Business Innovation to Combat Malnutrition Case Study Series

Two Wheels Turning: Public Disclosure Authorized Partnership in ’s Soy Sauce Fortification Program Case B

This case was coordinated NOVEMBER 2003 WAS supposed to be a groundwork, including certification of and free by Michael Jarvis (World celebratory period for Chen Junshi and his technical assistance to industry participants, it Bank Institute) and Bérangère China CDC colleagues working to ameliorate was disappointing for CDC staff to hear the Magarinos (Global Alliance for Improved Nutrition). the problems of iron deficiency and iron defi- objections voiced by soy sauce makers, just as We would like to express ciency anemia (IDA). After two years of testing funds had materialized to publicize the pro- our gratitude to the staff of and preparation, China CDC had received gram in seven provinces.

Public Disclosure Authorized Zhenji Brew funding from Geneva-based Global Alliance Group Company, Ltd, the Center for Disease Control for Improved Nutrition (GAIN) to launch its Four years later, not only had Zhenji been a and Prevention (CDC) in soy sauce iron fortification program in seven lead participant in the soy fortification project, China and their partner provinces and the municipality of Beijing, and but the program had made a tangible impact organizations for their had already held several provincial launch on the incidence of IDA among ’s 67 mil- invaluable contributions to the case’s development. conferences to kick off the campaign. But in a lion inhabitants. While iron fortified soy sauce recent conversation, Zhang Lin, CEO of Shijiaz- was unavailable to Hebei consumers in 2001, This case was commissioned huang Zhenji Brew Group Company (Zhenji), by mid 2007, fortified soy sauce was displayed by the World Bank Institute had relayed the resistance of his own managers if not sold in 90% of Hebei supermarkets. Iron with the support of the Global Alliance for to continued participation in the program. As deficiency anemia had fallen to 8.4% from a Improved Nutrition. one of the CDC’s strongest industry supporters, high of 20.1% in 2002, the date of the earliest Public Disclosure Authorized Chen worried that the resistance articulated by available survey. See Exhibit 1 for data on iron Zhenji managers meant that there was much deficiency anemia in Hebei province before and more hesitation among the CDC’s business after the project. The program had also been community participants in the program than expanded to six other provinces with promising the CDC had bargained for. results (see Exhibit Appendix for a map).

China CDC experts convened to discuss Chen credited this outcome to China CDC’s possible approaches to strengthening the soy new role in emphasizing social marketing. He fortification program’s appeal to the private and his colleagues had discovered that only sector without compromising its public health China CDC, working with local CDC teams, goals of counteracting IDA. China CDC was could persuade both consumers and soy sauce in no position to order any manufacturer’s makers of the benefits of participating in the Public Disclosure Authorized participation in the program. Indeed, one campaign against IDA. Having listened to the of the program’s advantages was its explicit grumbling from Zhenji’s management, in early voluntarism on the part of both consumers 2004 they had set out to do just that, using a and soy sauce makers. But after two years of broad array of channels and approaches to

Copyright © 2008, WBI - World Bank Institute, Washington, DC, United States, and GAIN - Global Alliance for Improved Nutrition, Geneva, Switzerland. The views expressed in this paper are those of the authors only. build as broad a consensus as possible behind the and county CDCs, health inspection and enterprise merits of iron fortified soy sauce. sales representatives, the principals in charge at the pilot counties and townships, village cadres, doctors of preventive medicine and heads of sales outlets. Laying the Groundwork: The intent was to build as broad a coalition as pos- The Case of Hebei Province sible at all levels before the campaign went public.

