity with food quality certifications went hand in hand with
higher levels of income and education, younger ages, and increased supermar-
ket shopping. Overall, this study found survey respondents were unfamiliar
with leading food labels; under 10 percent, for example, had heard of VietGAP
or GLOBALG.A.P. (Nguyen et al. 2017).
Consumers in LMICs vary in the level of trust they have in labels associated
with food safety. The literature on certified food in China shows generally low
levels of trust in these labels (Liu, Pieniak, and Verbeke 2013). Jin and Zhao
(2008) found that many Chinese consumers who would be willing to pay more
for food with safety guarantees did not have enough trust in China’s “green”
and “organic food” labels to pay premiums for these foods. This mistrust in part
relates to certification programs rarely providing actual evidence that these
foods are safer (lower levels of pesticide residues, heavy metals, and microbial
pathogens, for example). This reflects the fact that statistically relevant sam-
pling and testing certified products are almost never carried out in China or
other LMICs.
Evidence shows that consumers are sensitive to the actors behind food
safety labels. Studies show that consumers largely accept these labels if the
country of origin is trusted, whether or not they are backed by government.
For example, Wu et al. (2014) found that Chinese consumers were willing
to pay higher premiums for infant milk formula manufactured in China but
certified by a U.S. or European organic certification scheme rather than a
Chinese one. Evidence shows that Chinese consumers have more trust in

92 THE SAFE FOOD IMPERATIVE

government food safety measures than the private certification schemes of
civil society (Zhang et al. 2016). A study in Indonesia found that 60 percent of
consumers preferred organic food certification to be overseen by the central
government (Maghraby et al. 2013).
The availability of certified products in LMICs can be a significant limit-
ing factor, both in terms of the ability of consumers to buy these products and
their familiarity of and exposure to them. In many LMICs, certified products
are mainly distributed through supermarkets and are rarely available in tra-
ditional markets and local stores. This has been observed in China (Li 2007;
Qing et al. 2006; Tang Li, and Jiang 2010), the Russian Federation (Bruschi et al.
2015), and Thailand (Wongprawmas and Canavari 2017). In many cases, labels
are specific to individual distribution channels. In Thailand, for example, the
Carrefour Quality Line private label is only found in supermarkets operated
by Carrefour, while the City of Clean Food label is specific to wet markets in
Bangkok (Schipmann and Qaim 2011).
Although niche markets exist for foods certified to voluntary food safety stan-
dards directed at rich consumers in urban areas of LMICs, there is probably little
scope for these initiatives in informal markets for the poor and in rural areas.
Thus, efforts to promote certified foods, in effect, segment food markets into
those with higher and lower standards of food safety. This is especially so where
public regulatory systems are weak. These actions could also further undermine
food safety in markets for the poor as substandard food is diverted from markets
in which consumers demand higher food safety standards. This could happen
with contaminants over which producers have limited ability to control in the
context of traditional production technologies and where controls are costly.
In these cases, there may be incentives for foods simply to be sorted and for
contaminated products to be diverted into low-income markets. Certification
works best when it leads to overall improvements in food safety management
and risk reduction, rather than simply in the market segmentation of high- and
low-risk food.
The public sector can play a vital role in establishing and maintaining ­private
governance mechanisms for food safety in LMICs in four main ways. First,
public infrastructure is essential for upgrading food safety management capac-
ity (for example, a reliable supply of electricity and running water). Or pub-
lic infrastructure may be undersupplied by the private sector, especially when
demand is nascent (for example, laboratory testing facilities) and for which there
are significant public good elements (for example, cleaning up environmental
contaminants).9 Second, public oversight may be necessary to prevent consum-
ers from being mis-sold products that are falsely labeled as certified; this strongly
reflects the credence nature of many aspects of food safety, as outlined in box 1.2

9
For example, new landing facilities were required for Kenya’s Lake Victoria fisheries to meet
hygiene requirements for exports to the European Union. These were provided with donor and
government support (Henson and Mitullah 2004).

The Status of Food Safety Management in Developing Countries 93

 in chapter 1.10 Third, there may be little incentive or it may be too costly for the
private sector to support upgrading food safety management capacity by more
vulnerable value chain actors; for example, smallholder farmers and micro and
small enterprises. Because these actors are important for achieving the Sustainable
Development Goals, governments have an important role to play in training,
engendering collective action by small farmers and businesses, and providing
storage facilities. And fourth, the public sector can play a key role in defraying the
risks and costs associated with nascent private initiatives to enhance food safety
(for example, through public procurement of certified foods). The public sector
can also provide a convening function for collective action by businesses, give
direct financial support, and disseminate information that lends credibility to the
efforts of businesses to communicate the food safety benefits of their products.11
Examples are emerging of private initiatives aimed at enhancing the safety of
food directed at domestic markets in LMICs. In some cases, these are predominantly
driven by the private sector; and in others, they are part of public-private partner-
ships that vary in the level of formality of the relationship between the public and
private sectors. For example, in Kenya, Aflatoxin Proficiency Testing for East and
Central Africa is a private certifier that approves the testing protocols of millers and
tests randomly selected duplicate samples. Another example relating to enhanced
controls for aflatoxins is a pilot project in Nigeria that is promoting the adoption of
new aflatoxin-control technology through the public’s support of a price premium
in domestic markets for commercial feed (IITA 2013). The private sector is also
involved in adapting international private standards to local market conditions and
training suppliers to achieve compliance. Examples include local GAP programs
for producers selling into markets that are being promoted by GLOBALG.A.P. and
the Global Food Safety Initiative’s Global Markets Programme for small processors,
which provides defined paths for making progress on food safety management.
But what about the scope and limitations of market-based approaches for
improving food safety in informal markets or in circumstances where these mar-
kets still account for most marketed product? The International Livestock Research
Institute has participated in multiple initiatives focusing on farmers and informal
market operators. The institute provides training, introduces low-cost technolo-
gies, and occasionally offers incentives for behavioral changes. Some of the better
documented examples are summarized in table 3.3. Box 3.5 is a case study of afla-
toxins in maize in Kenya.
10
Another issue is that private firms have incentives to “game” compliance. In other words, it may
be cheaper to invest in the appearance of compliance rather than actual compliance. Here, private
firms may have quality control systems and even laboratory facilities, but in practice are tempted to
avoid compliance. There is anecdotal evidence that this occurs in the formal dairy industry, where
large-scale firms blend down milk with antimicrobial residues to below limits, and the meat indus-
try, where companies pressure veterinary inspectors to classify meat as fit for consumption. Brazil’s
2017 tainted meat scandal is a case in point.
11
Zhou, Huo, and Peng (2004) found that 20 percent more consumers were willing to buy “green
pork” when given detailed information on production and processing requirements, and they indi-
cated a willingness to pay a significantly higher price for it. In a controlled experiment, Birol et al.
(2015) found that consumers in Mumbai were willing to pay more for GLOBALG.A.P.-certified
grapes if they were given information on the food safety practices underlying the label.

94 THE SAFE FOOD IMPERATIVE

 TABLE 3.3 Training and Certification in Informal Markets: Selected Cases
Particulars Kenya Ibadan, Lagos Assam, India
Value chain Informal milk sector Butchers Informal milk sector
When 1997–2006 2009–11 2009–13
Number of traders 25,000–30,000 About 900 About 300 traders and 600 producers
Number of trained In 2010, 4,200 traders registered 80 directly by the project and about 420 by 265 traders and 480 producers trained
market actors nationally peer-to-peer training
In pilot areas, 85% of traders

Consumers reached About 500,000 to 5 million About 360,000 About 1.5 million
Intervention Training in hygiene and business Peer-to-peer training on basic hygiene, In-depth training needs analysis; training
practices, providing hygienic dairy cans provision of boots, hats, aprons, fly-proof of trainers, training covered hygiene
with wide necks, certificates given to netting, and food-safe disinfectants; banners and business skills; traders motivated by
successful trainees, which reduced and promotional material; using butchers’ better relations with officials and positive
harassment by officials. associations to monitor performance and publicity, and farmers by visible reduction
ensure compliance. in mastitis.

Documented impact Improved milk safety after training Reduction of unacceptable meat from Improved knowledge attitude and
(reduction in unacceptable coliforms 97.5% to 78.5% (p < 0.001). practice (KAP) after training.
from 71% to 42%). Significant improvements in KAP after training. Significantly higher milk production after
High economic benefits from the Cost of training US$9 per butcher and training and tendency for reduced mastitis.
initiative of US$33.5 million a year. estimated gains through diarrhea averted Sector-level benefits in Kamrup at least
was US$780 per butcher. US$5.6 million a year.

Current status of the Training and certification episodic and Pilot intended to investigate efficacy and Training and monitoring ongoing and
initiative project-led, but trained vendors have an acceptability, but did not have a strategy for supported by government.
important share of the market. sustainability.
Information sources Omore and Baker 2011 Grace, Dipeolu, et al. 2012 Lapar et al. 2014

The Status of Food Safety Management in Developing Countries

Kaitibie et al. 2010 Grace, Olowoye, et al. 2012 Lindahl et al. 2014

Sources: Works cited in the table.

95
 BOX 3.5 L
 imitations of Market-Based Incentives: Aflatoxin
Controls in Kenya

Kenyan maize is frequently contaminated with aflatoxin, a hepatotoxic carcinogenic

metabolite produced by certain fungi. The level of dietary exposure to aflatoxin in
Kenya is among the highest in the world because of a combination of high maize
consumption and agro-ecological conditions. The level of awareness and concern
over aflatoxin contamination in Kenya is high among consumers, the private
sector, and policy makers. Various interventions have been undertaken to address
the problem, including introducing various technologies, such as Aflasafe and
mobile dryers; improved product testing; and experimental studies gauging farmer,
consumer, and miller responses to incentives and information.
Much of the maize consumed in Kenya is produced by small-scale farmers
and never traded. Marketed maize consists of grain sold on the informal market;
branded (sifted) maize flour processed in large-scale, formal sector roller mills; and
unbranded flour processed by small-scale, often unregistered, hammer mills. These
market structure characteristics are important for understanding the scope and
limitations of market-based incentives to tackle aflatoxin contamination.
Hoffmann and Jones (2018) find that farmers producing maize for sale take
fewer actions to prevent aflatoxin contamination than those producing for only
household consumption. For the latter farmers, investing in aflatoxin control is
purely an investment in household health. The current market structure does little
to encourage aflatoxin control at its source on the farm. Instead, millers make their
brands safe by rejecting contaminated lots of grain. But this grain invariably finds
another buyer, typically serving a lower market tier. In this way, the safety premium
for maize concentrates aflatoxin exposure among poor consumers, who typically
buy low-cost brands or buy their maize from the informal sector.
Despite a growing capacity for food safety testing in Kenya, firms are reluctant
to label their food as “aflatoxin safe.” One reason is fear of attracting increased
regulatory scrutiny. A randomized study of consumer responses to this labeling
showed an initially large impact on sales, but the effect faded by the third week
of active marketing (Hoffmann, Moser, and Herrman 2017). Millers investing in
food safety are therefore more likely to be driven by fears of negative publicity or
regulatory action than by consumer demand for food safety certification.
Simultaneously building the testing capacity of mills in high-contamination
areas and the regulatory capacity of local authorities, and strengthening the links
between millers and local farmers, will be essential for bringing down aflatoxin
levels in maize sold through the market.
Providing premium prices to producers for safe maize has been shown to
increase the use of on-farm aflatoxin control technologies. But this strategy is
mostly limited to experimental studies and donor sourcing of food aid subject to
local procurement mandates. For the market premium for safe maize at retail to
be an incentive for reducing aflatoxin in the food supply, it will be necessary
to link farmers in affected regions directly to millers. Doing this will require
public intervention, which should focus on geographic areas where aflatoxin
contamination is most severe.

96 THE SAFE FOOD IMPERATIVE

 The scope for market-based approaches for improving food safety in infor-
mal markets is highly context-specific and needs to be carefully adapted to fit
particular food systems. The incentives for behavior change, which are key to
long-term sustainability, have also been difficult to generalize. In Kenya, where
the approach was first developed in the dairy sector, informal traders were
prone to harassment by the authorities, and a main motivation for training was
to get a certificate protecting them from this (Kaitibie et al. 2010). In Assam,
by contrast, traders were motivated by the good publicity they received after
being trained and the opportunity to enter a dialogue with government dairy
development partners (rather than being regarded as a nuisance by them). In
none of the three evaluated pilots in India, Kenya, and Nigeria were trained
traders able to charge a premium for selling higher-quality products, which was
initially considered to be a promising incentive.

ENABLING SMALLHOLDER FARMERS TO BE FOOD SAFETY

COMPLIANT

The participation of smallholder producers in LMICs in value chains directed

at predominantly export markets for higher value and differentiated agri-
food products is recognized as a vital opportunity to enhance and diversify
farm incomes and generate rural employment. Yet, concerns are widespread
that these opportunities go unrealized because smallholder farmers lack the
technical ability and financial means to meet evolving regulatory require-
ments and private standards, especially for food safety. Even where small-
holder farmers have production cost advantages over larger producers, these
can be outweighed by the potentially high transaction costs associated with
facilitating, monitoring, and certifying compliance with these standards. There
are concerns, too, that efforts in LMICs to upgrade food safety management
capacity for high-value foods, whether for export or domestic markets, could
be detrimental to the livelihoods of poor farmers, and thus for achieving the
Sustainable Development Goals.
Concerns about the potential for smallholders to be excluded from export
value chains dominated the academic literature in the early 2000s, and contrib-
uted to a wave of development assistance programs, especially in Sub-Saharan
Africa.12 More recently, it is being recognized that the process of including or
excluding smallholder farmers, especially in the context of strict food safety
standards, is more nuanced. For example, the assumed dichotomy between
low- and high-value markets represent an unduly simplistic image of the mar-
ket choices available to small-scale producers. In reality, a continuum of alter-
native supply chains exists with different levels of stringency and the specificity
of domestic or trade-oriented buyer requirements (figure 3.8). Thus, there is,
in effect, a progressive enhancement of the methods by which the safety of
12
The basis for these concerns, and the nature and efficacy of government and donor-assisted
programs, are assessed by Jaffee, Henson, and Diaz Rios (2011).

The Status of Food Safety Management in Developing Countries 97

 FIGURE 3.8 Smallholder Farmers, Agricultural Markets, and Varied
Conformity Requirements
Developing countries
Traditional Small/local High-end/international
retail markets supermarkets supermarkets
and
small stores Industrial countries
Retail markets High-end
Local stores supermarkets
Discount supermarkets
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6

+ Specifications
for more
advanced/quite
+ Specifications specific process
for more standards, yet
advanced and implemented in
+ Specifications often quite
for selected, the context of
specific process highly integrated
basic standards, standards with
basic Good supply chains
associated and where the
Upgrading steps

+ Internal Agricultural
quality greater detail in supplier has a
Practice: Good record-keeping
characteristics hygiene and relatively
of products approaches to sophisticated
+ Quality safe pesticide management
grades and +Basic use/storage and structure for
varietal requirements on associated quality control
+ Visual preferences pesticide use record-keeping and risk
characteristics systems management
+ Consistent
quality and
quantities + 2nd- and 3rd- + 2nd- and 3rd-
+ 1st- and 2nd-
+ 2nd- and 3rd- party party
party
+ Visual + Visual party conformity conformity conformity
inspections/
inspections inspection assessment assessment assessment
testing

Stringency of official and buyer’s requirements

Level of sophistication of the conformity assessment systems

Source: Jaffee, Henson, and Diaz Rios 2011.

food products are assessed and communicated.13 Most concerns about the
exclusion of smallholder farmers focus on one market segment, which is often
represented in the literature by GLOBALG.A.P. certification requirements for
export and domestic high-end supermarkets. In most LMICs, however, by far
the biggest market opportunities for smallholder farmers are markets where
less stringent product, process, and documentary requirements are the norm.
Two factors mainly explain the success or not of interventions to strengthen
smallholder participation in value chains in the context of stricter food safety
standards. The first is the degree of upgrading and change required by small-
holder farmers in the context of prevailing practices and the capabilities of
farmers, service providers, and commodity buyers. Incremental upgrades

13
From visual inspection at one extreme to intensive documentation of practices and outputs
based on second- and third-party conformity assessment at the other extreme.

98 THE SAFE FOOD IMPERATIVE

involving technical learning, institutional coordination, and increased record-
keeping are often very successful (Jaffee, Henson, and Diaz Rios 2011). But
radical shifts that involve costly investments and exposing smallholder farmers
to much higher levels of market risk are rarely successful or sustainable.
The second factor is the strength and capabilities of lead firms that engage
directly with smallholder farmers—and this is critical for success. If these firms
are well-managed and well resourced, and have a competitive position within
domestic or focal international markets, interventions are more likely to achieve
strong and sustained traction for getting smallholder farmers to upgrade (Jaffee,
Henson, and Diaz Rios 2011). Indeed, lead firms tend to drive the adoption
of improved standards by smallholder farmers through the requirements they
set, and from their advisory and procurement oversight systems. Conversely,
programs that try to bypass lead firms and upgrade weaker enterprises, and
poorly organized smallholder farmers, do not have a good track record.
Various market institutions have evolved in the context of stricter food
safety standards to overcome the transaction costs faced by smallholder f­ armers.
The participation of smallholders in contract production, and especially pro-
duction-based contracts that include inputs on credit before producers are
trained and intensive monitoring begins, was found to facilitate compliance in
Zimbabwe (Henson, Masakure, and Boselie 2005), Kenya (Okello and Swinton
2007), Peru (Lemeilleur 2013), and Senegal (Maertens and Swinnen 2009). In
Kenya and India, farmer groups play an important role in facilitating ­compliance
by providing extension and group monitoring (Roy and Thorat 2008; Okello and
Swinton 2007). Direct sourcing that offers scope for the compliance monitor-
ing of buyers can also play an important role, as found by Ding et al. (2015)
for Chinese fruit and vegetable growers supplying supermarkets. Cost-sharing
by exporters and public agencies facilitated farmer compliance in several coun-
tries (Kersting and Wollni 2012; Handschuch, Wollni, and Villalobos 2013;
Leimeilleur 2013; Subervie and Vagneron 2013; Henson Masakure, Cranfield
2011). In Thailand, exporters and donors pay for over 90 percent of all costs of
GLOBALG.A.P. certification (Kersting and Wollni 2012).14

THE STATE OF CAPACITIES FOR MANAGING

TRADE-RELATED FOOD SAFETY RISKS

The application of strict food safety requirements, both through regula-

tory reforms and private standards, is a concern in many LMICs. But there
is ­little evidence that this trend has adversely affected agri-food exports.
14
Compliance with higher regulatory or private standards may give rise to a wider set of benefits over
and beyond higher or more stable prices for farmers. Unnevehr and Ronchi (2014) summarize the
findings from about dozen studies and countries on this subject. Some of the additional benefits cited
include adopting improved technology with spillover benefits for staple crops (Minten, Randrianarison,
and Swinnen 2009), higher or more stable labor incomes (Maertens and Swinnen 2012; Minten,
Randrianarison, and Swinnen 2009), or improved health through reduced on-farm exposure to pesti-
cides (Kersting and Wollni 2012; Asfaw, Mithöfer, and Waibel 2009; Okello and Swinton 2009).

