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Aldi Five Forces Analysis & Recommendations (Porter’s Model)

Aldi and its competitive environment are evaluated in this Five Forces analysis using Porter’s model. Michael Porter’s Five Forces analysis model provides insights into the external factors influencing the competitive pressure on the discount supermarket chain. Aldi’s competitors, customers or buyers, suppliers, and substitutes, as well as new entrants in the industry are considered. Despite the competitive challenges noted in this Five Forces analysis, the retail market involves business opportunities for the company’s growth. The capabilities and competitive advantages identified in the SWOT analysis of Aldi strengthen the business to ensure its growth even when facing aggressive competition in a saturated market.

The satisfaction of the business purpose and goals linked to Aldi’s mission statement and vision statement depends on strategic effectiveness in addressing the competitive issues identified in this Five Forces analysis. The company’s strategies aim to overcome competition and related challenges in the retail operating environment.

Summary: Five Forces Analysis of Aldi

This Five Forces analysis case shows the significance of buyer power, new entry, and competition in influencing Aldi’s business performance. The grocery store chain uses this competitive environment to determine the best strategies for business growth. The following are the intensities of the five forces impacting Aldi:

• Bargaining power of buyers/customers: Strong
• Bargaining power of suppliers: Weak to moderate
• Threat of substitutes: Weak
• Threat of new entrants: Strong
• Competition/competitive rivalry: Strong

Recommendations. Aldi’s operating environment highlights the bargaining power of customers, the threat of new entrants, and competitive rivalry. However, all five forces are important strategic considerations. The trends discussed in the PESTEL/PESTLE analysis of Aldi are factors determining the intensities or strengths of the five forces. For example, economic and legal trends influence retail business strategies and market dynamics. Aldi’s marketing mix (4P) and related strategies and tactics can facilitate business improvement addressing competitive challenges in this case. Based on the results of this Five Forces analysis of Aldi, the following are the recommendations:

• Enhance marketing strategies to strengthen Aldi’s brands and to combat competitors and new entrants.
• Increase product innovation and development for unique private-label products that attract and retain customers.
• Consider vertical integration for some products as a strategic option to increase quality control, reduce costs, and enable further competitive pricing to attract more shoppers to Aldi stores.

Bargaining Power of Customers/Buyers

Customers and their ability to affect retail business performance are considered in this Five Forces analysis of Aldi. Shoppers and their buying decisions influence the retailer’s business decisions and performance. The following are among the factors that lead to the strong bargaining power of Aldi’s customers:

• Consumers’ low switching costs between retailers
• High quality of information (low information asymmetry)
• Low differentiation among retailers

Consumers’ low switching costs correspond to the high ease of switching from Aldi to competing supermarkets. In the context of this Five Forces analysis, the high quality of information relates to low information asymmetry. For example, consumers can readily access information about products and retailers and use this information to switch between Aldi and its competitors. Retail companies’ low differentiation also adds to the bargaining power of buyers in Porter’s Five Forces analysis model. Aldi’s competitive strategy and growth strategies are designed to attract and retain customers and to support business development while dealing with the buyer power evaluated in this Five Forces analysis.

Bargaining Power of Suppliers

Suppliers’ influence on supply chains, inventory, and other business areas is evaluated in this Five Forces analysis of Aldi. Suppliers’ strategies and decisions affect supply availability and the related costs in the retail business. The following factors contribute to the weak to moderate bargaining power of Aldi’s suppliers:

• Moderate population of merchandise suppliers
• High level of merchandise supply
• Aldi’s low to moderate cost of switching between suppliers

The moderate population of suppliers, including manufacturers of Aldi’s private-label brands, strengthens the bargaining power of suppliers. However, in the context of Porter’s Five Forces analysis model, high supply levels are seen as a factor that limits supplier power. For example, this factor and the low cost of switching enable Aldi to change the suppliers of products sold at its stores. In this Five Forces analysis, the combination of such factors creates weak to moderate supplier power. Supply chain management and related areas of Aldi’s operations management ensure the efficiency of the supply chain despite the challenges linked to suppliers considered in this Five Forces analysis.