In late 2004 and into early 2005, project launch con- The health bureaus of Hebei’s four main cities – ferences were conducted at provincial and munici- Shijiazhuang, , , and – pal levels and training programs were conducted for selected the pilot counties and districts that would the core project staff at the county and district levels promote iron fortified soy sauce (see Exhibit 2). The in seven provinces. 35.2 million inhabitants of these four cities com- prised 52% of Hebei’s total population. Each county Hebei Province occupied 190,000 square kilometers and district appointed selected 50 demonstration of the plain, surrounding the Beijing villages. The health authorities in turn set up teams and Tianjin municipalities. Hebei was divided into at various levels. At the provincial level, the leader- 12 prefectural level cities, 172 counties and districts, ship group comprised 10 members including the and 1,971 townships. Launch of the iron fortification relevant leaders from the provincial health depart- program in Hebei was held in October 2004 at the ment. At the municipal level, the leadership group provincial capital, Shijiazhuang. Over 110 partici- consisted of the directors in charge of municipal pants attended, including leaders from the national health bureaus, work groups, campaign groups and Ministry of Health’s Department of Disease Control, a work team (143 individuals). Corresponding lead- the Hebei Provincial Health Department, the Shiji- ership groups and work groups were formed at the azhuang Municipal Health Bureau, and the national level of the pilot counties, districts, and cities (191 and provincial CDCs. Representatives of the Bill persons). At the village level, the local doctor served Gates Foundation and of GAIN also attended, along as project liaison officer. with senior Zhenji managers, state and provincial ex- perts, and the media. Similar project launches at the municipal level were sponsored by the health bureaus Getting the Word Out of each city and organized by each city’s CDC. Making it Official At the next level, 12 project launch and training conferences for core project staff were held at 12 In May 2005, the Hebei Province Health Depart- pilot counties and districts within Hebei. Each pilot ment issued a “Notice to promote the project on county in turn held a training and a mobilization iron-fortified soy sauce to prevent IDA,” and put the conference for core project staff. These activities provincial CDC in charge of implementing promo- reached 2,500 persons, including principals from tional programs for iron fortified soy sauce in Hebei. provincial and municipal CDCs and experts in The Hebei Health Department instructed the health charge of nutrition and health education, county bureaus of the province’s major cities to lead the and district government officials, leaders from dis- change in a firm yet cooperative way. The document trict and county health bureaus, staff from district also required the provincial CDC and all the pilot

2 cities and counties to use media outlets to promote, Bringing the Message to the Grassroots educate, and increase public awareness of the risks of IDA and to encourage consumption of iron forti- In rural areas, local CDC teams promoted the cam- fied soy sauce. paign by painting over 500 slogans on various walls in the communities. In addition, short clips about IDA were shown 69 times before outdoor showings Using the Media of feature films in the countryside, thereby reaching over 30,000 people. Furthermore, a total of 76,200 Building upon the initial social marketing with posters went up, one at every township clinic and which China CDC experimented in its 2002-2004 food retail outlet that carried iron fortified soy pilot scheme, a new, wide ranging TV campaign was sauce. Campaigns were conducted in the form of launched to get the message out. Provincial, mu- special consulting program on town squares. In ad- nicipal, and county TV stations broadcast dozens of dition, CDC teams throughout Hebei publicized the news reports on the iron fortified soy sauce project. campaign through lectures by experts on iron forti- Unlike TV advertisements, which were by far the fied soy sauce, itinerant road shows, distribution of most expensive element of CDC’s promotional campaign flyers and placards from the mobile cam- campaign, news reports cost the CDC nothing. In paign, combined with the annual health campaigns fact, CDC staff recounted, reporters and other on “May 20 Student Nutrition Day” and “Support media people were typically so sensitive to the value to the Rural Regions.” See Exhibit 3 for summary of the CDC’s educational mission that they ran ad- statistics on the various campaigns. vertisements longer than contractually required and worked in other ways to give greater prominence to The thrust in urban areas was slightly different. CDC goals. TV stations also broadcast ads related Over 220 shops were authorized to sell iron forti- to the iron fortified soy sauce during the workshops fied soy sauce and were thereby allowed to install run by the experts, focusing on the harms of IDA plaques promoting this status on their storefronts. and the role of iron fortified soy sauce in reducing it. Experts dispensed advice and free lectures. Cam- paign wall maps were produced and 11,200 of Coverage in the print media was also extensive in them were posted in neighborhoods, schools, and 2005 with 83 articles focused on IDA. The headlines sales outlets. The local CDC team printed 100,000 ranged from “Films to be shown in rural areas on campaign flyers and distributed them to students in knowledge about preventing anemia” in the August alone. A total of 3.5 million flyers 18, 2007 Shijiazhuang Daily to the August 5, Hebei were posted in support of iron-fortified soy sauce in Daily’s article titled, “Why has iron fortified soy Hebei’s four main cities. sauce been snubbed?” CDC staff remarked that newspaper coverage, while less prominent than ads or news reports on television, was cheaper and Overcoming Zhenji’s Objections typically offered the opportunity for a discussion of greater depth. It was also clear from that last head- The CDC’s campaign to building awareness of IDA line that the press coverage could not be entirely and demand for a solution would not have worked controlled when first efforts to roll out the fortified without reliable industry partners to manufacture soy sauce were slower than expected. and distribute iron fortified soy sauce. Zhenji was