The Status of Food Safety Management in Developing Countries 99

 Indeed, many LMICs have recorded impressive growth in agri-food exports,
with total food exports from these countries rising from US$113 billion in
2001 to US$475 ­billion in 2016. This included a fourfold increase (to a level of
US$220 billion) in LMIC exports of high-value food that are more food-safety-
sensitive, including fish, animal products, fresh fruit and vegetables, spices, and
nuts (figure 3.9).
LMIC exports of high-value food are dominated by upper-middle-income
countries, accounting for 69 percent of the total of these exports in 2016.
Twenty-eight percent of high-value food exports were from lower-middle-
income countries and 2 percent were from low-income ones. While exports
from low-income countries grew at 8.6 percent a year over 2001–16, they were
valued at less than US$5 billion, and mainly consisted of niche products to
specific markets.
Many LMIC countries are participating in the rising trade in high-value
food, although 10–15 countries account for most of this expansion. In 2016,
the 10 largest LMIC exporters accounted for 66 percent of total high-value food
exports, compared with 59 percent in 2001. The top five (Brazil, China, India,
Mexico, and Thailand) accounted for 46 percent, compared with 40 percent

FIGURE 3.9 LMIC Exports of High-Value Foods by Product Group,

2001–16
55
Fish
50 Fresh fruit
Vegetables
45
Meat
40 Processed meat, fish
Processed fruit, vegetables
35 Nuts
US$, billions

Dairy, eggs
30
Spices
25

20

15

10

0
11
01

12
10
02

03

09

13

16
06

07

08

14
04

15
05

20
20

20
20
20

20

20

20

20
20

20

20

20
20

20
20

Source: International Trade Centre Trade Map Database.

Note: LMIC = low- and middle-income country.

100 THE SAFE FOOD IMPERATIVE

 in 2001.15 Nine of the top 10 exporters in 2016 were also among the leaders in
2001; Vietnam was the new entrant (figure 3.10).
The trade in individual categories of high-value foods is typically more
­concentrated than for high-value food in the aggregate. For example, the
10 ­largest LMIC exporters of fresh vegetables accounted for 78 percent of total
LMIC exports of high-value food, with two countries, Mexico and China,
accounting for half. The top 10 countries also accounted for 84 percent of
LMIC spice exports. Meat exports are even more concentrated, with the top
10 exporters accounting for 91 percent of the total, with two-thirds of this
from Brazil and India.
Proxy indicators can be used to show the status of trade-related food
safety management capacity in LMICs. These indicators—three of which are
discussed here—suggest that considerable advances in capacity were made
in recent years, but these are concentrated among a small number of larger
­middle-income economies.

FIGURE 3.10 High-Value LMIC Food Exports by Income Group,

2001–16
250
Lower-middle income
225 Upper-middle income
Total high-value food exports
200 Low income

175

150
US$, billions

125

100

75

50

25

0
11
01

02

13
03

10

12
06

09

16
08
05

15
04

14
07

20
20

20

20
20

20

20
20

20

20
20
20

20
20

20
20

Source: International Trade Centre Trade Map Database.

Note: LMIC = low- and middle-income country.

15
The concentration level would have been even higher if Chile had not attained high-income
status in 2012.

The Status of Food Safety Management in Developing Countries 101

 The first relates to adopting GAPs. Table 3.4 shows the area of
GLOBALG.A.P.-certified fruit and vegetable production.16 Globally, growth
has been impressive in the certified areas since 2010, largely because of the pri-
vate sector’s response to evolving market requirements in industrial countries,
especially in the EU. The largest expansion in certified area was in high-income
countries. The ­certified area in LMICs increased from 700,000 hectares in 2010
to 1.86 ­million hectares in 2017. Most of this growth has been in upper-middle-
income countries, primarily in Latin America and the Caribbean, but also in
China, the Philippines, and South Africa.
Among LMICs, 15 countries account for 89 percent of the area of fruit and
vegetable production certified to GLOBALG.A.P. (table 3.5). These countries
account for 59 percent of LMIC fresh fruit and vegetable exports, but accounted
for more than 80 percent of the LMIC trade directed at high-income countries.

TABLE 3.4 A
 rea of GLOBALG.A.P.-Certified Fruit and Vegetable
Production by Region and Income Group, 2010 and 2017
Hectares (thousands)
Area 2010 2017
Region
Asia 92.7 325.6
Europe 868.6 2,735.5
Latin America and the Caribbean 519.4 1,344.4
Middle East and North Africa, Eastern Europe 111.6 195.7
North America 130.9 371.2
Sub-Saharan Africa 192.2 278.4
Total 1,915.6 5,250.9
Income group
Low income 4,648.8 23.6
Lower-middle income 134.4 340.3
Upper-middle income 560.6 1,501.7
High income 1,215.9 3,385.1
Total 1,915.6 5,250.8
Source: Based on GLOBALG.A.P. data. secretariat.

16
GLOBALG.A.P. certification would normally only be undertaken for export-oriented
­ orticulture, but this is the only proxy for GAP for which data could be obtained. Many national
h
GAP schemes are running, but information on area coverage is difficult to find and of uncertain
­reliability. GLOBALG.A.P. data, while accurate, convey only a partial picture.

102 THE SAFE FOOD IMPERATIVE

TABLE 3.5 G
 LOBALG.A.P.-Certified Area for Fruit and Vegetables in
LMICs, 2017
Country Total certified Total fresh fruit, vegetable Fresh fruit, vegetable exports
area (2017) exports (2016) to high-income countries (2016)

Hectares Share US$ Share in Share in US$ Share in Share in

(%) (‘000) LMICs with LMICs (‘000) LMICs with LMICs
certified (%) certified (%)
area (%) area (%)
South Africa 201,237 15.5 3,086,363 4.3 3.7 2,257,245 4.8 4.5
China 153,509 11.8 16,030,742 22.1 19.3 6,970,928 14.7 13.9
Mexico 106,231 8.2 12,148,599 16.8 14.7 11,831,093 24.9 23.7
Costa Rica 95,963 7.4 2,221,518 3.1 2.7 2,117,545 4.5 4.2
Peru 87,371 6.7 2,679,460 3.7 3.2 2,404,449 5.1 4.8
Ecuador 75,725 5.8 3,011,083 4.2 3.6 1,922,275 4.0 3.8
Egypt, Arab Rep. 73,425 5.7 2,163,247 3.0 2.6 1,433,728 3.0 2.9
Argentina 66,936 5.2 1,737,314 2.4 2.1 807,734 1.7 1.6
Brazil 58,167 4.5 860,027 1.2 1.0 767,545 1.6 1.5
Philippines 54,946 4.2 1,146,205 1.6 1.4 879,093 1.9 1.8
Colombia 50,593 3.9 1,055,240 1.5 1.3 1,045,233 2.2 2.1
Morocco 43,652 3.4 1,644,846 2.3 2.0 1,427,096 3.0 2.9
Guatemala 37,458 2.9 1,448,972 2.0 1.7 1,381,736 2.9 2.8
India 21,822 1.7 2,756,906 3.8 3.3 1,870,628 3.9 3.7
Turkey 19,950 1.5 4,814,706 6.6 5.8 2,957,617 6.2 5.9
Other LMICs 149,468 11.5 15,763,950 21.7 29.0 7,407,540 15.6 14.8
LMICs with — — 72,569,178 100 47,481,485 100
certified area
LMICs with no — — 10,347,172 12.5 2,497,692 5.0
certified area
Total LMICs 1,296,452 100 82,916,350 100 49,979,177 100
Source: Based on GLOBALG.A.P. data.
Note: LMIC = low- and middle-income country; — = not available. Area of coverage corresponds to GLOBALG.A.P.-
certified area for first quarter, noncovered crops’ first harvest.

This is ­indicative of the far greater importance of GLOBALG.A.P. certification

for food exports to high-income countries.
The second proxy measure of trade-related food safety management capac-
ity is the adoption of certified organic production systems. Successfully using
these systems is an indicator of capacity to adopt process controls and related
certification, which requires sophisticated management and well-developed
monitoring and record-keeping through the supply chain. Organic certification

The Status of Food Safety Management in Developing Countries 103

 is a good indicator of growing capacity for managing quality and safety, even
though it does not specifically address food safety.17
For fruit, vegetables, cereals, and pulses (legumes), most of the certified
organic area is in high- and upper-middle-income countries (table 3.6). For
oil crops, nuts, and beverage crops, low- and lower-middle-income countries
account for a greater proportion of the certified area. For nuts and beverage
crops, low-income countries have over 500,000 hectares under organic produc-
tion, equivalent to more than 15 percent of their total land area for these crops.
For fruit and vegetable production, Mexico and China account for almost
57 percent of the total harvested area under organic certification in LMICs
(table 3.7). The Arab Republic of Egypt and Turkey account for a further
12 ­percent. Over 11 percent of Mexico’s total harvested area of fruit and veg-
etables is organically certified. Other countries with a high proportion are
Bulgaria and the Dominican Republic.
The third proxy measure of trade-related food safety management capacity
in LMICs relates to the number of businesses and food-processing facilities that

TABLE 3.6 Organic Production Area by Commodity and Country

Income Group, 2017
Commodity Low Lower- Upper- High
income middle middle income
income income
Fruit and vegetables
Organic area (hectares) 40,237 140,169 664,111 828,966
Share of organic area in total area (%) 0.22 0.21 0.86 5.62
Cereals and pulses (legumes)
Organic area (hectares) 57,170 367,231 1,394,879 2,800,959
Share of organic area in total area (%) 0.07 0.13 0.53 2.08
Oil crops
Organic area (hectares) 107,227 677,779 762,584 772,593
Share of organic area in total area (%) 0.69 0.70 0.67 1.18
Nuts and beverage crops
Organic area (hectares) 571,559 353,368 784,691 222,167
Share of organic area in total area (%) 15.60 1.85 6.87 12.16
Source: FiBL 2018.

17
Some lower-income countries have tried to take advantage of a situation in which there is very
little use of purchased inputs and therefore only modest changes are needed to convert to organic
production systems. These “organic by default” strategies have been used in some African coun-
tries. The mixed experience with this strategy is reviewed by Jaffee, Henson, and Diaz Rios (2011).
In circumstances where the initiative centered only on certification and product marketing, the
gains were temporary, compared with initiatives that also aimed to raise productivity through
improved agronomic and postharvest practices.

104 THE SAFE FOOD IMPERATIVE

 TABLE 3.7 Certified Organic Fruit and Vegetable Production Area in LMICs, 2017
Country Harvested area Organic harvested Organic area as Proportion of LMIC
(hectares) production area proportion total harvested organic harvested
(hectares) area (%) area (%)
Mexico 2,208,609 253,448 11.48 30.01
China 49,634,732 224,621 0.45 26.60
Turkey 2,251,820 54,359 2.41 6.44
Egypt, Arab Rep. 1,556,705 43,749 2.81 5.18
Dominican Republic 210,856 26,473 12.55 3.13
Kenya 606,174 25,778 4.25 3.05
Ecuador 528,634 19,590 3.71 2.32
Vietnam 2,403,979 19,350 0.80 2.29
Madagascar 840,405 19,161 2.28 2.27
Bulgaria 119,663 19,068 15.93 2.26
Other LMICs 100,887,981 138,923 0.14 16.45
Total 161,249,558 844,520 0.52 100
Source: Research Institute on Organic Agriculture annual survey.
Note: LMIC = low- and middle-income country.

The Status of Food Safety Management in Developing Countries

105
 have shown an interest in exporting to high-income countries. In the United
States, for example, facilities that process or handle food and beverage prod-
ucts must be preregistered with the U.S. Food and Drug Administration (FDA),
and provide information about their facilities, including the categories of food
being manufactured and types of activity within the facility. As of January 2018,
213,441 companies were registered with the FDA, of which 118,270 were based
outside of the United States.18 Of these companies, 30 percent were in upper-
middle-income countries, 10 percent in lower-middle-income countries, and
only 1 percent in low-income countries. China and Mexico accounted for
37 percent of total FDA registrations in LMICs (table 3.8). Fifteen LMICs

TABLE 3.8 LMIC Food Businesses Registered with U.S. Food and

Drug Administration, January 2018
Country Number Share of HVF exports Share in total
of valid total valid to United HVF exports
registrations registrations States in to United
(%) 2017 (US$) States
2017 (%)
China 9,994 20.7 4,856,230 10.4
Mexico 8,291 17.1 16,857,494 36.2
India 3,585 7.4 3,136,250 6.7
Brazil 1,975 4.1 1,158,774 2.5
Colombia 1,500 3.1 383,223 0.8
Argentina 1,469 3.0 739,454 1.6
Vietnam 1,467 3.0 3,128,254 6.7
Thailand 1,416 2.9 2,145,821 4.6
Peru 1,348 2.8 1,945,749 4.2
Russian Federation 1,203 2.5 483,134 1.0
Turkey 1,200 2.5 408,165 0.9
Ecuador 973 2.0 1,463,616 3.1
Indonesia 960 2.0 2,293,579 4.9
South Africa 911 1.9 212,651 0.5
Philippines 713 1.5 646,998 1.4
Total Top 15 LMICs 37,005 76.5 39,859,392 85.6
Other LMICs 11,383 23.5 6,689,857 14.4
Total LMICs 48,388 100 46,549,249 100
Source: Based on data provided by the U.S. Food and Drug Administration.
Note: HVF = high-value food; LMIC = low- and middle-income country.

18
In October 2012, 273,000 foreign food companies were registered with the FDA. Many companies,
however, have not chosen to recertify, and some were still registered but had gone out of business.

106 THE SAFE FOOD IMPERATIVE

collectively accounted for 75 percent of registrations, and these same countries
accounted for 85 percent of high-value exports to the United States.
For a wide range of food products of animal origin in the EU, processing
facilities are required to be inspected and approved for export by a recog-
nized competent authority in the country of origin. These facilities must have
hygiene standards equivalent to the EU. Table 3.9 details the countries with
facilities approved for the export of chilled or processed fish to the EU. Nearly
1,900 processing facilities in 28 lower-middle-income countries were approved
to export to the EU in 2018. Nearly all upper-middle-income countries have
EU-approved fish-processing facilities, with nearly 2,100 approved facilities.
Only eight low-income countries have fish-processing facilities approved to
export to the EU, but their ratio of approved facilities to the value of exports is
greater than for all other country income groups.
The impressive performance of LMIC food exports since 2000, especially
for high-value food, testifies to the advances made not only in production
capacity and efficiency but also in upgrading food safety management capacity.
Many LMICs have undertaken administrative reforms and increased invest-
ments in the public and private sectors to facilitate market access and respond
to changes in food safety requirements in export markets (see box 3.6, which
looks at Ukraine’s efforts to secure new food markets). These investments have
in some cases been made strategically as part of efforts to establish or enhance
exports for businesses or sectors. In many cases, however, these investments
were stimulated by acute food safety problems, including temporary restraints
on trade, subpar grades on inspection visits by trade partner regulators, and
significant numbers of border rejections.
Instances of noncompliance with export market food safety requirements
have in some cases imposed heavy costs on businesses and sectors. For busi-
nesses and sectors that are large and well established, however, this often
means little more than a bump in the road. Here, trade disruptions tend to
be short-lived and these businesses and sectors often emerge from these epi-
sodes stronger and with greater displays of industry collective action, main-
tained or even enhanced reputations for management of food safety, and more
effective instances of public-private collaboration (box 3.7). These businesses
and sectors have also been able to achieve economies of scale in upgrading
their capacity and collective infrastructure (for example, fish landing sites,
inspection systems, and laboratories), and by applying industry norms and
standards.
There are examples of small sectors—often in smaller countries—that were
able to differentiate themselves on the basis of high product quality and best
practices in food safety management. Often, this has involved collective action
within the private sector or across the public and private sectors to overcome
logistical disadvantages and to establish a market presence. Notable examples
are Kenya’s and Peru’s fresh vegetable export industries. There are also instances
where efforts by even very small countries to upgrade food safety management
capacity were successful at gaining access to export markets. Smaller players in

The Status of Food Safety Management in Developing Countries 107

108
TABLE 3.9 Processing Facilities Approved for Chilled and Processed Fish Exports to the European Union
Country Total fish Number of Number of Number of Approved Value of fish
income group production, countries with approved chilled approved facilities per exports to EU,
2013–15 (tons) approved facilities, 2018 processed fish 100,000 tons of 2014–16 (US$)
facilities, 2018 facilities, 2018 production
Low income 3,924,474.8 34 -- -- 3.77 507,030.3

THE SAFE FOOD IMPERATIVE

with approved facilities 1,815,046.8 8 16 132 8.15 505,069.7
Lower-middle-income 56,403,544.6 47 -- -- 3.47 4,177,411.7
with approved facilities 54,850,217.9 28 102 1,855 3.57 4,176,711.7
Upper-middle-income 99,975,353.7 56 -- -- 2.15 5,968,850.3
with approved facilities 99,172,226.0 37 103 2,051 2.17 5,948,309.3
High income 33,415,466.0 80 -- -- 7.75 12,073,774.7
with approved facilities 20,666,836.1 20 377 2,212 12.53 2,342,717.3
Sources: Food and Agriculture Organization, FishStatJ; European Commission, Directorate General Health and Food Safety; UN Comtrade International
Trade Statistics.
Note: Fish production includes captures and farming outputs from marine and inland fisheries. Data from the European Commission is the number of establish-
ments from non–European Union (EU) countries from which imports of fishery products into the EU were permitted at January 27, 2018.
BOX 3.6 Investing in Ukraine’s Food Sector to Secure
New Markets

The International Finance Corporation (IFC), the private sector arm of the World
Bank Group, has worked over the past several years at all levels of Ukraine’s
agribusiness value chain and with the government’s food safety authority to
improve competitiveness. The goal is to diversify markets, either through exports
or access to new domestic markets, and to attract investments in Ukraine’s food
sector. As part of the public sector component, IFC helped the government to draw
up food safety legislation that meets international norms, streamline food safety
regulations, and introduce inspection systems equivalent to European Union (EU)
standards. IFC is working with industry to identify market barriers, and to develop
inspection training programs.
IFC’s partnerships with the private sector enabled the identification of
priorities and proved to be essential in gaining public support for regulatory
changes. Because of these and other efforts, the EU opened up for Ukrainian
poultry in 2013, with three firms being initially certified. Ukrainian dairy
products got market access to China in 2015 and to the EU in 2016. New export
markets are continuing to open for Ukraine’s food sector, most recently Saudi
Arabia and Turkey.
IFC also helped Ukraine’s private sector to secure new markets by providing
on-site consulting services to over 90 large and small firms in the food sector. The
partnerships of Ukrainian firms with multinational retailers, including Metro Cash
& Carry and Auchan, were a strong driver for better food safety practices for these
firms, encouraging 75 small and medium-sized enterprises in processing and eight
horticulture growers to improve food safety practices.
A survey of small and medium-sized enterprises that participated in the IFC
support program showed several benefits from improved food safety management,
including better product quality, reduced waste, higher productivity, and more
retained sales. Firms found that the benefits of increased revenue exceeded the
costs of improving food safety. And they were most successful when food safety
was part of a corporate strategy and employees were involved in the planning
process.
For the Ukrainian dairy-processing industry, results like these confirm an ex
ante analysis of the potential costs and benefits of using the hazard analysis and
critical control points (HACCP) approach for the industry. The costs included
capital investments, HACCP design and implementation, and the recurring costs
of using the HACCP approach. The benefits included higher sales, less waste and
other efficiencies, and increased attractiveness to investors. The costs of using the
HACCP management system were estimated based on expert opinion and resulted
in assumed increased sales of 15–25 percent. The payback period for investing in
HACCP was estimated at only one to two years, though this depends on the age of
firms’ capital equipment.

Sources: IFC (2011, 2016); Tetyora, Osmochescu, Onul (2017).

