United Nations Standing Committee on Nutrition (New York)
Nutrition and Business How to engage?
INTRODUCTION
The recent consensus document “Scaling Up Nutrition” (SUN 2010) laid out the main elements of an action framework to address undernutrition with relation to the landmark 2008 nutrition series in The Lancet. The SUN Framework calls for increased investment in nutrition interventions through partnerships between key nutrition stakeholders at the global and national levels including the private sector.
Nutriset has been answering this call to action for decades; first with its industrial development of therapeutic milks used in therapeutic feeding centres; later though the development of the first Ready-to-Use Therapeutic Food (RUTF) Plumpy’Nut®; and currently through its continued research and investment in nutrition supplements such as the Lipid-based Nutrient Supplements (LNS) Evol’Nutributter® for the prevention of chronic malnutrition. Even before the SUN Framework was drawn up, Nutriset has been (and continues) to contribute to its objectives by developing adapted products, establishing a network of local producers and collaborating with both development actors and governments alike.
There is growing recognition of the role the private sector can play in addressing issues related to undernutrition, especially when it comes to innovation and efficiency. In addition to food production, the private sector also has a role to play in employment and income generation. However, many groups are still concerned about profit motives, conflict of interest and more generally, how exactly to engage with the private sector and benefit from its ability to develop commercially viable business models in developing countries. Nutriset’s model is atypical in the sense that it shares its technology and know-how with its partners, allowing them to contribute to responding to needs in their respective countries without having to rely on imported solutions. Further, unlike other private sector actors, Nutriset only produces products destined for either the treatment or the prevention of the various forms of malnutrition affecting young children and other vulnerable groups.
ADDRESSING NUTRITION AT THE COUNTRY LEVEL
Following the first widespread demand for Plumpy’Nut® during the 2005 famine in Niger, Nutriset created and continues to expand a network of local producers of RUTFs. PlumpyField®, as it is now known, is a network of partners striving to achieve a common goal of increasing access to new nutrition solutions for at-risk populations while adhering to international quality standards of production. Currently the eleven PlumpyField® partners produce nearly one third of all Plumpy’Nut® used in humanitarian programming with all groups working to increase their respective production capacities.
WIDENING THE EVIDENCE-BASED OPTIONS
Nutriset realizes that there are many more challenges and opportunities in addressing undernutrition beyond the treatment of acute malnutrition and that the threat of malnutrition should be addressed from multiple angles. Through its partnership in the research consortium “The International Lipid-Based Nutrient Supplements Project” (iLiNS), Nutriset was engaged in the development of a complementary food supplement, Evol’Nutributter®. The product was originally designed for infants between six and twelve months of age, a critical time period for growth and cognitive development. Since then, Nutriset has partnered with various research projects to improve the effectiveness of Evol’Nutributter® for children from six months of age and at risk of chronic malnutrition.
Evol’Nutributter® was developed in an attempt to realize a low cost supplement to enrich children’s complementary food (diets provided to children in addition to breastmilk) with essential vitamins, minerals and fatty acids (see Table 1) during the critical months between the end of exclusive breastfeeding and two years of age. Research has demonstrated that daily consumption of Evol’Nutributter® all along the at-risk period during which the child receives nutritionally inadequate complementary food (for instance, lack of products of animal origin, fruits and/or vegetables) promotes the child’s growth and motor cognitive development and prevents long term nutritional deficiencies (chronic malnutrition) (Adu-Afarwuah et al. 2008). Similar to Nutriset’s other products, Evol’Nutributter® does not require any refrigeration or reconstitution, and can be made primarily from locally grown or processed raw ingredients. As is the case with Nutriset’s other products, Evol’Nutributter® is a patented product and there are plans in place for it to be produced in the United Republic of Tanzania. This is in reference to the announcement made in October 2010 where a proposed Usage Agreement is offered to any company or organization (with the exception of Europe and North America) to manufacture, market and distribute products covered by Nu-triset/IRD patents.
USING MARKET-BASED APPROACHES
Understanding the magnitude of the global nutritional crisis in terms of both acute and chronic malnutrition, and responding to the international calls for renewed attention to the potential of market-based approaches to enhance the access to a range of nutritious food products, especially for mothers during pregnancy and very young children (Shrimpton 2007), Nutriset is embarking on research for innovative delivery strategies with the objective of continuously striving to improve access to these nutrient supplements to vulnerable populations through the private market. Nutritional supplements are mostly distributed through government or non-government nutrition programmes. The private or retail market is an option to make products available in areas not benefiting from these programmes.