3 one of China’s eight largest soy sauce manufactur- fortified soy sauce was much less expensive than ers, and ranked second or third among China’s purchasing iron tablets on doctor’s orders. But some vinegar producers. Zhenji revenues came from Zhenji managers felt that rural consumers would soy sauce (56%) , vinegar (40%), with the bal- be too slow to absorb and change their decades-old ance from other products in four categories. The purchasing and consumption habits. company also had plants in the United States and Canada and exported 10% of its production from Zhenji managers who favored investing in mak- China to 20 countries. ing iron fortified soy sauce argued that Zhenji had the opportunity to make a great deal of difference “A company needs profitability,” its CEO Zhang to the lives of existing and potential new consum- Lin was fond of saying, “but at the start, it needs ers. The argument went as follows: rural customers vision.” And from the start, the China CDC team usually ate soy sauce anyway, so they only needed felt that they had a good chance to enroll him and to change from regular soy sauce (at a cost of about his management team in their vision. But even after 14¢ a bottle) to fortified soy sauce (at a cost of about certifying Zhenji as Hebei’s sole approved manu- 15¢ a bottle). The poor could not afford medicine facturer and distributor of iron fortified soy sauce or vitamins, but they could afford soy sauce. This in 2002, it was no easy task to get Zhenji on board became Zhenji’s major sales argument. for the broader launch in 2004, as early results had not been encouraging. As a participant in China CDC’s 2002–04 pilot program to test the impact of Taking the Plunge iron fortified soy sauce on anemic Chinese in Hebei, Zhenji already had data on consumer purchases On September 1, 2004, Zhenji agreed to participate of iron fortified soy sauce. The data showed that in the expanded program. Zhenji worked with He- Zhenji’s sales of the iron fortified product rose and bei provincial CDC officials to coordinate its own fell in direct correlation with CDC and company marketing efforts with the CDC’s public health promotional efforts. When the pilot program for campaign promoting iron fortified soy sauce as Hebei ended in 2003, and promotion of iron forti- a weapon against IDA. Zhenji’s aims were over- fied soy sauce along with it, Zhenji’s sales of the whelmingly commercial. Despite their concerns, product slumped. Zhenji managers therefore feared Zhenji managers concluded that fortified soy sauce that government promotion of iron fortified soy presented an opportunity in two respects. First, sauce would be inadequate to support ongoing sales it was a new market for their products, one that of iron fortified soy sauce. no other manufacturer in the province had been given access to. Second, marketing fortified soy Zhenji managers also worried that the company’s sauce, especially in conjunction with an ongoing participation in the program might be hurt by sev- public health campaign, was likely good for mar- eral additional potential problems. Some worried ket penetration. It would expand the market for that rural consumers would find the price of iron Zhenji soy sauce, especially among anemics, and in fortified soy sauce too high, even if they knew that rural areas, where the company had only a slight it would improve their health. It was indisputable marketing presence. that – even if more expensive than the poor quality bulk soy sauce available in the countryside – iron