The Status of Food Safety Management in Developing Countries 109

 BOX 3.7 Training of Trainers: Bangladesh Aquaculture and
India Spices

The Joint Institute for Food Safety and Applied Nutrition, which is supported
by the U.S. Food and Drug Administration, has carried out long-term “train
the trainers” programs in Bangladesh and India. Both programs have given
intensive training to an initial cadre of experts, who then adapt them in local
languages and provide training to value chain actors through training centers.
The Bangladeshi program started in 2009 and the Indian one 2012. Long-
standing problems with import rejections and market access prompted the
programs, motivating public-private partnerships and local matching funding
to help counter the problem.
One indicator of the programs’ success is a decline in U.S. import rejections
for Bangladeshi shrimp and Indian spices. In both countries, the train-the-trainers
approach resulted in broad impacts in terms of the number of trainees who were
trained and the subsequent training of supply chain actors. In both countries,
thousands of individuals were trained using this approach, including farmers,
food-processing and laboratory staff, and public inspectors. The resources needed
for these successful training programs were modest compared with the value of the
exports involved.
A key factor for the success of the training programs was their use of public-
private partnerships for promoting exports. Training was one programmatic
element among several strategic, complementary efforts to promote exports,
and training was a major component, strengthening public accreditation in both
countries. In Bangladesh, demonstration farms were set up to reach smallholder
farmers, which led to improved safety and productivity. In India, industrial
parks were set up to support private investments in processing and value-
added products for spices. These examples show that training did not occur in
a vacuum, but supported and furthered a public-private partnership strategy to
enhance exports.

Source: Background paper prepared by C. Narrod, X. Dou, and C. Wychgram.

the global high-value food trade, however, have tended to struggle to recover
from food safety lapses. Often, a “one and done” situation prevails, whereby one
lapse or even a suspected problem tarnishes the industry’s reputation, causing
buyers to flee to alternative sources. A case in point is the cyclospora outbreak
in the late 1990s in the United States, which was traced to raspberries from
Guatemala, and which put the sector out of business.
Almost all the attention given in LMICs to agri-food exports and the impor-
tance of food safety management capacity has focused on high-income coun-
try markets, with the growth of South-South trade and the role of food safety
being largely ignored. While this growth seems to reflect the relatively favorable

110 THE SAFE FOOD IMPERATIVE

position of LMICs for complying with food safety requirements in high-income
countries, the evidence suggests that South-South trade suffers from significant
transactional and quality barriers (UNIDO 2015).19 For example:

• Middle-class consumers in growing middle-income country markets are

increasingly aware of food safety and seek out safer products. Many of the
highest-profile food safety incidents have taken place in some of the most
important LMIC markets. In the growing urban areas of middle-income
countries, retailers are also increasingly using the same private standards as
in high-income markets to attract consumers.
• LMIC governments are just as concerned about plant and animal health
protection as high-income countries when it comes to imports. LMICs
often have large and economically important agricultural sectors and want
to ­protect their animal and plant health. Examples of countries with both
growing high-value imports and important agricultural sectors include
China and South Africa.
• In many ways, South-South trade is subject to greater barriers than trade
with high-income countries. Often, this trade has higher border costs due to
noncompliance with sanitary and phytosanitary principles. These include a
lack of transparency for import requirements, discriminatory practices that
impose different requirements on exporters, and high transaction costs for
entry, including long waits at borders and corruption.

Taken together, these issues highlight the need for LMICs to tackle trade
barriers related to food safety and other sanitary and phytosanitary issues.
And, more widely, they highlight the need to take advantage of the growth in
demand for food products in other LMIC markets.
Regional initiatives to harmonize standards and streamline border proce-
dures are often proposed to promote South-South trade. Examples of regional
trade alliances include the Association of Southeast Asian Nations (ASEAN)
GAP, the Common Market for Eastern and Southern Africa Green Pass,
and East Africa Community dairy standards. Humphrey (2017), however,
concludes that progress has been slow in implementing these regional stan-
dards. Furthermore, harmonization does not address other transaction costs

19
UNIDO (2015) explores several cases where standards are potential barriers in growing South-
South trade. One example is imports into South Africa from the rest of Africa. Countries in
Sub-Saharan Africa have trouble competing with established suppliers in Latin America and the
Caribbean in the South Africa market. UNIDO concludes that even regional harmonization will not
tackle some basic cost and quality issues in Sub-Saharan Africa’s supply of food products, including
for tea, bananas, nuts, and maize. UNIDO also examines Argentina’s fruit exports to Brazil. In Brazil,
market segmentation is emerging mainly based on quality, with high-end retailers demanding the
same quality as the EU and lower-quality produce going to smaller retail chains at a discount. It is by
no means clear that the lower-quality product is unsafe. Other examples are found in fruit exports
from Malaysia, Myanmar, and Vietnam to China and other Asian countries. This trade encounters
phytosanitary barriers because of differing requirements and inconsistent border practices.

The Status of Food Safety Management in Developing Countries 111

 (for example, corruption and road tolls). ASEAN GAP, a voluntary standard
promoted by member-state governments to facilitate trade, may be the one
modest success story of these efforts. ASEAN GAP allows one standard for
ASEAN members trading with larger regional countries, such as China or India,
and is generally in line with or moving toward more stringent GAP standards
for high-income markets. The ASEAN GAP standard also provides a common
basis for government extension efforts with farmers. Conceivably, initiatives
such as this could support growth in South-South trade, while complementing
efforts to strengthen the safety of domestic food supplies.

MOVING TOWARD RISK-BASED IMPORTED

FOOD CONTROLS

The progress being made by LMIC agri-food exports tends to overshadow

trends in the scale and composition of agri-food imports. LMICs on average
are showing double-digit growth in agri-food imports, especially imports of
high-value foods, which in value terms are about a third of LMIC agri-food
imports (and 20 percent of the agri-food of low-income countries). From
2001 to 2016, LMIC imports of agri-food products rose from US$89 billion to
US$414 billion, with imports of high-value food rising from US$30 billion to
US$149 billion in the same period.
The most rapid growth in high-value food imports has been in meat, fish,
dairy products, and fresh fruit and vegetables (figure 3.11). Historically, most
LMIC imports of high-value food have come from high-income countries, but
this is rapidly changing. Half of LMIC high-value food imports come from
other LMICs. In the case of low-income countries, 60 percent of high-value
food imports are from other LMICs.
Among LMICs, 10 countries accounted for two-thirds of high-value food
imports in 2016 (table 3.10). These tend to be larger and rapidly developing
middle-income countries in which the size of the middle class is expanding at
a fast pace (for example, China, Mexico, and the Russian Federation). Many of
these countries are also leading agri-food exporters, reflecting differences in
domestic production and the demand patterns of the population for type and
quality of food products.
Importantly, the rapid growth in imports of some high-value foods reflects
the concerns of LMIC consumers over the safety of domestically produced
foods. A case in point is the explosive growth in imports of dairy products,
which not only reflects the rapid expansion of consumer demand but also spe-
cific instances of adulteration and other food safety issues. In 2008, 20 busi-
nesses in China were involved in the deliberate adulteration of milk and infant
formula, with the scandal resulting in 300,000 hospitalizations, including
54,000 children. Concerns over the safety of domestically sourced milk are not
isolated to China. Hanford, Campbell, and Elliott (2016) review the impacts of
numerous cases of milk fraud during the latter part of the first decade and the

112 THE SAFE FOOD IMPERATIVE

FIGURE 3.11 LMIC High-Value Food Imports by Product Group,
2001–16
35
Meat
Fruit, nuts
30 Fish
Dairy, eggs
25 Vegetables
Processed fruit, vegetables
Processed meat, fish
US$, billions

20 Spices

15

10

0
01

02

03

06

08

09

10

11

12

13

16
05

14
04

15
07
20

20

20

20

20

20

20

20

20

20

20
20

20
20

20
20

Source: International Trade Centre Trade Map Database.

early part of the second decade of the 2000s, including in Brazil, East Africa,
India, and Pakistan.
Growing agri-food imports pose new challenges for the effective man-
agement of food safety in LMICs, especially when these imports are from
other LMICs that themselves have weak food safety management systems
or whose trade is carried out through informal channels across borders.
These challenges are especially acute for smaller countries with signifi-
cant agri-food imports. It is generally not possible to have oversight of
food production and processing in exporting countries, which means that
border inspections are the only protection. It is of course not possible
to check all or even a high proportion of consignments imported into a
country. Furthermore, the import inspection systems of most LMICs are
­underresourced or ­ineffectively organized. The low pay of many inspectors
can also blunt their efforts to be proactive in detecting hazardous foods and
makes them prone to corruption.
To ensure that rising food imports enhance rather than reduce domes-
tic food safety, risk-based import controls need to be developed and applied
in LMICs. These typically require the categorization of food safety risks on
the basis of product type and country of origin, among other factors, and

The Status of Food Safety Management in Developing Countries 113

114
TABLE 3.10 Largest LMIC Importers of High-Value Food, 2006 and 2016
2006 2016
Country Value Percent Percent Country Value Percent Percent
(US$) LMIC world (US$) LMIC world

1 Russian Federation 11,762,546 17.2 3.4 China 29,651,926 19.6 5.0

2 China 6,151,661 9.0 1.8 Vietnam 15,348,910 10.2 2.6
3 Mexico 5,740,605 8.4 1.7 Russian Federation 12,570,855 8.3 2.1

THE SAFE FOOD IMPERATIVE

4 Poland 3,186,166 4.7 0.9 Mexico 8,576,822 5.7 1.5
5 Thailand 2,303,197 3.4 0.7 India 7,618,310 5.0 1.3
6 Malaysia 2,088,382 3.1 0.6 Thailand 5,822,059 3.9 1.0
7 India 1,856,772 2.7 0.5 Malaysia 4,739,234 3.1 0.8
8 Nigeria 1,533,803 2.2 0.4 Brazil 4,268,894 2.8 0.7
9 Brazil 1,378,709 2.0 0.4 Egypt, Arab Rep. 3,907,502 2.6 0.7
10 Ukraine 1,303,013 1.9 0.4 Indonesia 3,569,083 2.4 0.6
Subtotal (top 10 LMICs) 37,304,854 54.6 10.7 Subtotal (top 10 LMICs) 96,073,595 63.6 16.3
Subtotal (top 10 LMICs) 30,960,787 45.4 8.9 Subtotal (top 10 LMICs) 54,940,626 36.4 9.3
Subtotal LMICs 68,265,641 19.6 Subtotal LMICs 151,014,221 25.7
Subtotal HICs 279,176,466 80.4 Subtotal HICs 437,204,313 74.3
World total 347,442,107 588,218,534
Source: International Trade Centre Trade Map Database.
Note: HIC = high-income country; LMIC = low- and middle-income county.
the combined application of preborder, border, and postborder measures
(FAO 2016). The following briefly describes these different types of controls:

• Preborder controls. This is a way of trying to ensure that controls in an

exporting country—for example, for food production, processing, and
exports—lead to safer imported food. Preborder controls cover the pro-
filing of exporters, manufacturers, imported products, country of origin,
consignment source country and port of entry, agreements with import-
ing c­ ountries, controls put in place by importers on their suppliers, and any
other initiatives that can increase confidence in the safety and quality of the
product being imported.
• Border controls. These cover the application of import permits by food
­businesses, and the processes for admissibility and inspections of consign-
ments and importer inspection.
• Postborder controls. These refer to activities in an importing country after
a product has been imported into that country. Postborder controls cover
two basic types of controls. The first is any control of the importer; for
example, assessing the importer’s due diligence arrangements to ensure
the safety of imported food and the standard of the importer’s ware-
houses. The second are actual controls over specific imported food prod-
ucts, which are either still in the importer’s warehouses or already in the
domestic market. This type of control may involve market surveillance
and product recalls.

Facilitating trade while ensuring the safety of agri-food imports requires

adhering to practices and principles that are consistent with Codex Alimentarius
Commission guidelines. As well as having decisions that are risk-based and
guided by robust evidence, these good ­practices include:

• Transparency in legislation and operating procedures

• Clearly defined institutional roles and responsibilities
• Consistency and impartiality in the application of controls
• Harmonized standards, guidelines, and recommendations
• Recognition of other food control systems, including equivalence, among
trading partners

Among LMICs, these principles are often not applied to food safety
import controls, and import control policies are generally not based on
­scientific ­evidence. Information on food safety requirements and proce-
dures is often difficult to find, operating procedures change frequently,
and coordination is often lacking among the multiple agencies involved.
Although a systemic picture of the “state of the art” in LMIC food safety
import controls is not available, a recent Marshall School of Business
study, based on a survey of companies, gives a sobering picture of declin-
ing tariffs being replaced by a growing array of protectionist technical

The Status of Food Safety Management in Developing Countries 115

 barriers to trade measures, which are applied as “on/off valves” in response
to domestic market conditions (APEC Business Advisory Council 2016).
Furthermore, food safety and other sanitary and phytosanitary measures
are often ambiguous and inconsistent, and are enforced in a discriminatory
manner.
Table 3.11 compares the scores for applying transparent rules and prac-
tices for agri-food imports in middle- and high-income economies that are
members of the Asia-Pacific Economic Cooperation forum. The scores range
from 1 for lowest to 5 for highest. Scores of 4 or 5 signal proximity to inter-
national best practice; scores of 1 or 2 indicate significant shortcomings.

TABLE 3.11 Scores for Applying Transparent Rules and Practices for

Agri-Food Imports in Middle- and High-Income Economies
Economy Technical Sanitary and Information Administrative Enforcement Total
barriers phytosanitary burdens consistency
to trade measures
Middle income
Peru 3 3 5 3 3 17
Mexico 4 3 4 2 2 15
Malaysia 2 2 4 3 3 14
Philippines 3 3 2 2 1 11
Vietnam 3 3 2 2 1 11
Thailand 2 2 3 2 1 10
Russian 2 2 2 1 3 10
Federation
Papua New Guinea 3 2 2 1 2 10
China 2 2 3 1 1 9
Indonesia 1 1 1 1 1 5
Average 2.5 2.3 2.8 1.8 1.8 11.2
High income
Singapore 5 5 5 5 5 25
New Zealand 5 4 5 5 5 24
Taiwan, China 4 3 5 4 5 21
Japan 3 3 5 4 5 20
Australia 3 3 5 4 5 20
United States 3 3 5 4 4 19
Chile 4 4 3 3 5 19
Canada 3 3 4 4 4 18
Korea, Rep. 3 2 3 3 3 14
Average 3.7 3.3 4.4 4.0 4.6 20.0

Source: APEC Business Advisory Council 2016.

116 THE SAFE FOOD IMPERATIVE

Country scores are considered in relation to five criteria: the clarity and suit-
ability of technical barriers to trade, sanitary and phytosanitary measures,
the state of information and the administrative burdens pertaining to food
import controls, and the consistency of enforcement measures among stake-
holders, and locations.20
High-income economies generally get mixed scores for applying technical
barriers to trade and sanitary and phytosanitary measures. Yet these econo-
mies often score well for information disclosure, enforcement consistency, and
administrative matters. New Zealand and Singapore score highest among high-
income economies. The Marshall School of Business survey found that high-
income economies apply stringent food standards, but do this in a transparent
and fair way.
The situation for middle-income economies that are members of the Asia-
Pacific Economic Cooperation forum is rather different than for high-income
economies. High scores for middle-income economies are rare for any of
table 3.11’s five rated areas. Some economies, including Peru and Mexico,
scored much better than others. Indonesia received the lowest score on each
of the five criteria. Among LMICs, the worst situations relate to adminis-
trative burdens and enforcement consistency. More common than not, the
prevailing situation is one of (1) multiple agencies with overlapping respon-
sibilities, (2) redundant documentation, (3) frequent policy changes, (4) lack
of adequate technical and human capital, (5) facilitation payments often not
being required, (6) lack of or frequently changing protocols and document
requirements, and (7) discriminatory behavior on the basis of economy, busi-
ness, or mode of delivery.
These result in higher costs, affecting suppliers to these markets as well as
domestic consumers, yet do not contribute to safer food. The Marshall School
of Business study argues that micro, small, and medium-sized enterprises are
especially hard hit by administrative burdens and inconsistent enforcement
because of the costs involved, the lack of a dedicated staff to deal with these
matters, and discriminatory treatment, as these enterprises are powerless to
exercise “voice.” This type of situation either drives down the involvement of
these enterprises in trade or leads them to find informal cross-border channels
that are detrimental for the control of food safety.

SUMMARY

This chapter has explored the state of food safety management capacity in
LMICs, using a wide variety of indicators. Capacity has several dimensions,
which naturally evolve as economies develop and the motivation for safety
from food system actors strengthens. The available evidence on the state of this

20
None of these five areas should be affected by an economy’s level of development. The Marshall
School of Business study also considers other criteria, including transportation and information
and communication infrastructure.

The Status of Food Safety Management in Developing Countries 117

 capacity reinforces the conclusion that there are significant gaps between food
safety management capacity and food safety needs in LMICs.
The most comprehensive measure of capacity from the World Organisation
for Animal Health shows large gaps in basic elements of the public food safety
system in most LMICs. Furthermore, a clear relationship exists between a
greater burden of FBD and lower capacity. Many LMICs have a clear need for
greater capacity, whether measured through trade indicators or domestic mar-
ket trends. But they have relatively little capacity to meet their needs. Other
indicators of capacity are more tentative, but also point to a gap.
The chapter has examined examples of LMIC governments that partner
with the private sector (for example, to support food safety certification) and to
facilitate smallholder inclusion in high-value food chains. There are successful
examples of these efforts, but too few of them.
The international trade arena provides more concrete evidence of food safety
management capacity in LMICs, but it also reinforces the gap between need and
capacity. As expected, the private sector, especially in well-­established exporting
countries, has made major investments to certify improved production practices,
both in farming and processing. But the scope of these investments is not wide,
which means they are probably having only a limited effect on domestic food
safety in LMICs. The public sector in LMICs has only a l­imited capacity to facili-
tate international trade by providing transparent and consistent border controls.
This gap will become more important as many LMICs source more high-value
food imports from other LMICs. The following chapters explore how to tackle
the gap between capacity and need.