Threat of Substitutes

The influence of substitutes for merchandise is considered in this Five Forces analysis of Aldi. Substitution affects consumers’ purchasing decisions and the retailer’s revenues and profits. The following are among the factors leading to the weak threat of substitutes against Aldi:

• Low availability of substitutes
• High cost of switching to substitutes
• Consumers’ low to moderate propensity to substitute

There are many substitutes for Aldi’s products. For example, consumers can opt for alternatives, including home-cooked foods (sauces and other ingredients), freshly picked spices and vegetables from home gardens, and freshly made ingredients and other products from artisanal shops. In Porter’s Five Forces analysis model, the low availability of these substitutes, especially in urban areas, limits the threat of substitution. Also, the high switching costs (time, expense, and effort) discourage consumers from using substitutes instead of Aldi’s products. Moreover, consumers’ low to moderate propensity to substitute equates to their limited tendency to substitute, considering their busy schedules, the convenience (or inconvenience) of using substitutes, and other variables. In this Five Forces analysis case, such factors contribute to the weak threat of substitution against Aldi.

Threat of New Entrants

New entrants and their corresponding effect on competition are evaluated in this Five Forces analysis of Aldi. New firms can attract buyers away from the discount supermarket chain. The following factors contribute to the strong threat of new entry against Aldi:

• Buyers’ low cost of switching to new entrants
• New firms’ low to moderate cost of entry
• Moderate cost of brand development

Customers can readily shop at new entrants’ stores because of the low cost of switching. This external factor strengthens the threat of new entrants against Aldi in the context of Porter’s Five Forces analysis model. The low to moderate cost of entry also helps facilitate the entry of new retail companies into the market. However, the moderate cost of developing brands, such as Aldi’s private-label brands, limits this threat of new entrants. Nonetheless, these factors and related variables in the retail industry create the strong threat of new entry in this Five Forces analysis case.

Competitive Rivalry with Aldi

Competition and its impact on business performance, growth, and profitability are considered in this Five Forces analysis of Aldi. Competitors impact the company’s sales revenues in the saturated retail market. The following are among the factors that lead to the strong force of competitive rivalry with Aldi:

• High number of retailers
• Stable but low market growth rate
• High level of competitive aggressiveness

The retail industry is saturated with many companies. For example, Aldi competes with Lidl, Whole Foods , Costco , Walmart , and Amazon ’s e-commerce and brick-and-mortar stores. Home Depot , which is not a direct competitor, has the potential to diversify and influence the competition considered in this Five Forces analysis of Aldi. The market also has a low growth rate related to consumer demand, economic growth, inflation, population growth, and other variables. Moreover, low differentiation and high aggressiveness among competitors add to the force of competitive rivalry by making it likely for shoppers to switch between retailers. In the context of Porter’s Five Forces analysis model, these external factors lead to strong competition, especially as price-sensitive consumers can easily switch from Aldi to competitors.

• About Aldi .
• Aldi – Our Food Philosophy .
• Aldi Supplier Information .
• He, K., Lei, H., & Liu, J. (2024). Comparative analysis of business strategy and compensation system in the US retail industry. Highlights in Business, Economics and Management, 24 , 516-520.
• Kostetska, N. (2022). M. Porter’s Five Forces model as a tool for industrial markets analysis. Innovative Economy , (4), 131-135.
• Theeb, K. A., Mansour, A. M. D., Khaled, A. S., Syed, A. A., & Saeed, A. M. (2023). The impact of information technology on retail industry: An empirical study. International Journal of Procurement Management, 16 (4), 549-568.
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• Educators, Researchers, and Students: You are permitted to quote or paraphrase parts of this article (not the entire article) for educational or research purposes, as long as the article is properly cited and referenced together with its URL/link.