To attain this goal, Nutriset’s approach uses social marketing techniques in its design and implementation of programmes, which are inspired from traditional marketing principles but with the objective of addressing a public health need. Hence, in addition to the conventional four P’s (Product, Place, Price and Promotion) used in traditional marketing, social marketing also includes four more variables: “Public” (external and internal groups involved in the programme to be addressed by the organization), “Partnership” (the company has to team-up with other organizations in order for the programme to be successful), “Policy” (policy changes are sometimes needed in order to implement a favourable environment for the programme) and “Purse strings” (funding strategy to support the programme).
Based on a comprehensive understanding of the needs of the target population, social marketing programmes place special emphasis on understanding behaviours and employ communication and awareness raising strategies in order to improve the health and well-being of the population in question.
Since mid-2006 in Niger, Plumpy-Field® network member Société de Transformation Alimentaire (STA), in partnership with Nutriset distributes a locally produced ready-to-use nutrition supplement directly through the retail market. Grandibien® is a ready-to-use supplement for children aged 1-5 years which, when consumed daily, provides a minimum 50% of the daily recommended intake of vitamins and minerals.
Product promotion is based on social marketing methods and Grandibien® has been tailored (price, name, packaging, distribution channels and communication) to be accessible to vulnerable populations. One of the main lessons drawn from the Niger experience is the importance of public information campaigns and the funds required to ensure their continuity. In Niger, it was noted that sales of Grandibien® decreased significantly when the public campaigns ceased but quickly picked up again when the information campaign was relaunched (Beltran Fernandez 2009).
Building on the pioneering work of Grandibien®, other social marketing projects are currently either under way or planned in three other African countries.
THE TANZANIA PROGRAMME
In Tanzania undernutrition is an endemic problem with 42% of children under five suffering from chronic malnutrition and 16% suffering from chronic acute malnutrition in 2010. In addition to this, only 50% of children under six months are being exclusively breastfed whereas international health organizations recommend exclusive breastfeeding for the first six months of life and mixed feeding for at least 24 months to safeguard the nutritional status of young children as well as their general health, development and survival.
Last but not least, when the Infant and Young Child Feeding (IYCF) practices recommend that breastfed children age 6–24 months also be fed three or more other food groups daily, only one in four breastfed children in Tanzania meets this recommendation (National Bureau of Statis-tics 2011).
Lipid-based Nutrient Supplements (LNS) targeting children 6-24 months such as Evol’Nutributter® can be a convenient way to fill the nutrient gap of complementary food to enhance the child’s growth and development and reduce child mortality. Nutriset is committed to contributing to the promotion of key nutrition messages such as exclusive breastfeeding and adequate complementary feeding with continued breastfeeding and believes that multistakeholder approaches, including both public and private actors, are the most appropriate methods to improve these practices.
The Global Strategy for IYCF urges countries to formulate comprehensive policies to ensure children’s nutritional status (WHO/UNICEF 2003) and public-private alliances bring scale, effec-tiveness and innovation to development efforts thereby accelerating progress towards the Millennium Development Goals (Runde 2006). These alliances take place at different levels and stages of the programme, and can take various forms, from a simple interaction to a real partnership, involving shared decision-making (Hawkes 2011).
In 2009, and following lessons learned from the Grandibien® experience in Niger, Nutriset partnered with Power Foods, a local food producer in Tanzania, and the locally based non-governmental organization (NGO), Industrial Revelation. This public-private partnership was made possible thanks to institutional funding from the United States Agency for International Development (FANTA-2) together with Nutriset’s research and development funds.
The partners work in close coordination with the Tanzania Food and Nutrition Centre (TFNC), a semi-autonomous government institution under the Tanzania Ministry of Health and Social Welfare, in order to align development partners’ goals with those of the government. TFNC is known in particular for its ability to forge alliances for community-based actions and developing capacity for nutrition research and action so that even unconventional public health nutrition strategies can succeed at the national level. Involvement of the TFNC also ensures continuous governmental engagement throughout the planning and imple-mentation of the programme.
