Business Innovation to Combat Malnutrition Case Study Series Two Wheels Turning: Public Disclosure Authorized Partnership in China’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 Shijiazhuang 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 Hebei’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, Tangshan, Baoding, and Handan – 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 North China 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 Zanhuang County alone.