4 Taking a New Look at the Market China CDC and evidence of the CDC’s commit- ment to the campaign, particularly once GAIN had Zhenji’s market research showed, moreover, that committed its financial support for social marketing, differences between rural and urban consumers “we concluded that the government would promote could be overcome with appropriate marketing it,” a manager noted. to each group. For example, on the question of whether farmers were willing to spend more for iron fortified soy sauce, Zhenji conducted three Investing in Marketing market research surveys and a survey of its own staff, and held trials at the village level. “We dis- As a result, Zhenji decided in 2004 to invest RMB covered that the perception that farmers couldn’t 20 million ($2.4 million) in marketing and promo- afford fortified soy sauce was wrong,” a company tion of its iron fortified soy sauce over three years. manager explained. According to another manager, In recalling the reasoning to decide in favor of the farmers stated that, although they had a low income, investment and renewed participation in the CDC they had no other way to get iron in their diet, and program, a Zhenji manager made several points. feared having to spend more on medicine or treat- “First, we get all the benefits of being the first to ment for anemia in the future more than paying penetrate the market. Remember that brand loyalty more to get iron in their diet now. “For farmers, for- is high among soy sauce consumers. Second, be- tified soy sauce would cost only a bit more per year. ing the only certified soy sauce producer in Hebei These surveys made us realize that we shouldn’t distinguishes us from other local producers. Third, have underestimated consumers’ desire to protect iron fortified soy sauce allows us to segment our themselves from health problems. Also, word of customers better. For example, our marketing tar- mouth support for iron fortified soy sauce devel- gets parents by emphasizing the contribution iron oped after some consumers felt better as a result of consumption makes to childrens’ concentration. It using it. This was very helpful to us.” targets women by emphasizing the beauty effects of iron consumption. And it promotes vitality for the Government promotion of iron fortified soy sauce general population. Finally, we think it’s fair for the for IDA helped Zhenji in another way as well. government to limit certification for iron fortified Zhenji managers worried that popular mistrust of soy sauce to 11 producers nationwide.” the claims advertised by the producers of other nu- tritional supplements would limit the credibility of On April 8, 2005, Zhenji established its own central Zhenji’s marketing of its iron fortified product. But office to promote iron fortified soy sauce, consist- in the event, Zhenji managers concluded, “Even ex- ing of three teams to plan, promote, and develop aggerated ads conveyed some useful health informa- consumption. Meanwhile, group level sales and tion, including on the connection between iron and marketing actions for iron fortified soy sauce were health. Furthermore, we relied on government sup- approved and implemented in the urban areas port to overcome consumer resistance because the of Shijiazhuang, as well as in the county areas of government was considered a much more reliable Shijiazhuang, Tangshan, Baoding, Handan, Cang- source of health information than companies that zhou, and . Internal training conferences were trying to sell something.” Thus, on the basis to increase staff awareness about IDA and Zhenji’s of both the relationship between CEO Zhang and new products were conducted for 580 staff in July