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 CHAPTER FOUR

Strengthening Food Safety

Management Systems

INTRODUCTION

T
he foregoing analysis highlighted the considerable economic and
social burden imposed on low- and middle-income countries (LMIC)
by foodborne disease (FBD), and the importance of improving food
safety management capacity in these countries for achieving the Sustainable
Development Goals. A considerable gap clearly exists between the needed
capability of LMICs to manage food safety and the actual level of capacity
across the public and private sectors. This is especially true for those LMICs
experiencing rapid economic and social change. Many upper-middle-income
countries have, in contrast, invested in robust food safety management systems,
which are beginning to pay dividends in terms of the safety of food for domes-
tic populations and the competitiveness of agri-food exports.
For LMICs, the challenges posed by food safety hazards and the opportuni-
ties to leverage food safety management initiatives as part of efforts to achieve
the Sustainable Development Goals are significant. This requires establishing
and implementing a coherent policy framework for food safety governance that
is both strategic and forward looking. In many LMICs, this framework is miss-
ing, making it difficult to make the case for more investment in food safety and
to ensure that the money that is made available is well spent. In most LMICs,
only modest investments are made in preventive measures and capacities, and
the attention that food safety hazards deserve tends to be given only in reac-
tion to sizable disease outbreaks, food scares covered by the media, and trade

123
 interruptions caused by food safety issues. The actions related to this response
also tend to be more demonstrative than effective in achieving standards com-
pliance or safer food. Enhanced inspections, testing, and fines may signal to
stakeholders that “something is being done,” yet reactive measures such as
these do not normally deal with the underlying causes of FBD and weaknesses
in capacities and incentives.
These modes of intervention in managing food safety also tend to occur in
a policy vacuum in which there is a lack of coherent and transparent prioritiza-
tion of investments, the roles and responsibilities of different stakeholders are
not clearly defined, and the contours of a food safety management system are,
at best, vaguely understood. This is hampering efforts for structured, evidence-
based decision making, and coordinated action within and between the public
and private sectors. In sum, policy incoherence is very much the norm for food
safety in LMICs.
Most of these countries, especially low- and lower-middle-income ones,
clearly need substantial investment in their food safety management systems.
But simply spending more is unlikely to be effective in significantly reduc-
ing FBD burdens in most LMICs. Governments need to invest more smartly
in food safety management capacity, and to do this using coherent, priori-
tized, and forward-looking policies on food safety governance. This means
that increasing investments in these systems must be made, alongside pol-
icy reforms for how governments engage private sector stakeholders in food
safety management.
This chapter offers broad-based guidance to LMIC policy makers on the
needed directions and modalities for enhancing food safety management
capacity. This report clearly cannot provide road maps or set specific invest-
ment priorities for individual countries. These priorities need to be determined
nationally (or subnationally, in large and diverse countries). These priorities
also need to reflect the status and trajectory of a country’s agri-food system, the
current and expected burden of FBD and how it relates to food safety manage-
ment capacity, and the perspectives of stakeholders on immediate priorities
and those in the short and longer terms.
The chapter offers guidance for establishing a more effective policy frame-
work to govern food safety. It makes the following recommendations, which
are then discussed in detail:

• Adopt a food safety system perspective and an inclusive concept of food

safety management
• Shift the focus from hazards to risks and address risks at every stage of the
agri-food chain
• Shift from a reactive to a preventive orientation that anticipates risks and
opportunities
• Adopt a more structured and consistent approach to prioritized decision
making

124 THE SAFE FOOD IMPERATIVE

 This chapter also offers guidance for improving the implementation of this
policy framework, and makes the following recommendations:

• Reform food safety regulatory practice, shifting from policing to facilitating

compliance
• Invest smartly in essential public goods for effective food safety management
• Institutionalize a structured approach to food safety risk management
• Leverage consumer concerns on food safety to incentivize better food
­business practices

STEPS TOWARD A MORE EFFECTIVE FOOD SAFETY POLICY

FRAMEWORK

Nearly all LMICs have laws for different elements of food safety and for defin-
ing the responsibilities of specific public institutions for enforcing these laws.
But far fewer LMICs have clearly defined policy frameworks governing food
safety that lay out (1) how the system for food safety operates; (2) the mecha-
nisms for coordinating activities and functions among concerned agencies;
(3) the modes of engagement with food business operators and consumers,
and the responsibilities of both; and (4) how food safety regulations and other
related actions are prioritized.
Without a policy framework, strategic decisions on investments to build and
maintain food safety management capacity tend to be lacking. And efforts to
ensure food safety become fragmented, thereby missing an opportunity to take
advantage of synergies or complementarities that could have helped fill impor-
tant capacity gaps. Because of this, scarce resources are not used optimally, and
capacity falls well short of needs. The following subsections delineate the priori-
ties for LMICs to put in place an effective policy framework for food safety.

Adopt a Food Safety System Perspective and an Inclusive

Concept of Food Safety Management
In many countries, official responsibilities for food safety are divided among
multiple ministries, departments, and agencies—depending on the product,
type of hazard, stage of the agri-food value chain, and, sometimes, the destina-
tion market. Ministries with responsibility for agriculture are often the lead
agencies for the oversight of farm practices and inputs and intermediate stage
operations; for example, abattoirs. Ministries of health are concerned with
water, sanitation, and public health, including monitoring disease outbreaks.
Ministries of trade are concerned with standards, border inspections and certi-
fication, negotiating trade equivalence, and promoting exports. Other agencies
may also be involved; for example, environment ministries (for soil contami-
nants and chemical use) and ministries charged with consumer protection
for food labeling and product fraud. Often, authorities operate at central and

Strengthening Food Safety Management Systems 125

 decentralized levels. For example, national agencies are responsible for moni-
toring food imports and municipalities are responsible for the oversight of local
markets and street food vending.
Most LMICs do not have a lead designated agency with overarching respon-
sibility for food safety regulation, or at least for coordinating functions across
the food safety area (though, as box 4.1 shows, there are some notable excep-
tions). The lack of a lead agency makes it difficult to set strategic priorities and
to engage effectively with stakeholders. Administrative procedures and hierar-
chies can also stand in the way of the effective management of food safety, espe-
cially where controlling FBD requires the aligned actions of multiple agencies.
As an example of this, consider where the management of foodborne hazards
requires action along the entire value chain. The overarching vision, therefore,
should be of an integrated system of food safety management with closely coor-
dinated actions and responsibilities, both vertically and horizontally.
A pitfall would be adopting institutional solutions ahead of a comprehen-
sive food safety policy framework. Some LMICs have set up U.S. Food and
Drug Administration–type entities, driven primarily, it seems, by regulatory
concerns about drugs rather than food. While similarities exist between drug
and food controls, there are significant differences. For example, regulatory
measures for drugs tend to be focused on a few, large companies, which pro-
vide for full cost recovery, and generally involve company licensing and prod-
uct preauthorization. Food controls need to address a broad range of hazards
and dispersed value chain actors, and they often use different types of regula-
tory tools. Food and Drug Administration–type agencies in LMICs also often
lack the mandate and capacity to tackle the risks associated with fresh or raw
produce.

BOX 4.1 Food Safety Lead Agencies in Chile and India

Only a few low- and middle-income countries have lead designated agencies coor-
dinating domestic food safety functions. Chile and India are among the few.
The Chilean Agency for Food Quality and Safety’s structure, tools, and work
methodology are geared toward generating and implementing collaborative inter-
ventions with different actors in food production. The agency’s main tools include
(1) national integrated programs (for example, on standards harmonization and
validation of methods); (2) a food safety alert network; (3) an integrated food labo-
ratories system; (4) a network of food safety scientists; and (5) chairing regional
advisory commissions for food safety and quality.
The Food Safety and Standards Authority of India has comprehensive national
and subnational programs. These include (1) coordinating scientific commit-
tees to create and revise standards, (2) oversight of food establishment licensing
and inspections, (3) fostering an effective system for testing foods in accredited
laboratories, (4) coordinating programs on food safety training and certification,
and (5) coordinating a multitargeted platform for inducing behavioral changes to
ensure safer food.

126 THE SAFE FOOD IMPERATIVE

 The concept of an integrated food safety management system needs to go
well beyond the centralization of functions and improved coordination within
government. The safety of food is the result of action—and inaction—by mul-
tiple stakeholders, including those directly involved with the production,
processing, and distribution of food, and those that affect the wider physical
and enabling environment in which food operations take place. The World
Health Organization promotes the concept of a shared responsibility for food
safety, which emphasizes the interdependent roles of government, business,
and ­consumers (figure 4.1), but with important additional actors, including
scientists, educators, and the media. The World Health Organization’s frame-
work usefully draws attention to the importance of leadership, partnerships,
resources, and a range of core functions that a food safety management system
needs to ­competently perform.
Applying the principle of shared responsibility diverges from the traditional
model of official food safety controls, which are centered on government regu-
lation enforced through the inspection of food facilities, product testing, and
legal penalties for infractions. Although more nuanced in practice, this model
is typified by (1) a strict application of rules, regardless of the relative impor-
tance of particular violations in terms of the risks to human health; (2) a focus
on the process of regulation, regardless of the impact on food safety outcomes;
and (3) a reliance on deterrence as the main driver of compliance, with a con-
sequent emphasis on sanctions and punishment.

FIGURE 4.1 Framework for Action on Food Safety

Government

Leadership

Policy
Information and legal
underpinning frameworks
evidence
Partnerships
Resources

Food
safety Risk-based
Incident and system inspection and
emergency enforcement
response

Communications
and education

Competency
Business Consumer

Source: World Health Organization.

Strengthening Food Safety Management Systems 127

 This authoritative model goes together with performance indicators that are
focused on output—notably, the number of infringements, value of fines collected,
and number of businesses closed down—rather than outcomes for the magnitude
of food safety risks or the prevalence of FBD. In practice, this system is susceptible
to corruption, either opportunistically by individual businesses or systemically by
enforcement agencies. This strict, authoritative approach is very appealing to the pub-
lic, media, and therefore policy makers. When extreme cases of noncompliance or
widespread outbreaks of FBD occur, even stricter enforcement and harsher penalties
are demanded. In this way, the system becomes self-sustaining and difficult to reform.
Conversely, a system of food safety management based on the notion of shared
responsibility tends to move from a regulator-regulated relationship toward gov-
ernment efforts to incentivize and facilitate the delivery of safe food production,
processing, and distribution. The role of regulation in this context is to lay down
an absolute minimum food safety standard that leaves businesses with some flex-
ibility for how this standard is reached in terms of the processes and procedures
that they use. This approach requires government to play a substantial, facilitative
role by providing information and other resources, and support to motivate and
help leverage investments and actions by actors along agri-food value chains and
those providing supporting functions. The regulatory and facilitative actions of
government are also risk-based, in that they are purposively directed at invest-
ments that can deliver the most significant food safety outcomes.
There is compelling evidence that more participatory systems of food safety
management, in which governments play a facilitative and incentivizing role,
use resources more efficiently and have better food safety outcomes. That said,
implementing these systems can be challenging. Moving away from the long-
standing and predominantly authoritative approach to food safety regulation
typically requires significant institutional change and a cultural shift among
actors along the entire agri-food system. In this process, governments must
avoid accusations of being compromised by agri-food business interests.
Opportunities also exist for shifting toward a shared-responsibility approach,
even where the traditional regulatory approach is firmly entrenched.

Shift the Focus from Hazards to Risks and Consider Risks at Every
Stage of the Agri-Food Chain
The focus of food safety policies should shift from detecting foodborne hazards
to prioritizing and addressing risks in the context of the foods eaten by the
domestic population. Risk-based approaches consider the potential hazards of
eating food and the probability that adverse health effects will occur. Because
of this, risk-based approaches have proven to be the best way to reduce FBD
within the population. These approaches also make better use of resources by
focusing attention on foods with the greatest health risk and away from foods
which, while hazardous in principle, present little risk to public health. These
approaches are becoming standard in high-income countries. But while inter-
est is growing in risk-based approaches to tackle FBD in LMICs, there are few
examples of them being applied (box 4.2).

128 THE SAFE FOOD IMPERATIVE

BOX 4.2 Uruguay’s Risk-Based Approach to Strengthening Food
Safety Controls

Since 2015, Uruguay’s Ministry of Husbandry, Agriculture, and Fisheries has based
the inspection and surveillance of firms in the dairy industry on risk-based principles.
This involves identifying microbiological and chemical hazards, risk mapping prod-
ucts and production plants, and organizing inspections on the basis of these factors.
Table B4.2.1 summarizes the changes from adopting this approach, which is
planned for expansion for other food chains under the Ministry of Husbandry,
Agriculture, and Fisheries’ authority.

TABLE B4.2.1 Comparison of Uruguay’s Traditional and Risk-

Based Inspection Approaches
Component Traditional approach Risk-based approach
Purpose of Designed to find problems if Designed to anticipate problems, thereby
inspection they occur minimizing risk
Noncompliance is ranked based on risk
Deployment of Based on reaching More flexible resource allocation with
resources administrative targets, such level of product- and process-specific
as coverage risks, and ongoing assessment of the
food safety performance of plants
Work to do Perform assigned Varies based on risk
procedures Basic procedures, based on inspection
findings and decision criteria
Results provide feedback to the system
Activities of Procedures designed to find Focused on where loss of control is
inspection noncompliance more likely to occur or have serious
personnel public health consequences
Intensify inspection if plant is losing
control
In small businesses, risk-based inspection
raises awareness of the importance of
controlling risk
Response to Evidence of compliance or Evidence of noncompliance could lead to
inspection noncompliance has no effect enforcement action
findings on intensity of inspection Intensity of inspection based on findings
Evidence of noncompliance Good controls mean less intense
could lead to enforcement inspection; poor controls mean
action intensified inspection
Response to Not designed to have Inspection personnel have flexibility, data,
emerging issues inspectors make a judgment responsibility, and training to be able to
about risk of noncompliance focus on emerging problems
Sources: Based on Masters and Derfler 2015, and interviews conducted by Jairo Romero.

Strengthening Food Safety Management Systems 129

 Frameworks have been developed for analyzing the risks associated with
hazards in food. The approach to risk analysis in the principles and guidelines
adopted by the Codex Alimentarius Commission is accepted as a baseline
worldwide. In this framework, the process of risk analysis consists of three
interdependent components:

• Risk assessment. This quantifies risks so that their burden can be better
understood, and progress in risk reduction can be measured. Risk assess-
ment is perhaps the most methodologically developed aspect of the frame-
work, which has four steps: hazard identification, exposure assessment,
hazard characterization, and risk characterization.
• Risk management. This is the process of weighing alternatives and imple-
menting strategies to reduce risk. Risk management involves considering
what is feasible, the costs and benefits of risk reduction, and the opinions of
stakeholders about appropriate levels of risk.
• Risk communication. This is the exchange of information on risk-related fac-
tors among risk assessors, risk managers, consumers, and other stakehold-
ers. Risk communication ensures transparency in policy making, leads to
informed actions by the public, and supports shared responsibility.

Parallel to adopting the risk paradigm should be the application of a sys-

tem approach to food safety that focuses on the entire value chain and the
wider environment in which the chain operates. This farm-to-fork approach
recognizes that food can become contaminated at various stages of the value
chain and, likewise, that corrective actions can be taken at multiple stages of
the chain (table 1.1 in chapter 1 shows the food safety hazards on the farm-
to-fork pathway). As part of enhancing food safety management capacity,
it is therefore necessary to locate and deal with the weak stages of agri-food
value chains, and to build in controls—often at multiple levels of the chain—to
ensure food safety at the point of consumption. The primary emphasis, how-
ever, should be on avoiding hazards from entering the agri-food chain in the
first place (for example, from soil, water, animals, production inputs, and food
handlers), and building in ways to detect, remove, and otherwise neutralize
hazards that occur.
Some food safety risks can best be managed—or in some cases, only
­managed—at the preharvest stage; for example, antimicrobial residues in
animal source foods or pesticide residues in fresh fruit and vegetables. For
other food safety risks, actions may be needed at multiple stages of the
value chain. A lot of progress is being in high-income countries to reduce
the risk of FBD that results largely from improving post-slaughter or post-
harvest practices. In LMICs, most efforts to reduce food safety risks have
focused on controls at aggregation stages of the value chain (slaughter-
houses, wholesale markets, dairy cooperatives, for example), and by chang-
ing consumer behavior.

130 THE SAFE FOOD IMPERATIVE

Shift from a Reactive to a Proactive Orientation That Anticipates
Future Risks and Opportunities
Given the lack of reliable data in many LMICs on the nature and extent
of foodborne hazards, and the prevalence of FBD and its economic
impacts, it may not be an exaggeration to say that, in this respect,
we know the future better than we understand the past or even the present.
For LMICs, the circumstances faced by upper-middle-income countries—
which have already experienced advanced rates of dietary transformation
and urbanization, and have had to play catchup to reverse escalating food
safety problems—can be observed. It is therefore reasonable to predict
that, everything else being equal, countries at earlier stages of the food
safety life cycle can expect a similar trajectory. This will be character-
ized by a ­rapidly escalating burden of FBD if these countries pursue a
business-as-usual scenario and only take serious action when major food
safety problems happen.
This is well illustrated by a study of FBD in India that predicts the prev-
alence of FBD will rise from 100 million cases in 2011 to 150 million–177
million cases by 2030 in a business-as-usual scenario (Kristkova, Grace, and
Kuiper 2017). The predominant drivers of this trend are urbanization and
dietary change, in particular increased meat consumption. Those predicted to
be especially affected are higher-income population groups in urban and rural
areas where more significant dietary change is expected. The study cautions
that a rising FBD burden could compromise India’s nutritional goals if a signifi-
cant proportion of the population chooses to avoid or reduce the consumption
of nutrient-dense foods that are bigger food safety risks, such as meat and fresh
fruit and vegetables.
The notion of a food safety life cycle with levels of economic develop-
ment, as discussed in chapter 1, has considerable support. But the typical
trajectory of rapidly rising public health costs and trade disruptions from
FBD is not inevitable. A significant share of food safety problems can be
managed, and their heavy costs avoided. These costs can be lessened by rec-
ognizing the ways in which food safety challenges evolve with the level of
economic development, and by taking measures to ensure that food safety
management capacity is commensurate with that level. A proactive strat-
egy such as this, accompanied by properly prioritizing food safety issues,
will enable countries to avoid prospective economic losses and the burden
these impose on the domestic population and businesses. The size of these
avoided losses can amount to hundreds of millions of dollars a year—and
run to several billion dollars for larger countries.
In adopting a prevention strategy, it is essential to approach capac-
ity development as a continuous process of improvement that is guided by
anticipated needs. Here, it is important to calibrate investments in food safety
management capacity with current and anticipated needs, and to apply an

Strengthening Food Safety Management Systems 131

 incremental approach to upgrading. Aspirations for food safety capacity
building that are overly ambitious and out of sync with current and fore-
seeable short-term needs will result in critical capabilities being unused or
becoming obsolete, and heavy costs being imposed on the public and/or
private sectors. Regulatory requirements can also be set at levels that are
unachievable for key market actors, either rendering them meaningless or
leading to conflict and inequitable outcomes.
A preventive approach is an essential feature of effective food-risk com-
munication, but this not the norm. The communication of food risks in
LMICs tends to be largely reactive; in other words, after there has been a
significant risk incident. This primarily takes the form of crisis commu-
nication and rarely goes beyond attributing blame. This one-directional
form of communication is basically a monologue. A more effective way
of risk communication entails a long-term, interactive process, involving
a dialogue among different stakeholders and conducted through multiple
formats.

Adopt a More Structured and Consistent Approach to Prioritized

Decision Making
LMICs typically face a broad array of food safety challenges. These are
expected to become more difficult for low- and lower-middle-income
countries as they move along the food safety life cycle because of very
limited public and private sector resources. Because of this, it is essential
to set clear and evidence-based priorities for investments in enhancing
food safety management capacity, and to review these priorities as needs
change. Inevitably, LMICs will have to do this using incomplete informa-
tion, including a lack of reliable data on the prevalence of FBD and how it
spreads across society.
Establishing priorities for enhanced food safety management
­capacity often takes place between multiple potential investments and
vocal demands from competing and powerful interest groups. Against
this backdrop, it is vital that priorities are set in a structured and trans-
parent manner, not an ad hoc and opaque one. Fortunately, a frame-
work for establishing investment priorities for LMICs has been developed
by the Standards and Trade Development Facility—the Prioritizing
Sanitary and Phytosanitary Investments for Market Access Framework.
Although developed for enhancing sanitary and phytosanitary capacity
in the context of trade, it can also be applied to food safety management
capacity (box 4.3).
It is also worth highlighting that the Food and Agriculture Organization
has developed a multifactor decision-making framework that is shared
through a guidance document (FAO 2017). This approach is primarily
designed to guide decisions on how to implement food safety decisions;
that is, identifying which specific measures to take to manage a food

132 THE SAFE FOOD IMPERATIVE

BOX 4.3 Prioritizing Sanitary and Phytosanitary Investments for
Market Access

The Standards and Trade Development Facility launched the Prioritizing Sanitary
and Phytosanitary Investments for Market Access Framework to improve trade-
related sanitary and phytosanitary (SPS) capacity in low- and middle-income coun-
tries. The framework helps to prioritize SPS capacity building by using multiple
decision criteria. It is designed to be used where there are many trade-related SPS
issues requiring investments in capacity, but where resources are insufficient to
address them all, and where the data needed to establish priorities are limited or
of poor quality.
The framework process makes use of the best data available and clearly docu-
ments all the criteria and sources of information used, so that findings are open to
scrutiny. Typically, the criteria used include the cost of upgrading SPS capacity; the
costs of operating and maintaining this capacity; and the impacts on trade, agricul-
tural productivity, public health, and the environment, as well as the implications
on poverty and vulnerable groups. The framework uses a multicriteria decision
analysis approach and computer software (D-Sight) to derive SPS investment pri-
orities on the basis of these competing criteria.
A number of low- and middle-income countries have used this framework. They
include Belize, Ethiopia, Malawi, Mozambique, Namibia, Rwanda, the Seychelles,
Uganda, Vietnam, and Zambia. Their experience highlights the benefits of this
­structured and transparent approach for setting priorities. The benefits of using the
framework also include facilitating public-private dialogue on SPS i­nvestments,
increasing political awareness on the benefits of strengthening SPS capacity, ­informing
and improving national SPS planning and decision-making processes, supporting
project design, and leveraging additional funding to build SPS capacity.
A new Standards and Trade Development Facility project with the Common
Market for Eastern and Southern Africa (COMESA) plans to use the framework to
mainstream SPS investment priorities into the Comprehensive Africa Agriculture
Development Programme and other policy and planning frameworks—for exam-
ple, those focused on trade, the environment, and climate change—in selected
COMESA member states. Standards and Trade Development Facility project prep-
aration grants for Madagascar and Tajikistan are also making use of the framework.

safety risk. The framework’s elements for prioritizing food safety invest-
ments for m­ arket access can also be useful for guiding structured processes
to prioritize food safety capacity management investments. Five potential
decision factors are identified: (1) public health impacts caused by food-
borne hazards, (2) economic losses related to food products being removed
from domestic or export markets, (3) food security concerns, (4) consumer
perceptions and acceptance of food safety risks, and (5) sociocultural con-
cerns related to protecting vulnerable groups. The relative weight which
countries might give to these decision factors will likely vary. The frame-
work is discussed later in the chapter.

