Monday, 5 August 2013

Paying for nutrition? Challenges and lessons in selling healthy foods to the poor

By Ewan Robinson

Following the Nutrition for Growth event in June and the expansion of the New Alliance for Food Security and Nutrition, there is more interest than ever in using markets to tackle undernutrition, especially the so-called ‘hidden hunger’ of micronutrient deficiencies.

Some big businesses are trying to make low-cost products that are fortified with key nutrients, and to sell these to poor populations. Examples include Grameen Danone Foods in Bangladesh and Japanese multinational Ajinomoto’s venture with development donors in Ghana.

Early initiatives have shown that there are considerable challenges to be overcome. Despite operating for several years, Grameen Danone Foods hasn’t been able to turn a profit selling yogurt to rural mothers. In India, DuPont subsidiary Solae tried to market soy protein to poor women, but ended up closing the pilot due to inconsistent demand.

Obstacles to ‘selling nutrition’ to the poor
First off, very poor households already spend as much as 70% of their income on food, and are increasingly squeezed by volatile food prices. Social protection and getting people out of poverty has to be the first step. But for a number of reasons, it won’t be enough.

A second obstacle is that undernutrition is invisible. The groups who need nutrients most are babies and pregnant mothers (they also need to have access to water, sanitation, etc. so they can be healthy enough to use these nutrients). But the health benefits of good nutrition are years away. So you’re asking people to pay today for benefits in the future, which is always tricky.

And even if people know what nutrients they should be getting, it can be impossible to tell whether foods really contain these nutrients. (See this earlier blog post for more about the problem of invisible nutrients.)

People want much more than nutrients
This one is obvious: we choose to eat certain foods for many reasons: because they taste good, indicate our social status or connect with our identities. Most of the time, our main consideration is not nutrition.

Some recent research shows that once people move from extreme poverty to being able to afford enough rice, bread or cassava so they aren't hungry, they don’t use any additional money to ‘buy nutrients’. A study in China’s Hunan and Gansu provinces found that when the prices of staple foods were subsidised, very poor consumers decided to buy products that tasted good (like fish), and cut back on ‘poor person’s foods’ (like bean curd and vegetables). As a result, they actually got fewer nutrients in their diets.

A fourth problem is how people use foods once they have access to them. Some foods must be eaten regularly to provide health benefits (this is especially true for infant foods). Will poor consumers – whose incomes could fluctuate week-to-week – be able and willing to buy fortified products daily or weekly?

In spite of all this, there is evidence that poor people will pay relatively high prices for foods when they perceive them to be necessary for health. In Ghana and Nigeria, many lower-income households buy NestlĂ©’s Cerelac, a fortified product aimed at infants above 6 months. They prefer it over local products, even though Cerelac’s high price means they can’t afford enough of it.

The challenge of creating consumer demand for nutrition
Convincing poor people of the value of nutritious foods – whether nutrient-rich vegetables or fortified products – will be crucial to donors’ and businesses’ efforts.

Current initiatives are trying to create this demand in a number of ways:
  • through social marketing channels (tried by Grameen Danone) that deliver products to where standard distribution systems don’t reach, while also providing information on nutrition (and promoting the product);
  • by integrating messages about products into nutrition and health behaviour campaigns (tried by USAID in Ghana);
  • by focusing on a narrow range of products, especially those targeted at infants 6 months to 2 years old.
Will these efforts be enough to change how people buy food? How do they square with rapidly changing food systems, where many people increasingly aspire to eat the processed and branded products associated with higher income lifestyles? We need more evidence to say conclusively. But it seems that, given the scale of the problem, we need more comprehensive approaches.

Share your experiences: What examples can we learn from?
There is much to learn from research and experience with how markets work in other areas. Large-scale evaluations have tested how charging a fee for vital products, such as vaccines and bed nets, affects people’s use of these products. (See this J-PAL Bulletin for a useful summary of several of these studies.) The key findings include:
  • Small changes in cost have a major influence on whether people buy a product.
  • Charging even a small fee can exclude a major portion of the poor.
  • Although programmes long assumed that if people paid for a product, they would be more committed to using it properly; this turns out not to be true.
  • Educating people about the benefits of a product doesn’t necessarily make them willing to pay for it. (This one is particularly worrying for nutritious foods.)
What about you? There are surely many more examples to learn from. Do you have experience promoting the use of nutritious foods? What can we learn from other markets, places and contexts? Share your thoughts in a comment below!