5 and August 2005. These included 17 workshops for the requirements and specific details for imple- 3,210 rural doctors on how to popularize the sci- menting the project in the existing demonstration ence of iron nutrition. cities, the letter helped buttress official support for and attention to increasing public awareness of iron Especially in urban areas, Zhenji used a broad ap- fortified soy sauce. Locally influential publications proach to building demand for the new product but published the letter and a series of signing events with the retailer at its center. “We decided for our followed. As in 2005, volunteers were mobilized to part that we needed to mobilize retailers,” a Zhenji distribute the letter to citizens and retailers. TV ads manager underlined. “Word of mouth alone only were run and media coverage of events encouraged. gets so far. Back in 2004, we distributed leaflets and In addition, 35-second public service announce- posters along with gifts to retailers. The leaflets ments (PSAs) were broadcast by mainstream media stated at the bottom that if the reader finished two to four times each day from mid June 2006. The reading the flyer Zhenji would give them ¥1 [about announcements aimed to educate, but importantly 12¢]. This was a big success. In addition, we held for the success of the CDC’s collaboration with trials in retail stores, and bundled the soy sauce with industry, each PSA was followed by a company- little freebies. In villages, we offered a free pencil specific advertisement, focusing in Hebei’s case on case with purchase of five bottles of iron fortified Zhenji brands and products. Zhenji managers noted soy sauce. To boost initial sales, we paid consum- that booking advertisements for its iron fortified soy ers ¥0.10 [about 1¢] for every empty iron fortified sauce immediately following these PSAs exemplified soy sauce bag that they brought back to the point the type of collaboration fostered by their relation- of purchase. Through such efforts, retailers became ship with China CDC. marketing agents for us. Further, people with severe anemia told others about the beneficial effects of On the basis of the success in Hebei and seven ad- Zhenji’s iron fortified soy sauce.” ditional provinces (plus Beijing), in 2007 the CDC hoped to begin to extend the iron fortification Sales of Zhenji’s iron fortified soy sauce doubled campaign to the seven additional provinces of Hei- every year to date. Between October 2005 and Oc- longjiang, Liaoning, Shandong, , Sichuan, tober 2006, Zhenji sold 1,500 tons of iron fortified Xinjiang, and Zhejiang. “Now we need to scale the soy sauce, which was consumed by an estimated 8.4 program up,” explained Chen Chunming, a former million people. Sales no longer correlated directly China CDC leader. “We estimate that there are with the CDC’s public health campaigning. 130 million people at high risk for iron deficiency anemia. Our hope is to reach 360 million with our campaign. To get there we need to go beyond than Taking Stock Beijing and the seven provinces covered now.” A key thrust for 2007 was greater emphasis on rural CDC: Expanding, Experimenting, and Learning areas, both expanding the area of coverage and expanding the number of people covered. Other In 2006, the Hebei provincial CDC promulgated an- ideas included the provision of student lunches other document: “Letter regarding the further im- and the encouragement of group purchases as provement of the work on iron fortified soy sauce ways to further disseminate the product and project to prevent anemia.” In addition to specifying build word of mouth. As the CDC experimented,

6 however, it became clear that ideas were not lack- 25% and 35% of its total soy sauce sales for the year. ing. Instead, some CDC managers said, it was the Zhenji had yet to market fortified soy sauce to its efficient transfer of best practices across geogra- existing industry or restaurant clients, but this phies that needed improvement. With so many was a promising new market. Because Zhenji’s experiments underway, the CDC and its partners expansion of fortified soy sauce sales beyond the had to systematize their learning so as to become Hebei market depended on both CDC’s recom- even more efficient in every new province in which mendations as to its desired area of influence (since they invested. each province would have its own local producers working with CDC), CEO Zhang Lin expected to China CDC had already learned that it need not focus sales and marketing on Zhenji’s own back- limit itself to its historical role of research and yard, Hebei Province. Zhenji managers expected to prevention, but had the ability to influence public make a profit on fortified soy sauce in 2007 due to health by taking an active role in developing and increased volume. implementing policy. According to China CDC FFO vice-director Sun Jing, “CDC staff changed from As they looked back on progress to date, Zhenji being purely scientists to operating more as social managers had become convinced of the power of advocates.” CDC collaboration with social actors the CDC to build demand. “Urban consumers do and the media was the key proselytizing tool, but not trust the claims of company advertisements,” without building relationships with industry pro- explained Chen Chumning, “so they suspected that ducers to supply and distribute a product that the this could not be right either. This is where the trust CDC could not, all its media and face-to-face work enjoyed by CDC made the difference: unlike the pri- would have had no impact. vate sector, the CDC had a high level of credibility.” In addition, CDC promotion built the demand that Zhenji had worried might not materialize. Zhenji: Thinking Through Next Steps