Building on the increasing evidence of the efficacy of Evol’Nutributter®, plans are under way to develop a locally produced version of the product for introduction into the local market. A three-phase programme (see Fig-ure 1) was initiated in early 2010 with a market study analyzing the target population – eating habits and food purchasing behaviours as well as other political, environmental, social, technological, economical and legal (PESTEL) factors that will influence the programme. The research included the assessment of the need for a supplement for the target population and support of the programme by nutrition experts in the country, including the Tanzanian government.
In addition, an in-depth study of international guidelines and national regulations concerning products targeting children from 6 to 24 months of age – such as the International Code of Marketing of Breastmilk Substitutes (WHA 1981) - was carried out. The document review was conducted with the help of the Global Alliance for Improved Nutrition’s working paper (GAIN 2010) on how to use this Code, and the National Regulations for Marketing of Breast-milk Substitutes and Designated Products (1994) of Tanzania to ensure the promotion of appropriate breastfeeding and complementary feeding practices. Simultaneously, a qualitative study assessed the mothers’/caretakers’ perception of the product, the associated communication materials including packaging, product name and design.
One of the driving forces of Nutriset’s qualitative methodology is to incorporate community participation at all levels in an effort to ensure the effective integration of the product into the local market (Nutriset 2010). Fifty participants took part in the focus group discussions, which included ten in-depth interviews, ethnographic observations and 315 respondents participated in the secondary data research that led to recommendations for product packaging, price, communication and awareness strategies as well as methods of distribution.
The survey was piloted in Dar es Salaam and subsequently carried out in three diverse regions (urban: Dar es Salaam, Mwananyamala; rural: Mtwara – Ziwani; semi-rural: Mwanza – Kisesa). An effort was made to ensure the points of view of both male and female participants were captured and ultimately secured feedback from 76.5% female – 23.5% male re-spondents. The criteria for selection of interviewees were: primary care-takers of children 6 - 24 months with a household income less than TZS 300 000 per month.
The second and final stage of research focused on empirical field in-vestigation of issues around taste, usability, packaging and other elements of the marketing mix of the proposed supplementary food. As a result of these studies, the product and the programme have been adapted to the local context to be in compliance with international guidelines and national regulations alike.
Evol’Nutributter® is specifically designed to meet the needs of children 6 - 24 months. This approach is in line with and supports the exclusive breastfeeding of infants through six months of age. Furthermore, any social and behaviour change communication (SBCC) materials will recommend that the LNS be mixed with the child’s complementary food and that the child be fed the supplement only after s/he has been breastfed. This approach is being adopted in order to ensure the introduction of the product does not displace breastfeeding and furthermore, in order not to undermine traditional feeding practices.
Due to restrictions on the promotion of food products destined for children under five in Tanzania, Nutriset will share all available SBCC materials with local actors for integration in their respective programmes.
Following the infant formula controversy in the 1970s, which has led national authorities to lose confidence in private sector players, the Government of Tanzania has established National Regulations regarding products targeted to young children which are more restrictive than the World Health Organization Code (by extend-ing the prohibition of promotion to all products, even those that are not promoted as breastmilk substitutes). Although these laws are put in place to protect the child’s growth and development, they also restrict the access to LNS that could be an option to improve the complementary food of the child.
To overcome this challenge, Nutriset has undertaken a public-private approach to make the product accessible to the target populations, while emphasizing its appropriate use.
Evol’Nutributter® will be distributed through both the private and the public sectors concurrently, using a unique packaging design known and recognized by all (see Figure 2). On the one hand, NGOs would distribute Evol’Nutributter® through their nutrition programmes (provided free of charge or sold at a subsidized price depending on the type of programme being implemented), allowing for tighter control over the target beneficiary population; and on the other hand, Nutriset and Power Foods would make the product available through the retail sector in areas that are not covered by these programmes, all the while respecting National Regulations and working in close concert with local actors.
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Besides controlling distribution, this approach allows for increased coverage for a larger target population and could be the basis for a sustainable model in the long term. The combination of these different but complementary distribution systems can contribute to a greater impact on preventing malnutrition in Tanzania.
As alluded to the above, perhaps the greatest challenge facing Nutriset and Power Foods in Tanzania are the National Regulations linked to foods for children under five, which forbid advertising or any form of promotion from the producer or the distributor to the general public.