Ewan Robinson is a Research Officer in the IDS Globalisation Team working on agriculture nutrition value chains, in order to contribute to policies that leverage value chains for nutrition.

Previous Globalisation and Development blog posts on nutrition:


elise said...

Dear Ewan,

I always appreciate your blogs. Thank you for taking the time to share your opinions and your experiences of what you’ve been working on!

I also had an Orwell experience when I lived in Guatemala – I’d see undernourished families spending money on crisps when they could buy an entire sac of oranges for the same price. It baffled me. And perhaps at that time, I’d relate more to Orwell’s idea that, ‘when you are underfed, harassed, bored, and miserable, you don't want to eat dull wholesome food. You want to eat something a little bit tasty.’

I can understand, then, the push for fortification and ‘sneaking’ nutrients into food that ‘tastes better’. But to me, it seems like this is just moving us further and further away from real, nutritious food, when instead, what we could be doing is putting our efforts into changing perceptions about what is ‘tasty.’

It’s fascinating that diets tend to get worse when people start earning more and no longer want to eat what they (or their neighbours) consider to be ‘poor people food. But what I want to know is whether that is something that can be changed.

So often we look at what has happened in the past (e.g. your example of people in China eating worse food when they get more money) and we try to adapt to that, rather than seeing it as something that actually needs to change. Behaviours, cultures and perceptions can (and do) shift quite quickly. Do we want to be going in the direction of more processed and engineered food?

To me, marketing makes a big difference. Yogurt, sparkling water, fortified breakfast cereals, even candy bars are marketed as something to ‘aspire to’, something that makes you ‘feel good.’ More meat is perceived as something for the higher classes. So it isn’t surprising that people aspire to these foods. Perhaps this is a bit naive, but can’t we also make an effort to market ‘wholesome food’ in the same way? Maybe even capitalize on the fact that a sweet juicy mango or a dish of velvety sweet potatoes is less expensive than a packet of crisps or a cadbury’s bar or a yogurt?

Perhaps reviving (where necessary) local traditional recipes or teaching people new ways to cook the same foods? Some people, such as Mark Bittman and Michael Pollan are doing this in the states, and it might be starting to catch on amongst some populations.

To me, it seems more logical to try to change people’s relationships with and perceptions of food, and what makes them feel good, rather than trying to sell them fortified foods or sneak micronutrients into ‘junk food’, especially given the challenges that you've discussed.

Ewan said...

Hi Elise,

I’m glad you enjoyed this post! Thanks for sharing your insights and experience from Guatemala and for the quote from Orwell. Clearly this problem isn’t new, nor is it about ‘developing countries’. Big problems with nutrition and food consumption exist in almost every Northern country, today as in Orwell’s times.

You point out two things that are going on today:
1) In almost every country, consumers’ tastes and expectations are changing, as people move to cities and work and commute long hours, and as big businesses market processed and packaged foods in more places. The urban poor aspire to higher income lifestyles (and what we eat is central), even though few of them can hope to see higher incomes.

2) Big businesses, when they decide to sell some kind of nutritious product, opt to fortify processed products, rather than looking at fresh foods. Most donors are behind them here. The World Bank, for example, has argued that global food markets will operate efficiently if poor countries export fresh nutritious foods, and import cheap staple foods that can be fortified. Not everyone states it this starkly, but there is the assumption that the cheapest nutritious products will be fortified ones.

I find this approach unpalatable. Once we create highly processed food environments (and consumer tastes), how well can we shape consumer behaviour, so people eat the nutritious “good products” and avoid the fatty/sugary/salty “bad products”? Experience in the US and UK suggests this is very hard to do.

Even ignoring the “bad foods”, markets require mechanisms to distinguish “good foods” from less-good alternatives - otherwise businesses don’t have incentives to produce fortified products. There are several options, but other than mandatory fortification of wheat flour, etc., there are few concrete examples in emerging or developing countries.
I wrote about this in an earlier blog:

After doing some background research for this blog, a big question for me is: Can interventions really influence people’s behaviour as consumers and their relationship with food (and other products)? Some observers are very critical of the potential of behaviour change communications to do this. I’m not familiar enough with the evidence to make a call.

I have a hunch that small-scale initiatives and efforts focused on the demand side won’t be enough. So is it about shifting what is available and at what price? Do we need to change the course of our food systems at the supply and demand sides?