Behind the scenes: Formula milk mission
PUBLISHED ON 03 Aug 2018
Formula milk prices had been rising significantly. Parents, lacking awareness about infant nutrition, were buying into the idea that more expensive formula milk is best for baby. The Government assembled a high-level team in May 2017 to combat the problem. Petir takes a closer look at how the team members collectively worked with multiple agencies to ace their mission.

Up till the point they start on solid foods at six months old, newborn babies do not have much choice when it comes to nutrition. They either drink breast milk or if mummy is unable to breastfeed, formula milk.

The problem was, the prices of formula milk in Singapore had risen significantly. The average price of a 900 g tin of formula milk had increased 120 per cent over the last decade. Parents who were unable to breastfeed had little choice but to pay.

Some even went to Johor Bahru to stock up on more affordable options.

The Competition and Consumer Commission of Singapore (CCCS), which regulates competition in Singapore, was alerted to this issue. It spent nearly a year hitting the ground to find out why milk prices were going up.

In a report which was released in May 2017, one of the conclusions was: Manufacturers were raising their prices after convincing consumers that they were paying for “premium” and improved milk formulas.

That same month, the Government swung into action and set up a high-level team to tackle the issues.

“Babies have no alternative other than breast milk or formula, it’s a   captive group,” said task force leader Dr Koh Poh Koon, who was then Senior Minister of State, at the Ministries of National Development (MND) and Trade and Industry (MTI), when Petir asked him about the decision behind the huge effort.

“Based on the CCCS report, the problem was clearly multi-faceted and would require the involvement of multiple government agencies. A task force, above all the agencies, can work across agency boundaries,” he said.

Hence, the task force comprised representatives from the Agri-Food & Veterinary Authority of Singapore (AVA) which was under Dr Koh’s purview at MND then, and the Ministry of Health and the healthcare institutions under Dr Amy Khor. Also on the task force are MPs who can speak for young parents, Sun Xueling and Rahayu Mahzam, and medical professionals, while secretariat support was provided by the Prime Minister’s Office.

Working closely, the task force quickly achieved results. More affordable brands were imported. Efforts were made to increase parents’ awareness of the nutritional requirements of their babies, including the importance of weaning and that all formula milk approved for sale in Singapore, regardless of price and brand, is nutritionally adequate for their babies. There was also a push to foster more conducive environments for breastfeeding at hospitals.

The task force is continuing to monitor the market to assess the outcome of longer- term public education initiatives and regulatory changes.

If there is one takeaway from the mission, it was that all the task force members are convinced that a coordinated approach across agencies is one that will be increasingly relevant as issues become more complex to solve.

Said Dr Khor, who is Senior Minister of State at the Ministry of Health: “As there were representatives from the different agencies, it was easier for us to understand one another’s challenges and coordination was smooth and effective.”

Added Dr Koh: “This experience has given us insights into how to pull people together from different teams with different mandates. For instance, someone who is concerned with safety may not agree with someone who is only concerned with efficiency, but what we have to do is talk to everyone, balance all the different perspectives and achieve an outcome which matters to the man-on-the-street. That’s what Government is about.”

More choices, lower prices 

Problem: Formula milk prices were high 
Aim: Import cheaper but equally good quality formula milk to give parents more choices — and bring down prices.
Method: The task force quickly made it easier and faster to import formula milk so that there would be more choices on the shelves.

Instead of requiring distributors to obtain all the relevant certifications on the safety of formula milk from manufacturers, the AVA, which supervises food safety in Singapore, communicated directly with the regulators in those exporting countries to check if the milk had met the necessary requirements. This shaved the time needed to obtain an import permit — from several months to just several weeks.

This meant a change in the way the AVA did its work. Dr Koh observed: “While there was some degree of adjustment to internal workflows, the agencies understand that it is their job to facilitate the work of industry and partners, for the benefit of both consumers and enterprises.”

With the streamlining of import requirements, retailers like NTUC FairPrice were able to quickly introduce a new range of formula milk into its stores in June 2017, a month after the task force was set up. FairPrice also introduced an infant milk formula under its own house brand – FairPrice Gold – the first in Singapore, which was priced lower than comparable brands while meeting international requirements on the nutritional needs for babies.

Said FairPrice CEO Seah Kian Peng: “In bringing in new products, we had to make sure manufacturers adhere to very high quality and safety standards but were also affordably priced. We also had to work very closely with the authorities to ensure the necessary approvals and checks were done expeditiously, so that we can bring these products to market quickly.    

“To date, customer reception to these new products has been positive as we continue to play our part in moderating the cost of living for Singapore,’’ said Mr Seah, who is also MP for Marine Parade GRC.

Pasir Ris-Punggol GRC MP, Ms Sun, who is now the Senior Parliamentary Secretary for Home Affairs and National Development, worked closely with retailers. On the ground, she attended new product launches, learnt about their nutritional value, tried out the new products with her two children aged five and one, and shared her knowledge with residents about the new brands.

She also ensured that even as new formula milk products were swiftly brought into the market, safety was not compromised. “I was confident of AVA’s stringent food safety checks and know that they have conducted their due diligence. Retailers also took steps to ensure the nutritional composition of their products meet regulatory requirements. For example, a retailer which started its own house brand also engaged an Institute of Higher Learning to conduct nutritional testing on its product.”

Result: Between May and November 2017, average prices of formula milk fell by 4.8 per cent. Prices of those for infants below six months fell most, by 13 per cent. Six new brands and 25 new product lines of formula milk were introduced by May 2018. In response to increased competition, some premium brands also re-packed their products from metal tins to value packs to cut costs, passing the savings to consumers.