Strengthening Food Safety Management Systems 133

 BETTER IMPLEMENTATION: MOVING FROM POLICY
TO ACTION

Operationalizing the principles discussed in the previous section will not be

straightforward for most LMICs. Adopting a facilitated approach based on
the principle of shared responsibility that is risk-focused, proactive, and with
clearly articulated priorities represents a formidable cultural shift for most
LMICs that will likely require significant institutional change and the realign-
ment of responsibilities and resources. Operationalizing this new approach will
be especially challenging for the agri-food sector because it is predominantly
informal, and a large proportion of food produced is for household consump-
tion. Another challenge is that the structure and modus operandi of value
chains in LMICs are transforming rapidly.
So, what can public sectors in LMICs do to operationalize this fundamen-
tal paradigm shift? How can they make shared responsibility a reality? For
instance, they can make businesses allies in tackling food safety, move away
from an adversarial approach to enforcing food safety laws, and encourage the
private sector to adopt best practices. And how can consumers and marginal-
ized stakeholders—such as smallholder farmers and micro and small medium-
sized enterprises in food processing or distribution—become more engaged in
establishing food safety policies and accept the notion of shared responsibility?
How can these efforts move beyond a one-way street, with government com-
municating information about food safety risks, and what is it doing to protect
consumers in a situation when they become more responsible for their food
safety? They can do this, for example, through their demands on food sellers,
their food choices and shopping behavior, and their food preparation and stor-
age practices in the home.
A way forward is to leverage the public sector’s convening power to moti-
vate and coordinate actions within agri-food value chains. Governments
potentially have a wide range of tools at their disposal to incentivize and
empower businesses to enhance their food safety management systems, both
individually and for the value chains and sectors in which these systems
operate. The public sector can use a stick-and-carrot approach to motivate
the desired actions by actors along agri-food value chains, and can make
strategic public investments where there are substantive public good ele-
ments and a lack of private incentives to invest. In doing this, governments
should ideally be informed by behavioral insights to optimize the use of
scarce resources and to maximize the impacts of their engagement with
business (box 4.4).
It is worth noting that some countries have been pursuing these transitions.
There is also a growing body of experience and learning on how to make regu-
latory systems work better. Much of this is happening in high-income coun-
tries, including Australia, New Zealand, the United Kingdom, and the United
States. But there are also nascent and more advanced efforts in some countries
in Latin America, Eastern Europe, and Asia.

134 THE SAFE FOOD IMPERATIVE

BOX 4.4 Professionalizing Food Inspectors and Food Service
Industry Workers

Professionalization—which is generally achieved through a combination of train-

ing and complementary interventions—works through the “induction” of trainees
into a professional group and identity. This approach builds on the recognition
that individuals can be motivated to act in ways that they see as conforming to an
identity to maintain a sense of belonging to a group, whether in their own eyes or
in the eyes of others.
By creating a sense of professional identity among participants, training and
complementary programs can contribute to the adherence of trainees to the prac-
tices they learned to conform to or reassert that identity.
Professionalizing food inspectors is particularly important. In low- and
middle-income countries (LMICs), food inspectors have the potential to take
on roles similar to extension workers in agriculture. Food inspectors are a
government workforce interacting with key actors in the food safety world if
the risk-based approach is properly applied, and their supportive approach to
enforcement gives them an advisory role. Experienced inspectors are aware of
how food businesses in their locality work, know what works and what does
not to gain compliance, and are well aware of those businesses that are trying to
improve and those cutting corners.
In high-income countries, the private sector can provide compliance advice,
but in LMICs that service is rarely available, especially to small and medium-
sized enterprises. Food inspectors can, however, fill that gap by their remit being
extended beyond sanctioning to include advising. In both LMICs and high-income
countries, using “assured advice” has been a breakthrough in regulatory delivery
methods.
There is scope to professionalize food service industry workers. They, too, can
be given the opportunity to see themselves as professionals, and be motivated to
assert this identity if it becomes a source of increased self-worth and social recog-
nition. If keeping food safe is central to that identity, one way of asserting it would
be to demonstrate “responsibility” by using safe food handling techniques and
keeping food safe at different points in the ­supply chain.
The power of professionalization is that it can bring about self-policing behav-
ior. To professionalize food service industry workers and reap its self-policing ben-
efits, programs must not stop at teaching safe food handling protocols or even the
importance of food safety. Programs need to cultivate this knowledge in tandem
with a professional identity—preferably one that is demanding in terms of food
safety and barred to the undeserving—through a combination of training and com-
plementary interventions.

Reform Food Safety Regulatory Practice with a Shift from Policing

to Facilitating Compliance
Many LMICs need to reform food safety regulatory thinking and practice.
The implementation of regulatory systems is seeing a growing trend in the
move from an authoritative model to a more extensive mixture of tools,
predominantly related to supporting regulated businesses.

Strengthening Food Safety Management Systems 135

 The traditional assumption behind deterrence and sanctioning is
that regulated entities will try harder to be compliant under these condi-
tions. But this ignores extraneous factors and the consequences of these
actions. For example, a fined business can lose money and market share
to such an extent that it is less able to upgrade its food safety manage-
ment capacity. Where lack of capacity rather than explicit intention is the
reason for noncompliance, a fine does not deliver an improved outcome.
Food businesses that do not understand basic hygiene will not become
more hygienic simply by being fined. Instead, they need to be informed
about better hygiene and provided with the knowledge to be able to imple-
ment good hygiene practices. Punishment or the threat of punishment may
well influence the decisions of some businesses. But this form of sanction
needs to be credible, and the financial consequences substantive. In many
LMICs, not enough resources are available for inspection and other forms
of conformity assessment procedures. Because of this, the chances of being
caught for breaking food safety regulations are generally slim outside of
city centers. To combat this, enforcement agencies need to adopt innovative
approaches.
Feeding an urban population of millions safely can be achieved only by
raising the food safety management capacity of the food businesses that
handle a large proportion of the food consumed. For LMICs, and especially
low- and lower-middle-income countries, this includes many micro and
small enterprises operating in the informal sector. Because the resources
to enforce food safety standards are limited, public agencies charged with
managing food safety must find ways to encourage and support businesses
to enhance the food safety management practices of these enterprises so
that they are able to comply with minimum regulatory requirements. In
practice, the number of businesses that knowingly break food safety regula-
tions in a criminal sense tends to be small. Most businesses, when aware of
the standards, try to comply within the context of the financial and other
constraints they face.
The experience in many LMICs is that food businesses are generally try-
ing to get it right and respond to advice on how to improve safety levels.
Because of this, the food safety challenge in this context is about supporting
compliance, rather than going after what are probably a small number of vio-
lators that are knowingly—and therefore criminally—breaking food safety
regulations (figure 4.2).
Regulators must understand the constraints faced by food businesses
that impede their ability to comply with food safety requirements and find
ways of facilitating compliance in a way that imposes the least burden on
businesses. In some cases, the most effective way of removing barriers to
compliance is to make it easier for businesses to know what constitutes
compliance in the first place. This can involve simplifying regulations
and, as has proved e­ ffective, sharing with businesses the checklists used
by inspectors. Even better is explaining to businesses the reasons behind

136 THE SAFE FOOD IMPERATIVE

FIGURE 4.2 Reducing Noncompliance versus Raising Compliance

Enforcement challenge: Criminal

Increasing compliance levels Removing criminals does not
or reducing criminal levels Willing increase compliance by the rest
to comply

Compliant
Criminal Criminal
Stopping criminals
Willing
Willing to comply
to comply Supporting those willing
to comply
Compliant
Compliant

Source: Donald Macrae.

the regulatory requirements. The willingness to comply is generally stron-

ger if businesses know that the authorities are genuinely trying to work
with them.
While incidents of criminal noncompliance may be statistically insig-
nificant, they can nevertheless be politically sensitive, especially when
highlighted by the media or associated with notable FBD outbreaks. Even
the internationally publicized scandal of melamine contamination of infant
formula in China led to few fatalities relative to the population as a whole
and the routine burden of FBD. It is not surprising that public regulators
devote considerable resources to identify and prosecute those that are crim-
inally noncompliant, and typically these are large businesses. But it could
be argued that these resources would be better spent promoting enhanced
food safety management practices by the multitude of micro and small
enterprises that supply food to a large proportion of the urban populations
in LMICs.
Once most food businesses are compliant with minimum food safety
requirements, regulators should concentrate their resources on the smaller
businesses that need to upgrade their standards and otherwise divert atten-
tion away from supporting compliance. In Australia and the United Kingdom,
for example, regulatory compliance is increasingly being left to the private sec-
tor itself.1 Governments should also look to a wide set of tools to ­incentivize not

1
Australia’s red meat industry has the Livestock Production Assurance program, the National
Feedlot Accreditation Scheme, and the National Vendor Declaration, all overseen by Meat and
Livestock Australia, a producer-owned, not-for-profit organization. In the United Kingdom,
the Red Tractor Scheme has an on-farm assurance program for a range of commodities; the
Soil Association, a registered charity, certifies food products as organic; and the British Retail
Consortium oversees a meta-standard for food manufacturers and distributors.

Strengthening Food Safety Management Systems 137

 only compliance with regulatory requirements but also the continuous upgrad-
ing of food safety management capacity. These tools include tax exemptions,
concessional credit, and matching grants for advisory and auditing services.
These actions can also be “tiered” toward priority businesses on the basis of size
and market orientation, for example. One promising area is the direct or indi-
rect support that governments could provide small and medium-sized enter-
prises for industry benchmarking schemes, such as the Global Food Safety
Initiative’s Global Markets Programme.2
For the informal sector, regulatory sticks are not particularly effective in
bringing about enhanced food safety management capacity, and they tend to
have more symbolic value, in the sense of government being seen to be “doing
something about” food safety. But there is scope for broad interventions to
bring about behavior change. For example, many interventions have been
undertaken to address the safety of street-vended food. Programs to induce
behavior change tend to involve some combination of the following:

• Education and awareness-raising for vendors, consumers, and government

inspectors.
• Providing basic food preparation equipment, which is sometimes accompa-
nied by training and support for self-help groups.
• Registering, licensing, and rating vendors and their premises for food safety
risks.3
• Surveillance, involving routine and seasonal checks by inspection teams;
this can involve using mobile test kits and checklists for raw materials, food
handling, personal hygiene, and environmental surroundings.
• Infrastructure upgrades that improve access to potable water supply, access
to electricity, and waste disposal systems; these sometimes involve relocat-
ing vendors, as Singapore did.

Indeed, Singapore’s experience in promoting incremental upgrades in street

vendor food safety and environmental management, and the formalization of
street food businesses in hawker centers, is instructive for how a combination
of regulatory and facilitative tools was used in this process (box 4.5).

2
The program was launched in 2010 to provide an unaccredited entry point for companies with a step-
by-step approach designed to build capacity within production and manufacturing operations, and
improve market access through certification to one of the schemes recognized by the Global Food
Safety Initiative (GFSI). The program includes a toolkit for self-assessments based on a checklist of
GFSI requirements, a training and competency framework, and a protocol to guide the user. Toolkits
are available for primary production and manufacturing in many languages. Collaborative GFSI pro-
grams for training small and medium-sized enterprises have been implemented in China, Georgia,
Kazakhstan, and Ukraine, among other countries.
3
In some countries, it will be important to address the legal ambiguity of street food vendors to
reduce their vulnerability to punitive actions by local authorities.

138 THE SAFE FOOD IMPERATIVE

BOX 4.5 How Singapore Formalized Its Street Food Businesses

Some 40,000 hawkers plied Singapore’s streets and riversides selling food and
other low-cost goods and services in the 1960s, raising serious food safety and
environmental concerns. To tackle this, a licensing and inspection scheme was
introduced, but the main strategy to formalize Singapore’s street food business was
to relocate these vendors to hawker centers. Fifty-four of these were built in the late
1970s, and another 59 in the early 1980s.
During the 1980s and 1990s, a “regulate and educate” policy was used to improve
hygiene practices, with hawker centers being increasingly recognized as playing
important social roles in communities. In 2001, the government allocated S$420
million for infrastructure improvements to the sector under the Hawker Centre
Upgrading Programme. Some hawker centers were completely rebuilt, and most
acquired central freezers and cleaning areas. By 2014, 109 centers had been upgraded,
accommodating 6,000 vendors. In 2016, two hawker stalls were awarded a Michelin
star. Hawker centers have loyal local customers and are a tourist attraction.
The National Environment Authority manages and oversees Singapore’s hawker
centers. Its mission for these centers is for them to be “vibrant, communal spaces,
offering a wide variety of affordable food, in a clean and hygienic environment.” Here,
the authority’s role covers overseeing stakeholders, developing and implementing
policies for the hawker sector, and maintaining the infrastructure of centers and
developing new centers. The authority also manages the assignment and rents for
tenancies, licenses, and public relations.

Invest Smartly in Essential Public Goods for Effective

Food Safety Management
Governments of LMICs not only need to invest more in food safety but also to
invest more smartly. The chances of making more effective and efficient invest-
ments in food safety management capacity are greater if the following prin-
ciples are adhered to:

• Invest for the right reasons. This means being specific about the food safety
goals being pursued and how proposed investments relate to these goals.
• Invest in the right things. Investments in food safety should be driven both
by considerations of food safety risks and by seeking to achieve an appro-
priate and synergistic balance between the “hard” and “soft” aspects of
food safety management capacity. Laboratory infrastructure is an exam-
ple of a hard aspect; managing systems and procedures are examples of
soft aspects.
• Use public investment to leverage private investment. But avoid measures that
might crowd out private investment for food safety management capacity.
• Track the impacts of investments. This needs to be done for food system stake-
holder behavior, the safety of food, and FBD incidents. A rigorous approach to

Strengthening Food Safety Management Systems 139

 monitoring and evaluation will contribute to the cost-effectiveness of interven-
tions and show where adjustments are needed to realize desired outcomes.
• Ensure the sustainability of investments and capacity outcomes. This can be
done by ensuring that sufficient operating resources for food safety manage-
ment will be available on a continuous basis, and by maintaining physical
and human assets. This principle, however, is often ignored. Box 4.6 looks at
investments in laboratory testing capacity.

BOX 4.6 Investing More Smartly and Sustainably in Laboratory

Testing Capacity

Many low- and middle-income countries (LMICs) plan to expand or upgrade their
public food safety laboratory testing capacity to help boost food exports and for
domestic surveillance and regulation. Improved testing capacity is often an essen-
tial component of efforts to strengthen broader food safety governance. Even so,
experience shows that many investments in public food safety laboratories are
financially or technically unsustainable (or both). A World Bank (2009) review of
multiple investments highlighted the following contributing factors:
• Lack of a clear mission statement, either for individual laboratories or the labo-
ratory system
• Failure to realize economies of scale, either because of insufficient demand for
sophisticated services or the failure of surveillance and inspection agencies to
deliver samples or invest in the testing facilities capacities of other laboratories,
including in the private sector
• A disconnect between investment and operational decisions, with recurrent
operational resources often being insufficient to maintain purchased equipment
or professional laboratory staff
• Low incentives to improve quality management in the delivery of regulatory or
other services
• The absence of enabling rules and management capabilities to run laboratories
as a business
On the last point, many laboratories in LMICs do not have administrative or finan-
cial autonomy, are not permitted to charge fees which cover their full costs, and are
often not required to implement clear business plans. The contributing factors in the list
point to the need for a careful assessment of public laboratory investment needs, not in
isolation but as part of the capacity needs for overall food safety governance.
Larger LMICs need to consider the appropriate geographic distribution of test-
ing capabilities and the relationship between central and state/provincial laboratories
in their overall network. For all LMICs, and especially the smaller ones, the scope for
outsourcing laboratory services to certified private laboratories needs to be considered,
especially for specialized services. Argentina does this. Its public food safety agency has
authorized two private laboratories to test aflatoxin in groundnuts intended for export.
Where investments are made, strict attention should be given to quality control,
through proficiency testing, staff training, and accreditation.

140 THE SAFE FOOD IMPERATIVE

 It is important to point out that not all investments that can reduce the bur-
den of FBD are specifically “food safety” ones. For example, critical investments
that do not fall in this category can be those that tackle environmental health
issues, such as increasing access to potable water and improved sanitation,
and reducing or mitigating environmental contaminants in soil, water, and air.
Such measures reduce the propensity for cross contaminating the food supply
at various stages of agri-food value chains. Another important area is invest-
ment in public health systems, including increasing access to and the quality
of hospitals and clinics; training and funding more doctors, nurses, and other
health workers; and increasing access to immunization programs and phar-
maceuticals. These initiatives reduce the morbidity and mortality outcomes of
FBD, and thus the ultimate socioeconomic burden on LMICs.
Other potential investments are more dedicated to food safety. These can
include system-wide surveillance and testing for food safety hazards; address-
ing hazards and risks in specific value chains (infrastructure upgrades, promot-
ing better practices); and import controls (quarantine and preborder, border,
and postborder inspections). The relative emphasis that can and should be
given to these dimensions will vary among countries at different points in the
food safety life cycle, a topic discussed in chapter 5. Regardless of country cir-
cumstances, LMICs can make forward-looking investments for which they will
almost always have “no regrets,” because these investments are foundational
aspects of food safety capacity. The foundational aspects include:

• Sound science and evidence. This pertains to risk assessment and FBD sur-
veillance, the economics of unsafe food, and the effectiveness of measures to
enhance food safety management capacity.
• Human capital. This is the cadre of food safety professionals needed to pop-
ulate new technical and managerial positions in government and the private
food sector, and various technical service industries.
• Producer and consumer food safety awareness and knowledge. These should
be thought of as essential platforms for bringing about behavior changes
along agri-food value chains.