The Thrifty Business Model of Aldi

Suppose you ask people to recall the first brand that comes to mind while online shopping; the answer would unanimously be Amazon. Similarly, when you ask them to recognize a brand name in the offline retail space, the chances are that the answer would be Walmart. These two are often known as the Big Daddies of the retail world (online and offline). 

So, when the CEO of Walmart, Greg Foran (2014 – 2019), uses adjectives like “fierce,” “clever,” and “good” when talking about a competitor he admires, these words are not being used about Amazon but rather for Aldi, you sit up and notice. 

A grocery business that started in a small town in Germany is today a giant in the retail world with almost 12,000 stores globally. In 2021, Aldi Group’s net sales amounted to just under 134 billion U.S. dollars, a 15.3 percent growth compared to the previous year . 

So, what has made Aldi such a force to reckon with?

Before we understand Aldi’s business model and pricing approach, it makes sense to delve into its history. So, where and how did it all begin?

It started with two brothers obsessed with Frugality

After World War II, brothers Theo and Karl Albrecht decided to expand their family’s grocery business from a small-town Essen in Germany. They were pretty clear from early on that they would grow their business and do better than the competition by providing the best prices to their customers.  

To do that, the brothers knew that they had to keep their costs low, and hence they were mindful of every little expense at their store. In fact, Theo was switching off the store’s lights in the daytime and taking copious notes on every deal. They also kept the store design to a bare minimum. These principles of the brothers continue to remain the foundation of Aldi to date. 

However, the union between the brothers did not last. A dispute in 1961 on whether Aldi should sell cigarettes or not led to the brothers splitting the business into two: Aldi Nord (North Germany) and Aldi Sud (South Germany). Funnily enough, the area that divides the Aldi Nord and Aldi Sud regions in Germany is known as the ‘Aldi Equator.’ 

Even though the Albrecht brothers passed away, the two businesses remain separate. They operate in 18 countries between the two chains and are often known as just Aldi, irrespective of whether it is Aldi Nord or Aldi Sud. Together the two Aldi companies are the eighth biggest retailer in the world. 

Aldi operates with the motto: “the best quality at the lowest price.”, and its 203,000 employees around the world live this motto every day. 

Aldi SWOT Analysis

Aldi’s business model of keeping prices low

There are three key components of Aldi’s business model that help the brand keep low prices: Low Operating Cost, High Margin through Private brands & Limited SKUs. Let’s understand each one in detail.

1. Low Operating Costs :

One of the big reasons for Aldi to be able to keep its prices low is by deploying tactics that keep its operating costs as low as possible. These include:

• Essential Customer Experience Only : If you are looking for a delightful customer experience, then maybe you should remove Aldi from your itinerary because keeping the customer experience to a bare minimum is part of Aldi’s strategy to keep its costs low.

This means that Aldi customers are expected to go through a few inconveniences: change to rent a shopping cart, paper, and plastic bags at a fee and packing your groceries. As a result, Aldi does not need to have employees or their time going in retrieving shopping carts as the customer is incentivized/penalized if they do not return the cart. This practice is not new as supermarkets in Europe have been doing this for years, but the American customers find this an inconvenience from Aldi. 

• Smart Design Principles : Aldi employs several key design details that maximize efficiency at checkout, too. Aldi puts supersized barcodes on many of its products and prints them on multiple sides. This makes scanning relatively easy and quick. Once the billing is done, the cashier drops the groceries directly into the shopping cart. Aldi doesn’t waste time bagging groceries. It is left to the customers to bag their purchases, and each bag comes at a fee. 

Much of the Aldi store merchandise is put up in their original cardboard shipping boxes rather than individually. This saves a lot of employee time, which otherwise would go in stocking shelves with individual products. 

Not a single lie was told. pic.twitter.com/jFRhUE1T3r — Momba (@TMikaMouse) December 24, 2020

• Lower Real Estate : Aldi does not carry as many SKUs as its competitors. Hence, it can keep its store size limited to 12,000 square feet on average compared to 178,000 square feet for Walmart and 145 000 square feet for Costco. The benefit is that its returns per square foot are much higher, and there is less inventory storage, refilling, ordering, and cleaning. As a result, Aldi stores do not need to keep as much staff as their competitors. 