Meanwhile, by 2007 Zhenji had begun the first Taking Pride in the Outcome and phase of a project to boost annual output of iron Going National fortified soy sauce to 100,000 tons (the company had total annual integrated output capacity of As the various players looked back and planned 200,000 tons). Zhenji’s fortified soy sauce produc- ahead, they had pride in the outcome of their col- tion reached 13,000 tons in 2006, well below its ex- laboration to date. Indeed, by 2007, iron fortified isting capacity of 24,000 tons. Production in the first sauce was widely known, available, and consumed five months of 2007 was 8,000 tons, with a total of in the pilot areas. See Exhibits 4, 5, and 6 for aware- 20,000 tons of sales expected for the year. The goal ness, distribution, and sales data. In the pilot areas, for 2008 was 48,000 tons. Zhenji felt that 50,000 Chen Chunming noted, “child malnutrition is way tons was a mature market, but the firm’s plans to down. The program has been a big success. In ad- build a 100,000 ton capacity clearly signaled that dition, the program is sustainable: affordable, safe, Zhenji managers believed they could take the prod- and profitable with our help in social marketing to uct national. Zhenji sold US$3.6 million worth of generate awareness of the problem and acceptance fortified soy sauce in 2006, amounting to between of fortified soy sauce.”

7 On the basis of this success, China CDC in May 2007 signed a distribution agreement with French hypermarket Carrefour, which operated 49 stores in eight Chinese cities. The agreement stipulated that Carrefour would give shelf space to iron fortified soy sauce at no charge, and allow the manufacturers of the products that local Carrefour managers chose to feature on those shelves to conduct periodic in- store promotion of the product.

For soy sauce producers, the agreement created one way to get their products into a high-end retail environment that they might not otherwise have access to. For the CDC, the agreement created yet another venue to advance its public health agenda. For Carrefour, the agreement created a way to associate itself in China with health and nutrition at little cost, while also guaranteeing that, in a mar- ketplace full of adulterated and counterfeit goods, its soy sauce at least would come from nationally- certified producers.

8 Exhibit 1. Initial Results from Hebei Province, 2004–05

Baseline results for women and children in Hebei’s main cities

Number of Number of chil- women over 20 Anemia rate dren aged 3–7 Anemia rate Test date Location tested (percent) tested (percent) Oct 2004 Shijiazhuang 801 42.32 198 17.17 May 2005 Tangshan 933 28.40 190 5.26 June 2005 Baoding 931 27.18 220 11.36 July 2005 Handan 749 40.45 160 17.50 Total: 3,414 Average: 34.59 Total: 768 Average: 12.82

Baseline results for Shijiazhuang youth

Students Students found Anemia rate Test date Location Age level tested anemic (percent) Urban/rural Oct 2005 Zanhuang High school 495 167 33.74 Rural High School sophomores Oct 2005 Shijiazhuang High school 530 107 20.19 Urban High School sophomores #2 Oct 2005 Shijiazhuang 19–22 511 137 26.81 Urban University Total 1,536 411 26.76

Improvement of anemia conditions in pilot counties and districts: Hemoglobin levels among Shijiazhuang women and children

Anemia Improve- Anemia Improve- Number of Number rate ment Number of Number rate ment Location Year women anemic (percent) (percent) children 3–7 anemic (percent) (percent) Zanhuang 2004 401 192 47.88 100 22 22.00 county 2005 332 120 36.14 24.52 100 14 14.00 36.36 Chang-an 2004 400 147 36.75 98 12 12.24 district 2005 384 105 27.34 25.61 100 10 10.00 18.30 Shijiazhuang 2004 801 339 42.32 198 34 17.17 city 2005 716 225 31.42 25.76 200 24 12.00 30.11