As a result, Nutriset met several nutrition actors in Tanzania and in an effort to ensure that communication / labelling is clear and understood by mothers or caregivers, Nutriset and Power Foods is working closely with The Centre for Counselling, Nutrition and Health Care (COUNSENUTH). COUNSENUTH is a local NGO with strong ties to the International Baby Food Action Network (IBFAN) that aims to contribute to improving the quality of life through strengthening care for vulnerable groups and promoting preventive healthcare, nutritional care and counselling at the community level. Nutriset and Power Foods will work in collaboration with COUNSENUTH whose role would be to ensure the promotion of appropriate breastfeeding and complementary feeding practices and the appropriate use of the LNS (Evol’Nutributter®) in order to increase its efficacy via their existing SBCC channels.
Following the studies embarked upon in Tanzania, it was determined that the target population has the purchasing power to include this product in their diet if it is priced comparably with common snacks already being bought for children and assuming there are no other similar or competing products on the market. The price that was determined to be most affordable for households with total monthly income of less than TZS 300 000 (US$ 200) was TZS 150-200 (US$ 0.09-0.12). Of primary importance, this price would allow mothers to purchase the product in addition to complementary foods already being fed to a child 6 - 24 months.
All research carried out to date was considered when establishing the short and medium term goals. Based on the assumption that not all of the target population will purchase, forecasts for consumption over the next five years was estimated based on the target population size (children 6 - 24 months) (Tanzanian National Bureau of Statistics 2009). The programme evaluation identified the need for high initial investment costs and the preliminary consumer price would need to be TZS 150-200 in order to cover production and distribution in the most effective manner. With this business model, the break-even point for the programme would be in approximately three years after around 100 MT/year of production is reached which represents an estimated 30 000 children in the target population consuming Evol’Nutribut-ter® every day for six months.
This project expects to be supported by institutional grants for the first three years, specifically in order to finance part of the extension of the distribution network. Once the break-even point is reached at the end of the third year, the programme should be economically viable. Once sustainable, Power Foods will be able to re-invest profit to permanently reduce the price of the product in order to reach more people and specifically very low-income populations.
INVOLVING THE PRIVATE SECTOR IN THE EFFORTS TO SCALE UP NUTRITION
The private sector can contribute to establishing new and sustainable business models for delivering nutrition services or messages and food products to the target population and the private sector increases the potential to bring interventions to scale. Unfortunately, many groups still have questions as to how to engage the private sector and it will be some time before groups find their “comfort zone” and engage the private sector. Despite this reality, several private sector players have successfully managed to partner with public sector actors.
Specific examples include the longstanning relationship between Cargill and the World Food Programme (WFP).
More recent public-private partnerships are also showing promise, such as the newly established Partners in Food Solutions (PFS), a partnership between General Mills, Cargill and DSM, which aims to initiate transfers of technology to producers of fortified blended flours in the developing world.
With the local development of Evol’Nutributter® in Tanzania, Nutriset is proving its commitment to addressing the rampant undernutrition facing the Tanzanian population through supporting the establishment of a sustainable system to identify and make accessible the nutrients required for the proper development and overall health of vulnerable populations. Tackling chronic malnutrition also serves to address the new-found support in the world of public health towards addressing non-communicable diseases, to which chronic malnutrition is inextricably linked.
The challenges and main lessons learned from the development of Evol’Nutributter® in Tanzania will be considered and incorporated into Nutriset’s future initiatives and part-nerships.
One of the most important lessons, and one of the main challenges, is the development of a policy environment that incorporates all possible actors that have a stake in improving IYCF practices.
Another main challenge is reaching children 6-24 months with a food product and the target population (mothers and caregivers) with the right messages (product use, appropriate breastfeeding and complementary feeding practices) without direct communication to the general public as stipulated by the Tanzanian National Regulations.
Nutriset’s experiences in Niger and Tanzania highlight the importance of engaging with local actors in the public sector in order to achieve mutual goals. The efficiency and innovation of the private sector coupled with the public sector actor’s intimate knowledge of the beneficiary populations is essential for ensuring the success of these types of initiatives. By working in tandem, goals can be achieved and Nutriset’s experience demonstrates that it is indeed possible for the public sector to engage with the private sector in an effort to achieve its stated policy objectives.
article écrit par Virginie Claeyssens (Project Manager ACCESS, Nutriset), Omar Taha (Public Health Development Manager, Nutriset), Svenja Jungjohann (Nutrition leader, Nutriset), Leah Richardson (Independent Public Health Nutritionist)