Costco is a membership-only retail company, which offers goods in bulk at competitive prices. What is Costco’s business model?

• Employees do more than one role : Aldi does not follow the conventional approach like other supermarkets of dividing labor as per roles – cashiers, clerks, operators, etc. At Aldi, employees are cross-trained to do various jobs at the store. Aldi also does not want its staff to answer calls, so it does not publicly share its phone numbers. As a result, quite often, an Aldi store might just have three to five employees in a store, saving them significant money. 

All these savings are passed on to customers as discounts or lower prices. 

2. High Margins through Private Brands :

90% of Aldi’s portfolio in its stores comes from private labels. This helps them keep their marketing and distribution costs low and gives them flexibility on pricing and margins. In fact, the products and packaging of some of these private labels look pretty similar to the big brands. So do not be surprised if you find a ‘Tandil’ laundry detergent that reminds you of the ‘Tide’ brand. 

% of Revenue from Private Label Goods (Store Brand) Aldi: 90% Trader Joe's: 85% Save-A-Lot: 60% Dollar Tree: 30% Kroger: 29% Costco: 25% Walgreens: 25% CVS: 25% Target: 24% Walmart: 19% Amazon: 1% pic.twitter.com/VtwPMNWq17 — Alec Stapp (@AlecStapp) November 10, 2020

3. Limited SKUs :

Instead of providing its customers a wide range and aisles of products, Aldi carries only about 1,400 SKUs per store compared to the 40,000 traditional supermarkets carry and 100,000 Walmart supercenters hold. This allows Aldi to have a much faster turnaround of its inventory and helps the customers to make choices faster. 

USA: Exploiting The Retail Playground

Even though Aldi is from Europe, knowing the potential of the USA, Aldi Sud has been quite aggressively expanding its base and now has 2,100+ stores spread across 35 states of the country. It has ambitions to have 2,500 stores by the end of 2022, becoming America’s third-largest supermarket chain behind Walmart and Kroger. Illinois has 201 Aldi stores, which is 9% of all Aldi stores across the United States. 

Aldi as a strong competitor

One of the biggest mistakes retail chains have made in many different markets is dismissing Aldi’s entry and expansion and not considering it a significant threat to their own business.

Some of them were naïve enough to think that Aldi’s pricing and business model is different from theirs will cater to another segment of customers. This is where they were wrong, and as a result, countries like the USA, Hungary, Ireland, Switzerland, and United Kingdom are places where Aldi has really taken a massive chunk of the market, and the grocers realized this too late. 

Aldi not only caters to the low- or mid-income shoppers but also targets the wealthy shoppers. Walmart’s previous CEO, Greg Foran, marveled that he saw so many BMWs and Mercedes in the parking lot of the Aldi store he visited in Australia once. In fact, luxury cars like Jaguar and Tesla Model X are often seen in the parking lots of Aldi stores in the USA. 

Aldi has noticed this profile of shoppers as well, and it has smartly ramped up its portfolio and offer by keeping exotic items like brioche from France, Irish cheese, imported items, organic products, pastas from Italy, and much more, which not only helps it to get the high-income shopper but also allows it to earn high margins.

Trader Joe’s has no online presence, discounted sales, loyalty rewards, or membership program but is thriving with its 3 critical pillars in its business model. What are they?

Aldi’s Marketing strategy of connecting with the millennials shoppers

Purpose, private brands, great marketing.

Today’s Millennial and Gen-Z shoppers are much more mindful of the products they buy and more than the brand name; what matters to them are the authenticity of ingredients, the purpose behind the company, and of course, low prices and convenience. Aldi’s reliance on private labels ticks all these boxes and helps them win that set of consumers. 

100% of ALDI-exclusive chocolate bars and chocolate confectionery are from sustainable sources, and all of its coffee will be sustainably sourced by 2022.