Strong scientific capability is a prerequisite for introducing effective preven-

tive measures as part of measures for food safety management capacity, and
for effective risk surveillance and risk management functions. Some LMICs
have begun to invest heavily in food safety science, enabling them to adopt a
more risk-based approach to food safety management. China is one of these
countries. Under a World Bank–supported project in Jilin Province, 65 basic
and applied research projects were implemented over six years. These covered
a broad range of risk-based themes, including using alternative green and safe
techniques for pest and disease management, animal health and nutrition,
rapid detection methods for harmful substances, gauging links between envi-
ronmental hazards and food safety, risk analysis of food contact materials, and
using information platforms for product and hazard tracking.

Strengthening Food Safety Management Systems 141

 Advances are being made globally in chemical and microbiological risk
assessment and analytical testing using hazard detection technologies that are
both advanced and low-cost, and in processing and packaging technologies.
Whole genome sequencing has great potential for rapidly identifying foodborne
pathogens (box 4.7). While these advances can play a potentially significant
role in managing FBD in LMICs, their effective use depends on competen-
cies being substantially increased. Legal, administrative, and other barriers to
sharing data must be overcome. Nevertheless, multiple applications of informa-
tion technology—including mobile phones, internet, satellite imagery and “big
data”—are enabling new approaches to the detection and surveillance of FBD.
LMICs should monitor the experiences of first movers and how these can be
adapted to local conditions (Santillana et al. 2015; Wiedmann 2015).
It is important to emphasize that the private sector can play a major if not a
leading role in advancing food safety science and applying emerging biological,
information, and other so-called disruptive technologies. Food manufacturers
are investing heavily to reformulate products in response to multiple consumer
food safety concerns. They are developing new food products—for example,
“clean” meat—which may have profound impacts on the risk profile of chang-
ing diets. Food manufacturers are also exploring alternative food processing

BOX 4.7 Whole Genome Sequencing and Food Safety

Whole genome sequencing is an emerging tool with the potential to greatly assist
foodborne hazard surveillance, and to improve outbreak detection and response
(Allard et al. 2016). Whole genome sequencing involves identifying the entire DNA
sequence of an organism’s genome.
Knowing the complete nucleotide content of pathogen genomes enables public
health professionals to use the most specific form of molecular subtyping to more
accurately identify foodborne pathogens that are genetically related. For foodborne
disease outbreaks, this increased specificity can help to link the sequences of iso-
lates derived from clinical cases back to isolates derived from contaminated food or
environmental sources.
Information on subtyping, virulence, and antimicrobial resistance profiling are
a few examples of the power of whole genome sequencing and its immediate benefit
for public health and food safety. Whole genome sequencing can be used as part of
preventive controls to improve good agricultural and manufacturing practices. For
example, knowing the genomic sequence of multiple pathogens collected within a
facility over a given length of time can help distinguish between resident or transient
pathogens, thereby providing greater insight into the source of contamination events.
WHO (2018) summarizes the state of whole genome sequencing for food safety.
The World Health Organization will soon issue a guidance document on the pre-
requisites for using this technology successfully. The will include multiple technical
capabilities and institutional issues, especially those related to data sharing.
The costs of setting up whole genome sequencing capabilities and the ability to
sustain them are likely to be linked to broader national risk assessment skills and
infrastructure. Because of this, adopting whole genome sequencing may be difficult
for many low- and lower-middle-income countries. This is discussed in FAO (2016).

142 THE SAFE FOOD IMPERATIVE

and packaging methods. And blockchain technologies are being used or evalu-
ated by large food manufacturers to strengthen food product and ingredient
traceability, and to reduce their vulnerability to food fraud.
The significant contributions that the food industry is making in food sci-
ence and advancing supply chain traceability mean that LMIC governments
should be trying to leverage private sector initiatives and investments in food
safety management capacity wherever possible. This goes well beyond reen-
forcing the “business case” for the better management of food safety by private
companies. The private sector can make many contributions that extend well
beyond the specific context or operations of individual companies. Table 4.1
gives examples of investments that businesses can make to reduce food safety
risks and the constraints that sometimes inhibit such investments in LMICs.
Some of these constraints arise from government policy actions or inactions.
Regulatory and other reforms can be effective remedies for this.
A review of the practitioner literature shows there are promising, cost-effective
investments that governments can make or facilitate others to make. Investments

TABLE 4.1 Private Sector Food Safety Investments and Possible

Constraints
Private investment or service Possible constraints
Apply industry standards and codes of Lack of consumer awareness, nonrecognition by
practice at enterprise or value chain government or inconsistency with laws, lack of
levels adequate human capital
Promote safer production Weak regulations and enforcement on
practices and technologies among production inputs, restrictions on technology
farmers and intermediate suppliers. imports, restrictions on private advisory services
or direct sourcing from farmers
Invest in and/or manage improved rural Public monopoly or other restrictions on private
or urban food market infrastructure market facility operations, land use restrictions,
(i.e., collection stations, wholesale and absence of long-term financing, absence of public
community markets) utility services
Conduct food science, epidemiological, Restrictions on nonpublic research or access to
or other primary or applied research public or international research funding
Provide laboratory testing Competition from subsidized public laboratories,
services mandatory testing by public laboratories,
nonaccreditation, inadequate human capital
Provide professional food safety Nonaccreditation and recognition by public
training and education services agencies, and competition from subsidized public
and donor programs
Implement programs for consumer Conflicts or inconsistencies with public risk
awareness and education communication and other consumer outreach
Assume responsibility for Government does not adopt, or a trade
monitoring industry compliance partner does not recognize, comanagement
with regulatory requirements arrangements
Source: World Bank.

Strengthening Food Safety Management Systems 143

 in technologies, training, information, and new processes have often been suc-
cessful. At the farm and community levels, promising investments include those
involving organizing producers in cooperatives or self-help groups that make food
safety capacity building easier. These include, for example, community-based or
group certification to meet food safety standards, out-grower or contract schemes
that include farmer training and support, farmer field schools and training in good
agricultural practices and integrated pest management, and technologies to reduce
risk on farms, such as vaccines for pig tapeworms. These interventions can also
improve smallholder farmer incomes, introduce other practices for better busi-
ness and environmental protection, and improve the safety of food produced and
consumed by farmers. Along the marketing segments of agri-food value chains,
supportive public measures could include providing and upgrading infrastructure,
such as roads and electricity; improving community markets; supporting the adop-
tion of technical innovation, such as cooling devices and water disinfection; and
supporting enterprises to use good manufacturing processes and approaches, such
as hazard analysis and critical control points.

Institutionalize a Structured and Risk-Based Approach to Food

Safety Management
A wide range of instruments can be used to tackle long-standing or emerging food
safety risks in LMICs. These include traditional regulatory approaches, invest-
ments in public food safety; markets, sanitation, and other infrastructure; and
information, technical support, and other measures that can augment incentives
to investments in enhanced food safety management capacity within agri-food
value chains. The feasibility of these alternative measures and their effectiveness
in managing FBD depend on the soundness of administrative structures and
technical competencies. The challenge for LMICs is to make investments that
are appropriate to their stage of the food safety life cycle, and that form part of a
staged plan for the sustained enhancement of food safety management capacity.
In high-income countries, proposed food safety regulatory and other mea-
sures tend to be subjected to an extended process of public and intra-industry
consultation. For example, when regulations were proposed, the Food Safety
Modernization Act in the United States received tens of thousands of registered
comments from industry and consumers. A similar process occurred when the
European Union’s General Food Law was proposed. In Chile, a multistake-
holder advisory committee is permanently involved in reviewing and updat-
ing the country’s food code. In many LMICs, processes for getting stakeholder
feedback on proposed food safety legislation and other initiatives tend to be
less formalized, and often lack transparency. Because of this, investments tend
to be driven more by established interests that have the loudest “voice.”
Economic analysis, in the form of cost-benefit and cost-effectiveness ­analyses,
is frequently incorporated into decisions about proposed food safety measures in
high-income countries (box 4.8). Examples include the studies, ex ante and ex post,
quantifying the costs and benefits of implementing enhanced food safety controls,
such as hazard analysis and critical control points (Unnevehr 2000) and food safety

144 THE SAFE FOOD IMPERATIVE

BOX 4.8 Cost-Benefit and Cost-Effectiveness Analyses in Food Safety

A cost-effectiveness analysis for food safety compares the costs of alternative

capacity-building options with the benefits, with the latter measured in physical
numbers. The ratio of dollar costs to physical benefits is expressed as the cost per
physical benefit, and the program with the lowest cost is ranked as the most cost-
effective (Kuchler and Golan 1999).
The benefits can be expressed in absolute numbers (for example, numbers
of cases of animal disease) or as a percentage change (for example, a 10 percent
increase in the value of exports). When comparisons are made between interven-
tions that have identical benefits, cost-effectiveness analysis results in a cardinal
ranking of the options. The option with the lowest cost-effectiveness can then act as
a baseline against which all other options can be considered and a measure of the
sacrifice in terms of efficiency, should the most cost-effective not be chosen.
Cost-effectiveness analysis is generally used where it is difficult to assign a monetary
value to the stream of benefits associated with an investment (Mushkin 1979). It is also
an obvious choice when a decision has been made to enhance a particular aspect of sani-
tary and phytosanitary capacity; for example, access to a market that is subject to quar-
antine restrictions, but where various options are nevertheless available to achieve access.
In all these contexts, cost-effectiveness analysis can be used as a guide to mini-
mize costs. In general, cost-effectiveness analysis is a less costly and burdensome
technique than cost benefit analysis, making it attractive to decision makers faced
with time or resource constraints. It cannot be used, however, where the range of
options for capacity building has varying qualitative and quantitative impacts.
It is important to recognize that cost-effectiveness analysis does not show
whether a particular option yields a net benefit, since no attempt is made to value
the benefit side of the equation.

improvements more generally, predominantly in the United States. There are also
examples of economic analysis being applied to regulatory options, again mostly in
the United States (FDA 1995; FSIS 1996).4
Applying cost-benefit and cost-effective analyses to food safety measures
in LMICs is rare. The instances of these have been mainly for upgrading
4
Most of these studies focus on estimating the economic value of improvements in human health. Thus,
estimates tend to be highly variable and sensitive to the choice of key parameter values. To assess net
benefits, industry costs from regulatory requirements can be compared to the reduction in disease burden
in a cost-benefit analysis. Several studies of regulatory impact focus on the effect of the U.S. Pathogen
Reduction Hazard Analysis Critical Control Program on regulations for the meat and poultry industry
that began in the 1990s and were strengthened by subsequent regulation. For example, Crutchfield et al.
(1997) showed that U.S. industry costs of controlling microbial pathogens in meat were much smaller
than the value of improved human health resulting from these mandated controls, based on ex ante esti-
mates. Ollinger (2011), Ollinger and Moore (2008, 2009), and Muth, Wohlgenant, Karns (2007) provide
survey-based ex post evidence on Pathogen Reduction Hazard Analysis Critical Control Program rule
impacts. These studies found that (1) compliance costs were larger than ex ante estimates when the rule
was implemented, but still smaller than the public health benefits; (2) regulation tended to favor large,
more specialized plants over small, diversified ones, which have higher per-unit costs from using hazard
analysis and critical control points; (3) regulatory and private incentives fostered the adoption of new tech-
nologies to control microbial pathogens; and (4) regulation was not the only reason why plants invested
in technology or in third-party audits—market incentives from buyers were equally or more important.

Strengthening Food Safety Management Systems 145

 controls to overcome restrictions in export markets because of noncom-
pliance with food safety regulations. Henson, Saqib, and Rajasenan (2004)
estimated the costs and benefits of hygiene improvements in Kerala’s shrimp
sector to comply with European Union food safety regulations, including
government controls and upgrading of processing facilities. The nonre-
curring costs of compliance for processing facilities averaged US$265,492,
though this varied as a proportion of production value, from 2.5 percent to
22.5 percent. Many firms that bore the heaviest of these costs did not survive.
In 2001, Kerala had 51 shrimp-producing facilities approved by the European
Union, suggesting sector-wide nonrecurring costs of US$13.5 ­million, rep-
resenting 1.7 percent of the value of Kerala’s total shrimp exports over the
three years before the initial implementation of these investments.
Unnevehr and Ronchi (2014) review studies of high-value horticultural
exports in 10 countries that estimated the costs and benefits of compliance with
both regulatory requirements and private sector standards. The World Bank
(2005) gives other examples of estimates of compliance costs and benefits asso-
ciated with LMIC trade in high-value food. Box 4.9 summarizes the results of a
more recent study, using a cost-benefit analysis of food safety compliance among
CARIFORUM countries.
Cost-effectiveness analysis is being used to tackle aflatoxin risks in Africa.
In Kenya, comparisons have been made between the costs and effectiveness of
farmers or farm groups adopting various technologies and introducing product
testing, product labeling, and other measures. Training in aflatoxin manage-
ment, accompanied by providing plastic sheets for sun-drying crops, has been
shown to reduce aflatoxin contamination in maize and groundnuts by about
50 percent at a material cost of US$2.50 per farmer a year in Kenya and Ghana
(Pretari, Hoffmann, and Tian 2018; Hoffmann, Moser, and Herrman 2017). By
comparison, achieving the same level of reduced contamination was estimated
to cost US$5.24 through Aflasafe, and US$10.79 by using tarpaulins and a fully
subsidized drying service. Table 4.2 summarizes the broader evidence on the
strengths and weaknesses of the various approaches piloted in Kenya to tackle
aflatoxin risks (box 3.5 in chapter 3 looks at the limitations of market-based
incentives for aflatoxin controls for maize in Kenya).
A Food and Agriculture Organization guidance document on evidence-
based decision making provides a possible framework for LMICs to apply when
addressing risks that have already been prioritized (FAO 2017). In this frame-
work, the key decision factors to be considered for implementing a ­prospective
policy or risk management option are the expected

• benefits, including reduced health care costs

• costs (and who bears them)
• technical and institutional feasibility
• practicality in relation to the structure of production or the value chain; and
• political considerations, including coherence with other government policies.

146 THE SAFE FOOD IMPERATIVE

BOX 4.9 Investing in Food Safety for Small Importing Countries:The Case of
CARIFORUM

An Inter-American Institute for Cooperation on Agriculture (IICA) study of the costs of

compliance with international standards in 15 small Caribbean countries that belong to
the CARIFORUM shows the value of food safety investments for meeting many economic
goals, including export promotion, import substitution, public health, and tourism promo-
tion (Goulding 2017). The CARIFORUM countries are net importers of most foods, but
they export fish and horticultural products. For fish, these countries have few companies
which have approved access to European Union markets. Yet, if they could better comply
with international standards, this would lead to reduced transactions costs, better access,
fewer rejections, higher prices, and more scope for import substitution. The benefits for the
CARIFORUM countries would also be improved human and animal health, and improved
productivity. Compliance costs include public costs for investments in regulatory control and
related infrastructure; operating costs for inspections and risk assessments; private investment
costs for upgrading facilities; costs for developing hazard analysis and critical control points
and training; and operating costs for monitoring, control, and certification.
The IICA study explored three cases on the costs and benefits of compliance in detail: fish-
ery sector exports from Suriname to the European Union, processed ackee from Jamaica to the
United States, and poultry production for import substitution in the Dominican Republic and
Trinidad and Tobago. The findings are summarized in table B4.9.1. For fishery and horticul-
tural products, the benefits were added export value; the benefits for poultry production were
lower imports. All of these investments showed positive cost-benefit ratios.

TABLE B4.9.1 Case Study Costs and Benefits of Compliance

Industry Benefits Public costs Private costs Benefit/
(US$, millions) (US$, millions) (US$, millions) cost

Fishery 30.0 5.5 0.9 4.7

Horticultural 18.0 5.4 2.6 3.3
products
Poultry 16.1 3.0 3.6 2.4
Source: Goulding 2017.
Note: IICA = Inter-American Institute for Cooperation on Agriculture.

These cases were extrapolated for the entire agri-food sector to illustrate the costs and ben-
efits. Goulding (2017) finds that increasing investments in sanitary and phytosanitary compli-
ance of 2.4 percent of agri-food export trade value (US$97 million a year) would deliver trade
benefits of US$306 million a year for the 15 CARIFORUM countries as a group. The costs of
investment are about equally shared between the public and private sectors. Benefits that are
not included because they are difficult to estimate include reduced foodborne illness, greater
stability of income for smallholder agriculture, and lower risk of tourism losses.
The cost-benefit ratios are found to decline with country size, while still remaining posi-
tive. There are economies of scale in making sanitary and phytosanitary investments, with
higher costs and lower benefits for the smallest countries. Regional inspection and laboratory
services for the smallest countries might overcome these scale problems.

Strengthening Food Safety Management Systems 147

 TABLE 4.2 E
 vidence on Strategies for Aflatoxin Control in Kenya’s
Maize Market
Strategy Adoption Strengths Weaknesses
Test for Followed by Relatively cheap Testing capacity weak,
aflatoxins and most large- and incentives to accept failures,
reject medium-sized unsafe maize goes to
millers informal markets

Label for tested Attempted but Potential market Draws regulatory attention,
safe maize discontinued by advantage with difficult to maintain
one miller sufficient private or compliance, no lasting
social marketing effort market impact on sales
shown in studies
Premium for Exists in higher- Could be passed on Achieved through testing,
tested safe priced brands to farmers lower-priced brands are
maize despite lack of consumed by the poor
explicit labeling
Premium for Experimental or Encourages adoption Costly to implement
farmers donor-driven of aflatoxin control
technologies

Contractually None to date Reduces aflatoxin at Aflatoxin-prone areas are

linking farmers source far from premium markets,
to millers inclusion of smaller farmers
likely to require public
subsidy due to cost

Source: Background paper prepared by Vivian Hoffmann.

The guidance document contains several case study examples for using
the framework. To tackle risks associated with street foods, for example, the
options are (1) introducing a central government training, licensing, and
inspection program; (2) introducing similar programs involving local govern-
ments; (3) establishing community training and certification programs; and
(4) focusing on consumer education, leading to more informed choices. The
analysis weighs the likely effectiveness in reduced FBD, the social acceptability
of the interventions, the likely implementation costs, and the likelihood of sus-
tained changes in behavior.5
An alternative approach is the Standards and Trade Development Facility’s
framework for prioritizing sanitary and phytosanitary investments for trade-
related market access in both these areas. This framework can easily be adapted

5
Another example is tackling the presence of heavy metals in seafood. The options considered
included (1) an outright ban on the harvesting, catching, and sale of fish with potentially high mer-
cury levels; (2) putting limits on the harvest and sale of different species in different locations; and
(3) pursuing the second option in tandem with a consumer information and education campaign.
The analysis looked at the likely effectiveness, acceptability, and implementation feasibility of the
different options. Potential trade-offs are found among cost and compliance considerations. This
structured approach to policy and program decision making allows for the explicit consideration
of these and other types of trade-offs.

148 THE SAFE FOOD IMPERATIVE

to examine food safety management capacity specifically, but it can also be used
in domestic markets. For this purpose, the framework has been used in Belize.
A key strength of the framework is its participatory nature and the fact that all
its elements are highly transparent. This promotes accountability and more active
debates on priority investments and the bases on which priorities are established.
The framework can also be applied even where data are of poor quality or missing.
An important insight from using these frameworks is that there are often
significant and potentially complex interdependencies and complementarities
across investments in food safety management capacity, and in the risks asso-
ciated with food, such that it is often important to adopt multiple approaches
simultaneously. This is because of their potential to reinforce one another and
to help realize synergies. This concept appears to be especially relevant for food
safety because of the multiple pathways through which people can become
ill from exposure to food-related hazards (box 4.10). And there may be co-­
benefits from interventions to reduce food safety hazards (box 4.11).