9 Exhibit 2. Pilot Counties and Districts Promoting Iron Fortified Soy Sauce, Hebei Province

Population Total area Number of township/ Number of village/ City County and district (in 10,000) (km2) district committees neighborhood committees Shijiazhuang Chang-an district 40.0 110.2 3/8 35/85 Luquan city 36.0 603.0 13 208 Zanhuang county 23.0 1,210.0 11 212 Baoding New urban district 40.6 143.7 6/6 74/85 city 113.6 1,274.0 22/3 486/31 county 48.0 652.0 13 232 Tangshan Libei district 51.2 120.0 2/9 38/109 city 69.3 1,521.0 25/2 648/22 Qian-an city 71.8 1,208.0 19/1 534/10 Handan Fengfeng mining district 50.2 353.0 9 148/68 40.2 667.0 10 342 24.7 339.6 10 165 Total 608.44 8,201.5 172 3,534

10 Exhibit 3. Overview of CDC Marketing Efforts, Hebei Province

Forms Frequency Location distribution Theme Population coverage Films projected in 69 times Baoding, Luquan, Scientific 30,000 rural areas Dinzhou, Li County popularization Street performances 11 times Handan and Knowledge about 15,000 Shijiazhuang iron-fortified soy supermarkets and sauce communities Expert consultations 9 times Handan TV coverage of Q&A on iron- 250,000 programs at parks and fortified soy sauce, urban squares in Luquan, consulting service, Dingzhou, Li County, and and promotion Baoding Wall signs, posters, 602 times Communities and Knowledge about Close to 1 million banners, window supermarkets in iron-fortified soy displays, leaflets, Shijiazhuang, Tangshan, sauce desk calendars and Handan

11 Exhibit 3 (continued). Including campaign columns, wall signs, ceramic tiles, banners, window bulletins, exhibition boards, leaflets, flyers, and desk calendars.

Number of Forms publications Date Distribution Location Coverage Wall maps 55,000 pieces 2005 55,000 12 demonstration 1 million people counties and districts in Sjijiazhuang, Baoding, Tangshan, and Handan Leaflets 16,000 copies 2005 16,000 12 demonstration 1 million people counties and districts in Sjijiazhuang, Baoding, Tangshan, and Handan Placards 4 sets 2005 4 sets 4 demonstration — cities Plaques for shops 222 pieces May–Oct 222 Urban areas of Shi- — 2005 jiazhuang, Handan, and Tangshan Window displays 5 pieces — 5 pieces Supermarket in — Shijiazhuang Flyers 580,000 copies May–Oct 580,000 copies Urban and rural 580,000 people 2005 areas of Shijiaz- huang, urban areas of Handan, urban areas of Tangshan Health manuals for 100,000 copies — 100,000 copies All the large hospi- 100,000 people iron-fortifies soy tals in Shijiazhuang sauce Wall calendars 6,000 — 6,000 — 10,000 people Scrolls 1,860 pieces May–Oct 1,860 Communities in 650,000 people 2005 Shijizhuang, Baod- ing, Handan, and Tangshan Point-of-purchase 31,200 May–Oct 31,200 Supermarkets in 100,000 people posters 2005 Tangshan, Handan, and Baoding Advertisements on 60 — 60 Tangshan 600,000 people bus exteriors Display boards 375 pieces Jun–Dec 375 pieces County and urban 700,000 people 2005 districts in Baoding and Shijiazhuang Aprons 40,000 Jul 2005 40,000 Urban districts and 40,000 counties in Tangshan Wall advertisements 80 Aug 2005 80 Luquan city 150,000 Advertisements on 460 Aug–Nov 460 Demonstration coun- 500,000 people ceramic tiles 2005 ties of Shijiazhuang, Baoding, Tangshan, and Handan Source: Chinese Center for Disease Control and Prevention.

12 Exhibit 4. Consumer Awareness of IDA

Baseline survey results on the knowledge about iron nutrition

% known of iron % perception deficiency lead of being iron Survey date Survey location Survey cases to anemia deficient Cognitive level 2005 Shijiazhuang 400 46.12 16.24 0.20 2005 Tangshan 400 33.08 18.69 0.20 2005 Baoding 400 29.51 6.56 0.05 Source: Chinese Center for Disease Control and Prevention.