Aldi understands society and its customers’ needs and keeps their priorities at the forefront. It has several eco-friendly initiatives. ALDI has also been recognized by the EPA (Environmental Protection Agency) for its record-breaking green efforts . The retail giant is dedicated to sustainable business practices while delivering high-quality products and affordable prices. 

We believe in acting with integrity and are dedicated to reducing our environmental impact. We’re committed to  reducing, reusing and recycling waste , increasing energy efficiency, decreasing our carbon footprint and improving our green building standards across all of our stores and operations. Aldi’s Website On Environment

In fact, Aldi has a robust Corporate Responsibility Program that comprises of five main areas: 

• Employee Appreciation
• Supply chain responsibility
• Resource conservation
• Social commitment
• Dialogue promotion

If you thought that a low-priced chain would not be doing great marketing, let me tell you that Aldi’s ad was crowned 2021’s most effective Christmas ad . Research done by Kantar declared Aldi’s ad of reimagining Charles Dickens’ ‘A Christmas Carol,’ featuring Kevin the Carrot and new character Ebanana Scrooge, as the Christmas ad that would most likely deliver on long and short-term measures for the brand.

These are the perfect recipe to keep the millennials and Gen-Z customers hooked to the chain and coming back for more. 

Building Fan Following

With such a business model, you would expect customers not to be delighted with an Aldi experience other than the price benefits. Contrary to expectations, Aldi scores much higher on customer satisfaction surveys than Walmart and other supermarket chains.

In fact, as per Bain & Company, Aldi has one of the highest NPS of ~45 (Net Promoter Scores), which is an excellent indication of how likely customers are going to promote and advocate the brand to others. To give you a perspective, Walmart has an NPS of 16 .

Walmart is known for its EDLP or Everyday Low Pricing. However, such is the aura of Aldi that every time a new Aldi opens up, especially in the USA, it results in hundreds of people flocking to the opening as the prices are sometimes even lower than Walmart. 

This aura is not limited to people interested in Aldi’s low prices. Such is the cult following of Aldi that there is a fan blog called Aldi Nerd   (run by a stay-at-home mom of three kids), and there are people who love to buy Aldi Nerd merchandise. The community has 1.4 Mn members on Facebook .

Unchartered Territories

Aldi opened its first store in China only in 2019 and, to date, has a meager presence of 6 stores in the entire country where retail and e-commerce are part and parcel of everyday living. Aldi has not even made an in-roads into the Indian market as yet. 

So other than the frontiers that Aldi is crossing every year, there are still two huge markets that the retail chain has not even tapped into. Aldi’s business model shows you the brand’s potential and why all retail brands should continue watching their shoulder as soon as they see the presence of Aldi in their vicinity. 

A marketer by profession, a writer by heart and a traveller from the soul. Kunal calls himself a 'Collector of Experiences', who strongly observes human behaviour and societal truths. Kunal is an experienced professional across categories and countries in B2C and B2B industries. Currently, he is the Global Director: Marketing & Communication at DSM Nutritional Products, Switzerland and he has also worked in companies like Nestle, Britannia and Arvind Brands. Building and growing brands is a challenge that he enjoys and he is always on the lookout for great marketing, advertising or innovation stories from around the world. He regularly posts about these case studies on his LinkedIn.

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How Aldi Became A Global Supermarket Giant

Table of contents.

The Albrecht brothers had a vision to bring affordable food and goods to the people of Germany at the end of World War II. Their unique approach to bring a low-cost, no-frills business model has helped them stand out with their loyal customer base. Important Stats to Know About Aldi:

• Aldi employs 203,600 employees around the world
• Headquartered in Essen and Mülheim, Germany
• The combined brand generates about $80 billion each year
• Operates over 12,000 grocery stores worldwide
• Aldi is family-owned and not publicly traded

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The History of Aldi

In 1913, Anna Albrecht opened a small grocery store in Essen, Germany. The store remained relatively unchanged and even survived the widespread bombings and destruction in Germany during World War II. In 1946, her sons, Karl and Theo Albrecht took over the business with the goal of expanding its operations. By 1950, the brothers had grown the business to 13 locations across the Ruhr Valley.