BOX 4.10 Gains from Multisector Coordination:The One Health

Approach

Most human infectious diseases have their origin through cross-species transmis-
sion of pathogens from animals to humans, and many of the diseases in humans
evolved from diseases in animals. Among zoonotic diseases, foodborne diseases are
an important cause of morbidity and mortality in humans. Animals can be direct
sources of pathogens in animal source foods and also indirect sources through fecal
contamination of water and plant-derived foods. Having control measures on farms
and at subsequent stages of the food chain has proven to be most effective for reduc-
ing risks related to foodborne diseases.
The welfare of animals is also important because their condition has implica-
tions for food safety. For example, tail biting in pigs is a welfare issue and a well-
known risk factor for abscesses and infections in carcasses. The health and welfare
of animal populations contributes to the economic benefits that are derived from
them, and is connected to public health and the health of the environment. The One
Health concept recognizes these connections and promotes coordination across
sectors to better understand and manage health risks.
In applying One Health, the European Union (EU) has coordinated control
programs for salmonellosis that have reduced the number of cases in humans from
more than 200,000 reported cases each year before 2004 in 15 member states to less
than 90,000 cases in 2014 in 28 member states.
The EU’s integrated approach to food safety—from primary production to food
consumption—involves all major actors for zoonotic diseases in the EU: member
states, the European Commission, the European Parliament, the European Food
Safety Authority, and the European Centre for Disease Prevention and Control.
Several elements of the EU’s One Health approach have been key to its success,
including targets for the reduction of Salmonella in poultry flocks and pigs, and
trade restrictions imposed on the products from infected flocks.
Overall, the One Health concept formulates the need for and the benefits from
cross-sector collaboration.

Strengthening Food Safety Management Systems 149

 BOX 4.11 R
 ealizing Co-benefits for Tackling Farm Food Safety
Hazards

Many food safety hazards originate on the farm, and it is important to understand
the practices that exacerbate them. Interventions targeting the farm sector can help
prevent some food safety hazards from entering the food supply in the first place.
Moreover, certain interventions targeting the farm sector offer multiple win-win
opportunities, with benefits extending beyond food safety.
Measures can be taken to mitigate foodborne disease risks that can also benefit
pollution prevention and control—and hence for public health, wildlife protection,
climate stability, and even farm profitability. This potential for co-benefits is signifi-
cant from a cost-benefit perspective, considering that changing farming practices
can be both challenging and costly, especially where farming involves large numbers
of small farms with a limited capacity. Table B4.11.1 shows how responses to food
safety challenges that originate on the farm can sometimes address farm-related
pollution, although some responses present trade-offs and others are neutral.

TABLE B4.11.1 Win-Win Responses to Farm Food Safety

Challenges
Farm food Possible responses Pollution and public health
safety challenges co-benefits associated with the
response
Presence of Measures to (+) Less localized air pollution and
pesticide residues minimize pesticide exposure of farm workers and rural
on food crops use, and favoring communities to ambient pesticides
the use of less toxic (+) Less pesticide contamination of
and less persistent surface water and groundwater, and
chemicals hence of drinking water and habitat
Uptake by food Measures to (+) Less nutrient pollution of soil,
crops of toxic increase fertilizer water, and air—and hence less soil
heavy metals use efficiency and acidification, fewer harmful algal blooms,
present in soil, to reduce fertilizer less eutrophication of surface waters,
exacerbated by waste fewer fish kills and dead zones, less
soil acidification Switch to alternative nitrate contamination of drinking water,
crops less affected by less urban air pollution, and less climate
heavy metals destabilization
Presence of Measures to ( ) No pollution co-benefits
pathogenic reduce or eradicate
mycotoxins in soil pathogenic strains
or crops of fungi in soil or to
slow fungal growth
during plant growth,
harvest, and storage
(via temperature and
moisture control)
(Continued)

(Continued)

150 THE SAFE FOOD IMPERATIVE

BOX 4.11 R
 ealizing Co-benefits for Tackling Farm Food Safety
Hazards (Continued)

TABLE B4.11.1 Win-Win Responses to Farm Food Safety

Challenges (Continued)
Farm food Possible responses Pollution and public health
safety challenges co-benefits associated with the
response
Presence of Improved sanitation, (+) Less contamination of freshwater
pathogens in the using probiotics, (drinking and habitat) with pathogens
guts of animals and judicious use of via the release of manure—and hence
(which can go on antimicrobials and less contamination of food from using
to contaminate pesticides contaminated water in its preparation
foods downstream (–) Depending on the treatment chosen,
if exposed to potential contamination of freshwater
manure) with chemicals that could affect the
health of humans and wildlife
Storage and Measures to improve (+) Some forms of storage can decrease
management the storage and nutrient runoff and pollution of water,
of manure or management of improving drinking water quality and
feces-laden water manure and feces- reducing eutrophication
that create the laden water (+/–) Storage can either increase or
potential for cross decrease the volatilization of nitrogen
contamination (for from manure in the form of ammonia
instance, by wildlife and nitrous oxides, which contributes to
or by contaminated urban air pollution and, when it deposits,
irrigation waters) to biodiversity and soil fertility losses

Leverage Consumer Concerns on Food Safety to Incentivize

Better Food Business Practices
Empowering consumers to influence the food safety management capacity and
practices of actors along agri-food value chains is a major avenue for public
sector action, especially because governments have little direct influence on
the actions of food products, processors, and distributors. Frequently, public
regulators face difficulties in monitoring actors at different stages of the sup-
ply chain, limiting the potential to use a range of “top down” interventions
to change the behavior of food suppliers. And perhaps even more important,
many of the most promising interventions for influencing the everyday behav-
ior of agri-food value chain actors are the ones over which the public sector
has little control or leverage (for example, behavior engendering a food safety
culture). This is especially the case for the agri-food value chains that are domi-
nated by a multitude of micro and small enterprises operating predominantly
in the informal sector, as in many LMICs.
Governments can indirectly incentivize safer practices along agri-food
value chains by raising awareness of both FBD actions needed to minimize the

Strengthening Food Safety Management Systems 151

 risks associated with food among consumers. In so doing, consumers will not
only be more motivated to look for and demand foods they perceive to be safer,
but the inherent asymmetry in food markets on food safety information will
be reduced. For example, the public sector can play an active role in develop-
ing, implementing, and supporting schemes that give consumers the tools to
make more informed decisions about food safety, including the food they buy
and how it is prepared, stored, and handled by vendors. The public sector, for
its part, can do this through voluntary certification and mandatory disclosure.
Voluntary certification involves writing or otherwise supporting certifica-
tion standards that inform consumers about food safety and aligning these
standards with known food safety risks. Consumers often rely on labels for
food safety information, using them as a guide for safe food or at least what
they perceive to be safer food. Consumers sometimes use labels as sources of
information about the safety of food products, whether the labels are intended
to be used in this way or not.6 In LMICs, voluntary food safety certification
and labeling schemes are growing, and these often have the strong backing of
governments. For example, China’s Ministry of Agriculture supports three vol-
untary food standards: for safe (or hazard-free) food, green food, and organic
food.7 In Thailand, the government has backed the consumer-facing Q-Mark
label, which shows that good voluntary agricultural practices have been used,
and private actors have introduced other labels and brands linked to food
safety.8 In Vietnam, a “safe vegetable” program and label has been backed by
the Ministry of Agriculture and Rural Development for many years. It is too
soon, however, to know how effective these efforts are in fostering food safety
management in agri-food value chains. But, arguably, public sector support
for credible, science-based information in certification schemes can foster the
right kind of incentives as markets develop.
Through mandatory disclosure, some foods and food services are required
to disclose certain information about their production processes, food safety
precautions and performance, and other related areas. Food safety inspection
reports offer the public a means of evaluating food safety practices at restau-
rants and other food establishments. This information can be disclosed in dif-
ferent forms, including numerical scores (for example, 1–100); category grades
(A, B, C, or pass/conditional pass); pictures or nonalphanumeric symbols; and
as written narratives that describe inspection findings. This information can
also be made public in different places, including storefronts and websites.

6
For example, a review of studies of certified food in China found that food safety was the main
motivation for buying, followed by health, nutrition, taste, and environmental concerns (Liu,
Pieniak, and Verbeke 2013).
7
As of 2012, green food certification covered over 11 percent of China’s farmed area (Yu, Gao, and
Zeng 2014).
8
These include Safe Produce, which does not depend on independent certification, and the Royal
Project and Doctor’s Vegetables brands, which display the Q-Mark label and are certified as good
manufacturing practice and for using hazard analysis and critical control points (Wongprawmas
and Canavari 2017).

152 THE SAFE FOOD IMPERATIVE

Canada, China, and the United States are among the countries that are using
these kinds of disclosures. Posting inspection results on food establishments
sometimes has an effect on consumers’ perceptions of food safety and their
intentions to eat in these establishments. A report by the National Research
Council (2011) on the public disclosure of establishment-specific inspection
results in the United States across a range of food-safety areas found that they
not only helped consumers to make more informed choices but also height-
ened their sensitivity to a range of concerns, including impact on the environ-
ment and nutrition.
Engaging consumers constructively in the processes that drive enhanced food
safety management capacity in agri-food value chains can be challenging. Doing
this requires changing more or less well-founded consumer fears about food safety
risks that sometimes lead to perverse behaviors, such as avoiding healthy foods,
into beliefs and attitudes that motivate them to play an active and constructive
role in food safety management. Because consumers have only a limited knowl-
edge of food safety, they often find it difficult to interpret the “signals” on food
labels, even where these are available. Consumers are often reluctant to act on their
concerns about food safety; for example, by rejecting some foods or voicing their
concerns, especially in the context of local food markets that are a social setting
and where often long-standing relations exist between consumers and food ven-
dors. Informing and empowering consumers is very challenging in the absence of
consumer organizations that are trusted for the information they provide and that
command “voice” on the national policy stage. In most LMICs, such organizations
are weak or just not there. One measure governments can take to help remedy this
is to support the creation or strengthening of organizations that represent con-
sumer interests and are active in building awareness of food safety issues.
Governments can and should draw on behavioral insights to design smarter
food safety information programs and consumer campaigns to increase their
effectiveness, and to make best use of limited public resources. For example,
visual and sensory-rich formats can be used, including role models; “edutain-
ment,” including TV and radio shows and stars; and street theater. The
Government of India is using a range of behavioral-change communication
principles in its expanding food safety information programs (box 4.12).
Crowdsourcing is another instrument that can be used more to extensively
engage consumers, both in surveillance and in communications (Soon and
Saguy 2017). Crowdsourcing is already being used to engage consumers in iden-
tifying and tracing FBD, and reporting the unhygienic practices or conditions of
food businesses, including restaurants. Crowdsourcing platforms can also func-
tion as a two-way street, offering a means of alerting businesses and the public
to food safety risks. But the rapidity with which information can flow on social
media platforms has a good and bad side; while it may help to save lives when
risks are real, it can do unnecessary economic harm when they are not.
Crowdsourcing certainly has untapped potential, but exploiting it will
require tackling its challenges, especially in LMICs. Systems are needed to ver-
ify the validity and accuracy of the data that crowdsourcing efforts generate.

Strengthening Food Safety Management Systems 153

 BOX 4.12 India’s Behavioral Change Communication Principles for
Food Safety

A broad range of initiatives are being carried out in India to strengthen the contri-
butions that consumers can make to better food safety outcomes. In 2017, the Food
Safety and Standards Authority of India launched an interactive educational on-line
portal to convert “all food purchasers into smart, alert and aware consumers.” The
portal uses food safety display boards showing practices that food business opera-
tors must follow, and provides contacts for consumers to provide feedback, queries,
and complaints.
The authority’s Food Safety Connect initiative provides consumers with sev-
eral modalities to channel two-way information between regulator and itself.
Partnership programs are being pursued to promote improved food safety in
schools, workplaces, workshop, hospitals, and the railway system. Colorful mascots
are being used to raise food safety awareness among school-age children.
These programs are not unique, but their breadth of coverage is impressive.
Chile, for example, has also been using a broad-based program for consumer food
safety awareness and education, such as the food safety and quality agency’s food
safety theater.

Users sometimes make unintentional errors; for example, when they mistake
an allergic reaction for food poisoning or trace the source of an illness to the
wrong place. Consumers without technical food safety assessment tools or
expertise may also conflate an unpleasant sensory experience with food safety
risk, even if these are not objectively aligned; for instance, for microbiological
risk. Crowdsourcing is vulnerable to malevolent efforts to intentionally spread
false information.

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156 THE SAFE FOOD IMPERATIVE

 CHAPTER FIVE

The Way Forward

CONCLUSIONS

T
he data and analyses presented in this report make a compelling case
for greater and smarter investments in food safety management capac-
ity in low- and middle-income countries (LMICs). These investments
should be driven by rigorous and transparent prioritization of capacity-building
needs that is risk-focused and proactive, rather than seeking to offset food safety
problems when they happen. That said, effective surveillance and rapid response
are key aspects of the performance of food safety systems. Enhancing food safety
management capacity should be seen as an effort that cuts across the public and
private sectors, rather than as following an outdated notion of who does what.
The demands for public and private sector investment to tackle devel-
opment challenges in LMICs are often overwhelming, especially in lower-­
middle-income countries, where processes of economic and social change are
accelerating the fastest. Thus, ministries of finance face a constant stream of
stakeholders demanding action to address critical needs. It is only in countries
where the political commitment is sufficiently strong to deal with food safety
problems that the necessary investments are forthcoming. A critical first step
to get to this stage is to engage political decision makers at the highest level
and promulgate broad-based strategies for enhancing food safety manage-
ment capacity.
Some countries are working on addressing food safety risks, but they do not
refer to them as such and are not organized institutionally to tackle food safety
as a discrete problem. Instead, they tackle, say, diarrheal disease as a public

157
 health problem with interventions centered on water and sanitation, or they
bundle food safety with other trade and market access issues. This approach
also relegates food safety to the level of being the poor stepchild, so to speak, in
the regulatory oversight of food and drug agencies. These agencies have little or
no contact with the main actors in LMIC food systems, including smallholder
farmers, micro and small enterprises, and informal sector food distributors.
The challenge therefore goes beyond simply understanding the importance of
food safety or allocating adequate resources. In many cases, the most effective
and forward-looking way to engage governments on food safety management
may require restructuring the mandates of various government institutions.
Because this call to action may seem daunting or even overwhelming to
some, this final chapter synthesizes guidance based on a review of evidence
presented in the previous chapters. The recommendations are organized in
two ways to make them accessible to various audiences. First, specific recom-
mendations are provided for first steps and best practices for various food sys-
tem actors and stakeholders in the following section. These recommendations
follow an outline of the important roles and responsibilities for building and
applying food safety management capacity, and will be especially useful for
those who perhaps view their actions as peripheral by defining how best to be
engaged. Second, suggested actions by country level of development are offered
for the stages of the food safety life cycle. These may not fit all countries within
each stage, but the aim is to show that actions can be taken at all stages to get
ahead of food safety challenges and to avoid significant economic losses.

A CALL TO ACTION FOR VARIOUS STAKEHOLDERS

Many different actors are involved in efforts to strengthen food safety systems
in LMICs. This section lays out a call to action to a subset of important actors.
Local institutional settings vary, especially in the degree of formality of the
main food distribution channels and in how governments are organized to
provide food safety coordination and oversight. So, there will be some variance
among countries in with whom and how leadership functions are vested and
where critical competencies are needed. A flavor of this variation is reflected
later in the chapter in the different priorities proposed for countries at differ-
ent points in the food safety life cycle. The following are the calls to action for
specific actors involved in enhancing food safety systems in LMICs.

LMIC Ministries of Finance and Other Coordinating

Economic Ministries
• Make public spending proportionate to the challenges and opportunities.
Calibrate the level of spending on food safety to the economic costs of food-
borne disease (FBD) and to the benefits of investing in its prevention and
management. This calculation should factor in both near - and longer-term
impacts. Consider the economic costs of lives lost and disability, public

158 THE SAFE FOOD IMPERATIVE

 health spending, trade interruptions, reputational damage to the food sys-
tem in the eyes of trade partners and consumers, longer-term impacts on
the productivity of people, and forgone economic growth related to these
impacts.
• Implement preventive forward-looking investments. In multiyear national
strategies, draw on expert advice to factor in anticipated food safety risks
given expected changes in demographics, diets, and trade-related devel-
opments. Support investments that may prevent or minimize future costs
(avoidable losses) in relation to public health and market development.
Forward-looking, preventive investments in food safety are likely to be far
less costly than measures undertaken only in reaction to serious adverse
events.
• Balance hard and soft public spending. Important food safety investments
relate to both hardware (laboratories and market places) and software
(management systems and human capital). The effectiveness of investments
and the sustainability of enhanced capacities depends on the simultaneous
development and maintenance of both types. Sufficient spending on staff
and operations is critical for realizing the full return on larger, lumpy public
investments for improved food safety.
• Economically justify spending. Ensure that technical agency or other pro-
posals for significant public investments or programs for food safety are
justified on the basis of cost-benefit or cost-effectiveness analyses, and that
alternative approaches, including regulatory measures and facilitating pri-
vate investment, have been considered.
• Leverage public spending. Use public investment and public programs to
leverage and incentivize private investment and other nonpublic activities
to build food safety capacity and improve outcomes. The private sector can
play a major role in advancing food safety science, applying emerging tech-
nologies, developing human capital, and promoting safer practices in pri-
mary production and food value chains.
• Strategically focus resource allocations. Demand and, if necessary, facili-
tate the development of a unified strategy for food safety investment and
management to ensure that food safety resources are expended judiciously
on a coherent set of policies and interventions across all parts of the food
system. In the absence of a food safety agency, facilitate or arrange for an
­institutional mechanism for coordinating the action of technical ministries
and other stakeholders.

LMIC Lead Food Safety Agency or Other Coordinating Body

• Unify strategy and coordinate action. Develop a unified food safety strategy
that defines priorities and responsibilities, and establishes funding needs.
In developing a strategy and setting priorities, weigh trade-offs both ana-
lytically and by convening all relevant agencies and stakeholders to assist in
this. Coordinate actions by ministries, agencies, and private sector partners

The Way Forward 159

 to ensure that interventions are developed to address food safety at every
stage of the food value chain. In particular, coordinate with ministries of
agriculture, health, and commerce to ensure the prevention of FBD as far
upstream as possible.
• Apply a structured approach to prioritization. Define and regularly update
evidence-based priorities, using risk analysis to make more strategic use of
resources. Specifically, align resources with the risks in the domestic food
system, taking into account the hazards posed by actual consumption pat-
terns, as well as exposure and vulnerability to these hazards. Prioritize inter-
ventions that are feasible and cost effective.1
• Punish less and facilitate more. Redefine institutional roles to be less about
finding and penalizing noncompliance and more about facilitating compli-
ance. This can be done by providing information, advice, incentives, and
interventions to motivate and leverage investments and actions by value
chain actors. Reorient food safety inspection services to give more promi-
nence to awareness raising and capacity building. Focus the attention of food
safety inspection services on the parts of the food system where food safety
violations are likely to have the most serious public health consequences.
Foster a culture of proactivity by giving agents more autonomy and respon-
sibility to identify and focus on emerging problems, while providing them
with adequate data access, training, and agency support.
• Engage consumers more fully. Provide consumers with the tools to become
partners in food safety through their own actions, and through incentiviz-
ing and motivating food suppliers. To this end, develop education materials,
standards, certification infrastructure, and other signaling mechanisms—or
work with other ministries and technical partners to do this. For example,
support the development of voluntary food certification programs and the
quality infrastructure they rely on. Institute food business rating systems
and public disclosure systems. Educate consumers on food safety risks, risk
avoidance actions, and how to demand safer food.
• Use the science of behavior change. This should be incorporated in the
design and redesign of training programs, information campaigns, and
other interventions. For example, develop training programs and infor-
mation campaigns for farmers and downstream food handlers that are
more easily retained and put into action. Share food safety checklists with
enterprises. Develop certification programs that professionalize food
inspectors, food handlers, and managers of all kinds, and redesign admin-
istrative requirements to feature measures that improve participation and
compliance. Develop campaigns that inform consumers and food han-
dlers about food safety, and socially legitimize and normalize behaviors
that are consistent with the prevention of FBD.