Educate the parents

Problem: Parents believed that more expensive milk powder was best for baby. They thought formula milk was necessary, even after the child turned one.
Aim: Raise awareness on the nutritional needs of infants, and educate parents that cow’s milk can replace formula milk after the child turns one.
Method: Dr Koh described it as the “most important” part of the mission. “I can change regulations but if I put 20 cheaper brands out there and parents still keep buying the most expensive, the market is still distorted,” he said.

Parents also seemed to think that more expensive formula milk was better.

Expensive brands with advertisements that touted a host of added nutrients as being good for baby, were being snapped up. 

Task force member and Jurong GRC MP, Ms Rahayu, who has a one-year-old son, said: “It’s the parental instinct, to give the child the
best. I think surmounting this mindset was our biggest challenge. Even parents from low-income families would say they don’t want to short-change their child.”

The task force, with the help of the Health Promotion Board (HPB), went all out to educate parents on the nutritional needs of their babies.

The core message was that breast milk was best for baby but if mummy could not breastfeed, all formula milk sold in Singapore was sufficient for infant nutrition, as they all met international standards on the nutritional composition necessary for the healthy growth of babies.

Information cards, comparing the nutritional content of different brands of formula milk, were put up at 250 supermarkets across the island. Community road shows, where nutritionists were invited to give talks, were held to reach out to nearly 5,500 parents. Guidebooks were printed and over 20,000 copies were distributed at childcare centres and healthcare facilities, including maternity hospitals, outpatient clinics and polyclinics.

The task force took pains to also inform parents on weaning foods which were often superior to formula milk in providing a host of key nutrients. Ms Sun said: “We wanted to make sure consumers were making educated purchase decisions. For instance, we actively shared with residents that for babies six months and older, one and a half tablespoons of salmon can provide as much DHA as 30 bottles of formula milk. For babies above one year old who were no longer breastfed, they could switch to full cream cow’s milk.”

Result: A HPB campaign survey showed that more mothers today were aware that all formula milk sold here provide sufficient nutrition for their baby. There was also a 19 percentage point increase in the proportion of mothers who wanted to switch from formula to whole cow’s milk once their babies turned one.

Regulate labelling & advertising 

Problem: Formula milk companies made various claims in their marketing collaterals. They were using images on their labels which “idealised” their brands of formula milk.
Aim: Make provisions in the law to allow regulation of information on labels and advertisements for infant formula products. 
Method: The task force worked closely with the Attorney-General's Chambers (AGC).

The Sale of Food Act was enhanced to allow AVA to regulate information on labels and advertisements for infant formula products.

Parliament has passed the Bill, which was tabled by Dr Koh in Oct 2017, to amend the Act.

In all of its work, the task force also engaged those who would be most affected: The formula milk companies.

Before the Bill was tabled, Dr Koh met with company representatives, as a group and individually, to explain the proposed changes.

“They would prefer to maintain the status quo. But in the end, they understood that certain marketing claims are distorting the market, and that it’s better to work together to make sure the market is sustainable,” said Dr Koh.

To complement regulatory means, the task force and HPB engaged the Sale of Infant Foods Ethics Committee Singapore (SIFECS) to tighten its Code of Ethics, which directly relates to formula milk marketing.

Result: The tightened SIFECS code is still being drafted. Once it comes into effect, formula milk companies will have to ensure that their labels on products for infants aged 0-12 months do not promote formula milk over breastfeeding.

Baby-friendly hospital initiative 

Problem: Some hospitals where mothers gave birth received sponsorships from formula milk companies. Parents may be “locked in” to expensive brands which the hospitals used to feed infants who could not be breastfed.
Aim: Encourage hospitals to be certified under World Health Organisation and UNICEF’s international Baby-Friendly Hospital Initiative (BFHI)
Method: MOH and HPB worked closely with the hospitals, both private and public, to encourage a more conducive environment for breastfeeding.

Under the Baby-Friendly Hospital Initiative, the hospitals’ priority is to encourage and support mothers in their breastfeeding efforts. “Hospitals are an important touch-point for parents, and they can shape the behaviour of parents,” said Dr Khor.

“All three of our public hospitals with maternity services have attained BFHI certification in the past few years. We have also been working closely with private hospitals and providing the necessary support for interested hospitals to achieve certification under the international Baby-Friendly Hospital Initiative.” Dr Khor shared how she encouraged doctors from KK Women's and Children's Hospital to share their experience at other hospitals, on its journey to achieving BFHI certification.

When mothers were unable to breastfeed, hospitals would feed the infants with hygienically pre-packed ready-to-feed (RTF) formula milk. The milk used, however, was often the more expensive brands as these were the ones offered by the companies in RTF form. Once parents left the hospital, they tended to prefer to stick to the same formula milk which their baby had been fed, “locking” them into higher priced milk.

The task force worked to encourage formula milk companies to provide more affordable brands of ready-to-feed milk.

It also worked with the three public hospitals offering maternity services to change their formula milk procurement policies from July 1, 2018, so that they only offer more affordable RTF formula. This helps to prevent lock-in by expensive brands. Formula milk companies which
want to provide RTF formula must stipulate the cost of providing the same brand to the baby for an entire year as part of the procurement process. This takes into account the total cost of buying the RTF formula, and Stage 1 and 2 products until the baby reaches one year of age.

Result: Raffles Hospital is the first private hospital to commit to achieving BFHI status by early 2019. Separately, only more affordable RTF formula will be rotated at the KK Women's and Children's Hospital, National University Hospital and Singapore General Hospital from July 1, 2018. KK Women’s and Children’s Hospital has included more affordable RTF formula milk as part of its rotation schedule since March 2018.

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