Aldi’s Early Discount Strategy

The economic conditions in Germany following the war were difficult. The Albrecht brothers were frugal people and believed that consumers should have the opportunity to purchase high-quality food and goods at affordable prices.

At the time, people who wanted to purchase inexpensive goods would normally participate in a discount cooperative. These cooperatives would provide members with rebate stamps with each purchase that could be redeemed at a later date to get a portion of their money back. The challenge was that this process was time-consuming and painful to track. The Albrecht brothers decided on a different approach. Instead of making their customers pay full price and get their money returned later, they decided to offer the discount before the sale. This discount was restricted to 3% which was the maximum legal rebate amount allowed at the time. Thus, making Aldi one of the first discount stores on the planet.

The brothers were diligent to monitor their inventory to identify which products sold quickly and removed those that didn’t sell. Other retailers would often lose money if a product didn’t sell. In order to get the unpopular item off their shelves, they would have to spend money on advertising or discount them. Karl and Theo Albrecht refused to pay for any advertisements at all and removed items from their shelves that didn’t sell easily.

Times after the war were tough in Germany. The brothers chose to carry only non-perishable food items. This benefited the grocery store chain by reducing the risk of losing money from spoilage.

Another strategy was to keep the average store small compared to some of its competitors. With a smaller store, there was no need to spend large amounts of money on inventory to keep the shelves full. The brothers also didn't have the overhead (rent, utilities, etc.) of a larger commercial space. This allowed them to focus on keeping their shelves full of only the most popular items.

Interesting Fact

The albrecht brothers refused to pay for telephones to be installed in their stores until the 1990s. until this time, employees were required to use a local payphone to make business calls., splitting the company and creation of the aldi brand.

By 1960, the brothers had about 300 locations in operation. As the chain continued to expand, the Albrecht brothers needed to make some decisions to continue growing the company. Theo proposed that the stores start carrying cigarettes and other tobacco products to boost sales. Karl disagreed and felt that carrying these types of products would attract shoplifters.

This dispute led to the brothers making the decision to amicably split the company. While the two brothers would operate their own grocery store chains, they chose to both operate under a unified brand name. In 1962, the name Aldi (often shown in all caps, ALDI) was introduced as a shortened version of Albrecht Diskont . By 1966, the company was officially financially and legally separated.

Key Takeaways

• Karl and Theo Albrecht understood that the people of post-World War II Germany needed access to inexpensive products. They launched the first discount store that was not formed as a cooperative by offering discounts before the sale rather than post-sale rebates.
• The chain of stores focused on a no-frills experience to keep costs down. Strategies included removing unpopular items from shelves, reducing overhead through smaller stores, and spending no money on advertising.
• Despite its popularity, the Albrecht brothers chose to divide the company after a dispute over whether to sell cigarettes. The brothers wisely chose to continue operating the two separate companies under the same brand name — Aldi.

Two Companies, One Brand

When Aldi split into two entities, the companies were officially named Aldi Süd and Aldi Nord. Aldi Süd took the stores that were located in the south of Germany, while Aldi Nord took the northern stores. This dividing line is commonly referred to as the Aldi-Äquator (which literally means Aldi equator).

Both companies took a similar approach in the way they organized their extensive network of grocery stores. Stores are divided into regions. These regions are operated as limited partnerships that are managed by a regional manager. The regional manager then reports directly to the parent company headquarters — Aldi Nord in Essen or Aldi Süd in Mülheim. In Germany, Aldi Nord consists of 35 regional branches that operate approximately 2,500 stores. Aldi Süd comprises 31 regional branches with about 1,900 stores.

Although the two companies operate separately, they do work together in some respects. For example, they share many of the same marketing and store design strategies. The company even has a common company website — www.aldi.com — which redirects users to the appropriate site depending on the country they select. This effort appears seamless and has helped the Aldi brand reach millions of customers in numerous markets.