1. Awareness rate among the target population 4. Consumption rate for iron fortified soy sauce at surveillance sites: The awareness rate of the in the project regions: 24% of the targeted people from Changan district and Zanhuang population in Hebei’s four project cities. County in Shijiazhuang increased from 20% in 2004 to 80% in 2005, and to 70% in rural 5. Availability of iron fortified soy sauce at the areas. By 2006, the awareness rates for the pilot sales outlets in project regions: 40% in 2006 counties of the Shijiazhuang, Baoding, Tang- shan and Handan reached 90%, and 80% in 6. Reduction in morbidity rate for iron deficiency rural areas. anemia among the target population at the surveillance points 2. Population coverage rate in project regions for iron fortified soy sauce: reached 72% in 2006 Adult women in Shijiazhuang: 25.77% Adult women in Baoding: 26.47% 3. The number of Hebei people who have Children in Shijiazhuang: 30.23% consumed iron fortified soy sauce: about 8.4 Children in Baoding: 14.91% million in 2006

13 Exhibit 5. Availability of Iron Fortified Soy Sauce in All Sales Outlets, Hebei Province

Promotion of the coverage rate for outlets Year Urban (percent) Rural (percent) 2002 — — 2003 — — 2004 35.61 26.86 2005 47.81 37.17 2006 61.47 53.69 Source: Chinese Center for Disease Control and Prevention.

Exhibit 5 (continued). Retailers of Iron Fortified Soy Sauce in Hebei Cities, by Size

Large supermarkets Medium supermarkets Smaller retail outlets 2004 2005 2006 2004 2005 2006 2004 2005 2006 Urban Shijiazhuang 32 32 32 100 100 100 400 400 400 Market share 100% 100% 100% 100% 100% 100% 30% 50% 90% Urban Tangshan 10 10 10 70 70 70 500 500 500 Market share 100% 100% 100% 100% 100% 100% 50% 60% 70% Urban Baoding 10 10 10 12 12 12 1300 1300 1300 Market share 100% 100% 100% 100% 100% 100% 15% 30% 40% Urban Handan 10 10 10 20 20 20 1100 1100 1100 Market share 100% 100% 100% 100% 100% 100% 40% 50% 60% Total 62 62 62 202 202 202 3300 3300 3300 Market share 100% 100% 100% 100% 100% 100% 30.45% 43.63% 57.27% Source: Chinese Center for Disease Control and Prevention.

14 Exhibit 6. Shijiazhuang Urban Resident Consumption of Iron Fortified Soy Sauce, 2006

Survey contents Response numbers Percentage Sales outlets in urban Stocks available 191 40.90 areas/Market share of No stocks for sale 276 59.10 iron fortified soy sauce Intend to stock 14 5.00 Percentage of residents Currently consuming 210 44.97 who have consumed iron Not consuming 257 55.03 fortified soy sauce Prepare to consume 237 92.22 Not prepared to consume 20 77.88 Source: Chinese Center for Disease Control and Prevention.

Exhibit 6 (continued). Selected Statistics on Shijiazhuang Sales of Iron Fortified Soy Sauce

Increase over Number of Sales revenue Tons sold (in same period last consumers (in Increase over the Year (RMB 10,000) 10,000) year (%) 10,000) same period (%) Jun 2002– 221 0.100 — — — Apr 2004 Apr 2004– 66 0.030 — 36.52 — Oct 2004 Oct 2004– 708 0.320 1073 391.80 1073 Apr 2005 Apr 2005– 1372 0.620 194 759.26 194 Oct 2005 Oct 2005– 1483 0.670 108 820.70 108 Apr 2006 Apr 2006– 1505 0.680 101 832.86 101 Oct 2006 Total 5355 2.420 — — — Source: Chinese Center for Disease Control and Prevention.

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