1
For a structured approach to setting priorities, consider using tools such as multifactor decision
making, the Prioritizing Sanitary and Phytosanitary Investments for Market Access Framework
developed by Standards and Trade Development, and the Food and Agriculture Organization’s
guidance on evaluating trade-offs.

160 THE SAFE FOOD IMPERATIVE

LMIC Technical Ministries (Agriculture, Health,Trade,
Environment)
Where a lead food safety agency is not designated, then technical ministries or
coordination bodies linking these ministries will need to undertake the strat-
egy, coordination, and prioritization roles outlined in the previous subsection.
The other principles covered in that subsection also apply to programs devel-
oped by technical ministries. The following are more specific recommenda-
tions for these ministries:

• Shift objectives and measure outcomes better. Change key performance indi-
cators to be less about policing outcomes (value of fines collected, number of
infringements and businesses closed) and more about food safety outcomes
(magnitude of food safety risks, incidence of FBD, standards-compliant
trade). Invest in surveillance and reporting systems that enable effective
monitoring of risks and performance.
• Take measures to minimize hazard entry into the food supply on farms. Focus
particularly on measures that offer co-benefits for public health and envi-
ronmental protection. Examples include measures that improve the effi-
ciency of fertilizer and pesticide use, minimize the presence and spread of
pathogens in farmed animals, and improve manure management in ways
that reduce opportunities for cross contamination.
• Pay attention to small and informal actors in the food system. Facilitate
food safety compliance by businesses, especially micro, small, and
medium-sized enterprises and ones operating in the informal sector,
by helping them understand what compliance consists of and the rea-
sons for compliance requirements. Simplify regulatory texts, share the
checklists used by inspectors, and offer these enterprises opportunities
to learn about safe food-handling practices. Recognize the contributions
that informal sector actors such as street vendors and venues such as wet
markets make to vibrant and inclusive food systems. But also recognize
the risks they pose, and invest in their upgrading, professionalization,
and formalization.2
• Develop technical standards to help correct asymmetry of information. This
divides buyers and sellers of food, including ones engaged in farming, pro-
cessing, and marketing. When appropriate, consider enhancing standards
that consumers use as proxies for food safety—notably organic standards—
to help them better fulfill their actual use.
• Remove policy, regulatory, and other barriers to private investment and
services. The private sector can make major contributions to food safety
science, laboratory testing, human capital development, and standards
compliance. However, its initiatives may be hindered by nonaccreditation

2
Successful interventions have tended to combine multiple supportive instruments, including edu-
cation and awareness raising, surveillance, business licensing, and investments in electricity, access
to clean water, and waste management infrastructure.

The Way Forward 161

 and recognition by public agencies, public monopolies for certain services,
or restrictions on private activity (advisory services and direct purchasing
from farmers). These constraints should be reviewed to facilitate increased
private investment in capacities and services that contribute to national or
value-chain-specific food safety systems.
• Apply risk-based approaches to govern food trade. Develop basic trade facili-
tation capabilities to reduce barriers at borders, ensure the safety of food
imports, and promote exports. These capabilities include providing clear
information on standards and requirements, and implementing consistent
preborder and border controls that focus on the most important hazards.
They also include equivalence agreements with major trading partners,
participating in regional agreements to harmonize standards, and ensuring
that recognized sanitary and phytosanitary certifications can be obtained by
exporters.

LMIC Chambers of Commerce and Food Industry Associations

• Engage in national strategy and prioritization processes. Work with the p
­ ublic
sector to identify opportunities for public action. These include strategic
infrastructure investments, applied research and technology demonstration
projects, developing a cadre of food safety professionals, setting up food
safety advisory and auditing services, and negotiating with trading partners
for standards or capacity recognition. Also, participate in structured pro-
cesses to identify priority hazards and to evaluate the feasibility and cost-
effectiveness of alternative solutions.
• Play active advocacy roles. This is to ensure that small-actor interests and
constraints are factored into policy making. Advocate for the least-burden-
some means and realistic time frames for achieving regulatory compliance.
Educate members in food safety regulations and new developments in food
safety that are likely to affect their businesses.
• Take collective action. This is needed to build food operator awareness;
facilitate the adoption of good agriculture and management practices, and
industry codes of practice; and strengthen food quality and the safety man-
agement of industry leaders, small and medium-sized enterprises, and orga-
nized primary producers. Engage with the Global Food Safety Initiative and
other international and regional schemes to mainstream the adoption of
benchmarked standards.
• Support programs to improve food and pathogen traceability and transpar-
ency. This can be done by establishing industry-wide norms and standards
for record-keeping and sharing information along the value chain. Establish
industry standards for handling food safety failures, including voluntary
product recalls. To the extent feasible, provide consumers with information
on production methods and product origins.

162 THE SAFE FOOD IMPERATIVE

Research Institutes and Academia
• Build capacity in the basic disciplines to deal with food hazards. These
­disciplines include microbiology, parasitology, food chemistry, risk analysis,
food science, health economics, and consumer behavioral science. Use this
capacity to do research on the epidemiology of FBD, to carry out risk assess-
ments, and to evaluate feasible alternatives for risk management. Work with
the public sector to develop surveillance systems, and to use food safety data
to inform public priorities and public information campaigns.
• Develop, adapt, and pilot food safety technologies and approaches. This
should be done in partnership with private industry or civil society. Identify
whether available technologies can be adapted to local conditions and prac-
tices. Test the viability of these technologies with partners, such as food pro-
cessors or handlers. Consider potential consumer risk-mitigating practices
and whether these will be acceptable, taking into account gender-specific
constraints if they are adopted.
• Develop training and certification programs for food safety professionals. The
aim is to create a cadre of trained personnel for the food industry and the
public sector. These programs could train individuals at the postsecondary
level or be offered through extension and outreach to raise the skills of food
industry personnel.

Bilateral Development and Trade Partners

• Strengthen the incentives for preventive actions by LMIC trading partners.
This can be done by instituting more streamlined trade consignment inspec-
tion protocols for countries and approved suppliers that have demonstrated
certain capacities, and through memoranda of understanding, twinning
arrangements, and other programs to achieve mutual recognition of sani-
tary and phytosanitary management systems. Increase efforts to inform pol-
icy makers, technical counterparts, and industry representatives in LMICs
on proposed regulatory changes that may affect their exports.
• Improve the quality of bilateral food safety capacity support programs. This
can be done by using cost-benefit analyses; doing more rigorous monitoring
and evaluation; putting greater emphasis on capacity sustainability; balanc-
ing support for public and private sector capacity building; taking advantage
of potential synergies (One Health initiatives, for example); and investing in
networks of collaboration with universities, nongovernment organizations,
and consumer organizations, which can be maintained beyond periods of
specific project funding.
• Put a higher priority on food safety interventions to promote domestic public
health. A disproportionate amount of bilateral support for food safety has
focused on trade-related capacities that have often had few or no spillovers
for managing domestic food safety risks. Various factors contribute to this,
not least the self-interest of countries to protect their own consumers from
hazards from traded food products. Although less visible, the socioeconomic

The Way Forward 163

 burden of unsafe food is far larger in the domestic setting of LMICs than
is the impact on trade. To best contribute to the Sustainable Development
Goals, bilateral development assistance should be focused on domestic set-
tings. Even for trade-related capacity, increased attention is needed to sup-
port the adoption of risk-based food import controls as LMIC imports of
high-value food grow in importance.
• Promote low-cost, high-impact investments in food safety management capac-
ity. The aim of these investments is not only to make the most effective and
efficient use of scarce public and private sector resources but also to enable
these resources to be mobilized quickly. Another aim is to show the sub-
stantial economic and social benefits that can flow from efforts to enhance
food safety management capacity. Importantly, these investments will likely
revolve around insights into behavioral aspects of food safety management
by actors along agri-food value chains and by consumers, and this will be
combined with modest changes to support infrastructure. The challenge is
to determine what relatively small changes can be made to bring about sub-
stantial changes in food-safety-related behavior at a low cost and that do not
require premature regulatory action.

Multilateral Organizations and Partnerships

• Develop and apply a food safety commitment index. The index should be a
global or regional benchmarking tool to monitor the level of commitment
that LMIC governments are making to food safety, and to motivate them to
take action to improve underlying capacities and performance. The index
could be based on other “commitment type” models for indexes being
used for nutrition that cover legal frameworks, policies, and public spend-
ing. This could be combined with capacity measures along the lines of the
World Organisation for Animal Health and the Inter-American Institute
for Cooperation on Agriculture’s performance of veterinary services assess-
ment tools. It is important that ratings should be made public, periodically
updated, and based on objective data and expert assessment rather than
self-reporting.
• Promote experience sharing among LMICs. While LMICs can continue to
learn from the experiences and applied institutional models of high-income
countries, there is a need for more systematic sharing of experiences among
LMICs on the measures they are taking to enhance food safety management
capacity in the public and private sectors. This needs to be done in the context
of rapid economic and social change, weak regulatory systems, and the pre-
dominantly informal agri-food value chains that characterize LMICs. Sharing
mechanisms could involve establishing direct relations between LMICs for
the specific purpose of building food safety management capacity, most
probably within particular geographical regions and through, for example,
personnel exchanges. Multilateral agencies—such as the World Bank, Food
and Agriculture Organization, World Health Organization, United Nations

164 THE SAFE FOOD IMPERATIVE

 Industrial Development Organization, the Standards and Trade Development
Facility, the Inter-American Institute for Cooperation on Agriculture, Asian
Development Bank, and the African Development Bank—and international
foundations can play a role in monitoring and assessing the experiences of
LMICs in enhancing this capacity. They could also identify and promote best
practices for different levels of development.
• Promote the use of formal processes for prioritization. This should be done
as part of the development of national strategies for enhancing food safety
management capacity. Two potential approaches to the prioritization of
investments have been developed by the Standards and Trade Development
Facility and the Food and Agriculture Organization, which are both dis-
cussed in this report. Cost-benefit and cost-effectiveness analyses can be
combined with these frameworks. The objective of this approach is not only
to ensure that scarce resources are used effectively but also to engage stake-
holders across the public and private sectors to promulgate, promote, and
apply national food safety strategies.
• Promote multidisciplinary, development-oriented research. The dearth of
strong, empirically based evidence on the public health burden of FBD, its
interlinks with LMIC nutritional issues, and its economic consequences
persists, despite recent improvements in gathering this evidence. Even less
empirical evidence exists on the socioeconomics of alternative technolo-
gies, institutional approaches, and incentive-based schemes for improving
the management of food safety risks in a context dominated by smallholder
farmers and small food businesses operators. Resources to support global
and regional research in these areas that can inform strategies, policies, and
programs need to be mobilized.

PRIORITIES AMONG COUNTRIES AT DIFFERENT

STAGES OF THE FOOD SAFETY LIFE CYCLE

Building food safety capacity needs to be seen as a continuous process of devel-

opment, upgrading, learning, adjustment, and refinement. The World Health
Organization’s Regional Framework for Action on Food Safety in the Western
Pacific appropriately calls for a stepwise approach, associated with a country’s level
of economic development (WHO 2018). This begins by establishing basic mini-
mum rules and capabilities; moving on to preventive, risk-based approaches; and,
ultimately, developing a fully documented and coordinated system. The World
Health Organization’s advocacy for a stepwise approach is consistent with the find-
ings of this report and its understanding of the challenges and opportunities facing
countries at different stages of the processes of dietary transformation, economic
structural change, and food system modernization. In other words, advocacy for a
stepwise approach is consistent with this report’s concept of a food safety life cycle
with different stages. This approximates the World Bank’s classification of low-
income, lower-middle-income, upper-middle-income, and high-income countries.

The Way Forward 165

 As countries pass through this life cycle, they encounter a somewhat different mix
of food safety hazards and risks, and have different institutional circumstances and
capabilities for managing these risks.
Table 5.1 shows the different sets of priorities proposed for countries in the
traditional, transitioning, and modernizing stages of the food safety life cycle.
These are clustered under four headings: (1) policy, strategy, and regulation;
(2) risk assessment; (3) risk management; and (4) information education, and
communication.
At the strategic level, food safety is likely to be aligned with somewhat ­different
development goals over time. For example, countries at the traditional stage will
more typically link food safety concerns with matters of food and nutritional
security, while countries at the transitioning stage may more closely link the food
safety agenda with efforts to promote agricultural transformation and food trade
competitiveness. The degree of sophistication in food safety p ­ olicy development
and prioritization is expected to grow, sequentially, over time, with increased
access to scientific information, more use of economic analysis, and more com-
prehensive approaches to policy and regulatory consultation. Approaches to risk
assessment and risk management will also become more sophisticated. This will
involve a more systematic use of data, analytical tools, and information technol-
ogy, and more systematic approaches to documentation for hazard and illness
surveillance, and product traceability and recall, among other purposes. The
professionalization of food safety actors in government and the private sector is
expected to occur continuously and sequentially.
In traditional food systems, governments and other actors will need to give
considerable attention to mitigating risks in informal food channels. In the
progressive transitioning and modernizing stages, meanwhile, attention will
largely center on incentivizing and supporting better farm and enterprise prac-
tices in the formal sector and influencing consumer awareness and behavior.
The expectation for countries at the modernizing stage is that the private sector
will make most dedicated food safety investments, although supportive public
investments in science, human capital, and physical infrastructure will continue.
As noted in chapter 4, it is critically important to recognize the interfaces
between dedicated food safety measures and those addressing broader public
health or environmental health matters. Although to different degrees, these
measures also play a vital role in lowering the burden of FBD for countries
across the entire food safety life cycle. For example, improved access to basic
public health services can reduce the high levels of mortality associated with
FBD in traditional food systems, while reducing the exposure to food from
industrial pollutants becomes a significant challenge in many food systems in
the transitioning and modernizing stages.
Table 5.1 shows the priorities proposed for strategic, policy, and program
initiatives to address the evolving challenges for building food safety manage-
ment capacity and the stepwise approach for doing this for stakeholders along
food value chains. Greater specificity on this would come through country-level
structured discussions on priorities and needed short- and longer-term actions.

166 THE SAFE FOOD IMPERATIVE

TABLE 5.1 Priorities for Countries at Different Stages of the Food Safety
Life Cycle
Priority area Traditional Transitioning Modernizing
Policy, strategy, Integrate food safety Integrate food safety concerns into Integrate food safety concerns in
and regulation concerns in national food national strategies for agricultural national strategies for managing
and nutritional security transformation and trade diversification public health costs.
strategies to mobilize to mobilize attention. Strengthen regulatory
attention. Align sanitary and phytosanitary convergence with trading partners
Establish a basic legislative standards with the potential for trade and international standards.
framework for food safety in relevant commodities. Negotiate equivalence agreements
(roles and responsibilities, Develop a national multisector food to facilitate trade with important
legal authority). safety strategy that sets priorities, partners.
Update regulations for addresses institutional strengthening and Conduct cost-benefit analyses of
the use and marketing of coordination, and lays out approaches proposed regulatory measures
agricultural chemicals and for private sector collaboration and and incorporate regulatory impact
veterinary drugs. consumer engagement. assessments into policy making.
In line with available enforcement and
compliance capacity, strengthen the
legal framework and align it with the
Codex Alimentarius.
Participate in regional harmonization
efforts.
Risk assessment Undertake qualitative Set up programs for monitoring food Draw up a national research plan
assessments and quantitative consumption and purchasing patterns, to address food safety, with input
risk ranking, where feasible, and for estimating total dietary from industry.
to identify the most exposure to hazards. Set goals of continuous
significant risks to public Develop an FBD surveillance and reduction in FBD (as reported by
health. reporting system. surveillance system).
Incorporate information Pay particular attention to microbial Pay particular attention to
from other health-reporting hazards, and hazards-related emerging FBD and novel
systems. adulteration and use of agricultural technologies.
Pay particular attention inputs. Apply mechanisms for the
to issues associated with Establish programs to monitor food systematic collection, evaluation,
neglected zoonoses and safety hazards of public health concern and use of FBD surveillance data.
staple foods. and supplement them with studies to Ensure that laboratory systems
Undertake value chain generate additional surveillance data are internationally accredited,
assessments to determine to prioritize risks. effectively networked, and
the locus and nature of risks Invest and facilitate investment in financially sustainable.
in relation to food-safety- more extensive and professional
sensitive exports. quality assurance laboratory testing
Develop basic laboratory capacities
testing capacities while using
regional and international labs
for specialized or low-volume
testing.
Risk management Ensure synergies between Develop a registry of food businesses Build attitudes and incentives
water and sanitation upgrade in the formal sector and undertake to mix robust enforcement and
initiatives and community- risk profiling. Implement programs for constructive compliance support
level food hygiene programs. the hygiene grading of food premises. for businesses.
Improve basic hygiene Professionalize food inspectors and Incentivize the adoption of
conditions in markets by implement risk-based inspection plans. food safety management
investing in infrastructure, Introduce local good agricultural and systems by small and medium-
especially targeting markets animal husbandry practice programs sized enterprises (SMEs) and
where poor populations buy targeting specific commodities in internationally benchmarked
high-nutrient and perishable emerging formal sectors. standards by larger enterprises.
foods.
(Continued)

The Way Forward 167

TABLE 5.1 Priorities for Countries at Different Stages of the Food Safety
Life Cycle (Continued)
Priority area Traditional Transitioning Modernizing
Improve access to basic Leverage consumer awareness and Remediate important
health services to minimize demand for safer food. environmental hazards.
serious complications from Invest in (through public-private Strengthen fully documented
untreated FBD. partnerships, if possible) improved national food recall and
Support community-based food market infrastructure for traceability systems.
and peer-to-peer mechanisms perishable foods. Strengthen decentralized
for improving food safety in Mainstream the adoption of good capacities for regulatory oversight
smallholder agriculture and agricultural and animal husbandry and advice.
the informal food sector practices through technical and
linked with development Use emerging information,
market support programs, and ensure biological, and other technologies
initiatives. multisector synergies (through One in regulatory delivery and supply
Establish border controls Health, for example). chain management.
with a focus on likely high- Introduce procedures for investigating Ensure that border controls for
risk products. and responding to food safety food imports are consistent and
Target important single- incidents and emergencies, and for effective.
source hazards for feasible early warning systems.
control measures. Ensure that procedures for recalls
Strengthen border controls on a risk and food emergencies are well
Undertake public-private basis, and ensure that controls follow established.
initiatives to develop good trade facilitation practices.
compliance with external Develop an early warning system
requirements for sectors and contingency plan for food
with significant export emergencies.
growth potential.
Information, Educate consumers on basic Implement national food safety Establish a mechanism to
education, and food hygiene and avoidance awareness programs, targeting all systematically monitor public
communication of specific hazards. stakeholders and age groups. perceptions to inform food safety
Develop targeted training Work with industry and universities communications and education
for small and SMEs informal to develop training and advanced programs.
food retailers, and street education programs in food safety Develop communication
food vendors. management. strategies to correct public
Raise awareness of synergies Develop and implement various misperceptions.
and trade-offs between elements of a risk communications Use behavioral science
food safety, nutrition, and program, including guidelines for principles and empirical testing
equity; and food safety and different stakeholders and use of methodologies to design
Sustainable Development electronic platforms. programs that influence consumer
Goals. and food handler behavior.
Support private efforts to label
and certify products to promote
consumer trust and reduce
information asymmetry.

Source: World Bank.

REFERENCE

WHO (World Health Organization). 2018. Regional Framework for Action on Food Safety in
the Western Pacific. Manila: WHO.

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