International Expansion of the Aldi Brand

Aldi began expanding beyond the borders of Germany in 1967 when Aldi Süd purchased the Hofer grocery chain in Austria. Aldi Nord followed suit shortly after and opened its first international location in the Netherlands in 1973.

In its early years, Germany was still separated into East and West Germany. This limited Aldi’s ability to expand internationally, but once the Iron Curtain fell and Germany was reunified in 1990, growth accelerated rapidly.

To avoid competing against one another, Aldi Nord and Aldi Süd avoid operating in the same markets or countries. Today, Aldi Nord operates in Denmark, France, Benelux (Belgium, Netherlands, and Luxembourg), Portugal, Spain, Poland. Aldi Sud operates in Ireland, the UK, Hungary, Switzerland, Australia, China, Italy, Austria, and Slovenia.

The combined Aldi brand currently has over 12,000 locations around the globe. Aldi Nord and Aldi Süd together make up the fourth-largest grocery chain by the number of stores.

Growth in the United States

Outside of Germany, the only shared market is the United States. Aldi Süd opened the first US-based Aldi store in Iowa in 1976. Aldi stores quickly expanded throughout the Midwest and Eastern United States.

Aldi Nord also expanded operations to the United States in the same year but chose a different approach. Instead of using the Aldi name, Theo Albrecht found that the California-based Trader Joe’s had a loyal customer base and was committed to a similar mission to providing its customers with low-priced goods. In 1976, Aldi Nord purchased Trader Joe’s.

Between the Aldi and Trader Joe’s brand, the US operation makes up about 10 percent of Aldi’s global footprint.

Current Ownership of Aldi

The companies continue to be privately owned and are not traded on any public stock exchange. The Albrecht brothers ran their respective companies as CEO until they both retired in 1993. Upon their retirement, the control of the company was transferred to private family foundations. The Siepmann Foundation controls Aldi Süd and the Markus, Jakovus, and Lukas Foundation controls both Aldi Nord and Trader Joe’s.

The significant growth of the Aldi brand has led to Karl and Theo Albrecht being ranked among the wealthiest people on the planet. In 2010, Theo was ranked by Forbes magazine as the 31st richest person with a net worth of over $16 billion. Around the same time, Karl was ranked as the 21st richest person by the Hurun Report. Today, the Albrecht family is estimated to be worth a combined $53.5 billion.

Having a lot of money made the Albrecht brothers a target. In 1971, two kidnappers successfully abducted Theo and held him for ransom for 17 days. A ransom of 7 million Deutschmarks (about $3.5 million) was paid for his release. Following the incident, the brothers became very reclusive and would travel in armored cars to and from the office.

• With the company split into Aldi Nord and Aldi Süd, the Albrecht brothers agreed to divide the territory and work under a unified brand.
• Both companies focused their growth on international markets and agreed to not operate in the same countries to reduce competition with one another (Germany and the United States are the exceptions).
• In the United States, Aldi Süd opened stores under the Aldi name. Aldi Nord purchased the small grocery chain Trader Joe’s and expanded operations under this brand.

Trader Joe’s Recipe for Success

Theo Albrecht’s decision to purchase Trader Joe’s was a smashing success. What started as a handful of stores in Southern California has expanded to over 500 locations nationwide. The brand is recognized as having one of the highest sales per square foot of store space compared to its competitors. Despite making up less than 5 percent of the total number of Aldi-owned stores, Trader Joe’s accounts for approximately 16 percent of the total revenue. While Trader Joe’s does follow some of the similar strategies of the Aldi brand, there are a few differences.

Fun Atmosphere

When a customer walks into Trader Joe’s, they will immediately notice the island or tiki-themed decor. The brand works hard to give their customers a feel-good experience when they shop. Employees are referred to as “crew members” and can be seen wearing Hawaiian shirts (managers are called “captains”). They also have nautical bells that they use to communicate instead of the traditional PA system found in most grocery stores.

The original owner, Joe Coulombe, felt that his stores were too similar to boring convenience stores at the time. He set out to create something unique and different that customers would remember. Joe was obsessed with the South Pacific, so he went with that theme. While the island theme is found in all Trader Joe’s stores, most mix in elements from the local community. For example, a Trader Joe’s in Denver might feature artwork that has mountains.

Unique and Specialty Products

Trader Joe’s has a wide range of products that you can't find anywhere else such as their apple chicken sausage links or Indonesian salsa. They are big on having plenty of specialty options that are vegetarian, vegan, gluten-free, and other dietary restrictions. Customers can usually find free samples throughout the store. Employees are encouraged to try as many of the store’s products as possible so they can easily describe or make recommendations to customers.

Low Prices Through Trader Joe’s Branding

In a Trader Joe’s store, customers won’t see a lot of name-brand products. The reason for this is that about 80 percent of products sold in the store carry the Trader Joe’s brand. Many of these products are name-brand goods under the generic label. This helps Trader Joe’s secure lower pricing from its suppliers. Trader Joe’s has strict privacy agreements with its suppliers to not make their relationship known to the public.

Cult Following

While the Aldi and Trader Joe’s brands are known for low prices, they both attract a different type of crowd. Aldi is popular among low-income or blue-collar workers. Trader Joe’s has focused on catering to higher-income families and college students. They do this by constructing stores in more affluent neighborhoods. This has attracted more of a cult following. Trader Joe’s customers are extremely loyal to the brand.

Social Responsibility

Trader Joe’s is known for responding well to feedback and criticism from the local community. For example, it removed some Chinese-based food products due to consumer health concerns.

The chain also eliminated six unsustainable fish species from its shelves to help protect the environment. This helped earn Trader Joe’s the 3rd spot (up from the 15th spot) on Greenpeace’s CATO (Carting Away from Oceans) scale.

• Trader Joe’s has become a significant contributor to Aldi’s annual revenue by offering a unique set of products, catering to a specific customer base, and deploying a memorable tiki-theme in their stores.
• Their strategic placement of stores in affluent neighborhoods and near college campuses has allowed them to secure a cult following in many areas around the country.

A Brand Built on Frugality

There isn’t much known about the Albrecht brothers outside of their involvement in building the Aldi brand. However, they are known for being extremely frugal individuals despite being worth billions of dollars at the peak of their lives. This frugality bled over into their business model helping them create a company that was dedicated to keeping prices low while minimizing risk and overhead costs.

No Frills Shopping Experience

Theo and Karl Albrecht understood that every business expense must be charged back to the customer. For this reason, Aldi has focused on creating a shopping environment that provides customers with high quality, low-cost products, and nothing more.

Aldi has historically viewed any form of advertising as a wasted expense. Outside of their sales ad that shows the deals going on that week and social media presence, very little money is spent on marketing or advertising. Aldi has stuck to this stance from the very beginning. When you enter an Aldi store, you will see promotion of the company’s mission and value statement but nothing advertising the actual products.

While the brand has recently started investing money in the look of their stores, many traditional Aldi locations display goods in their original shipping boxes. This reduces the cost of paying store clerks to transfer the goods from boxes to the shelves.

Aldi also encourages its shoppers to bring their own grocery bags. Even in areas where this is now mandated by law, Aldi is historically charged for plastic or paper bags. Customers are also responsible for bagging their own groceries saving the salary of a bagger. Customers will often simply use empty or discarded boxes found throughout the store. This also reduces the cost for the store for garbage disposal.

Most grocery stores are forced to hire staff to go into the parking lot to collect shopping carts and bring them back for the next customers to use. Aldi took a unique approach to this by installing devices on the carts that lock them together. When a customer wants to use the cart, they must insert a coin (like a quarter). The customer then gets this coin back when they return the cart. Example below.

Aldi also carries far fewer products than a traditional grocery store. Many popular competitors can carry tens of thousands of different products. For Aldi, the store size is kept small (about 12,000 square feet) with approximately 1,400 products. Many of these products are displayed with Aldi’s brand name on the packaging. This helps keep the costs of goods low since customers aren’t paying for popular name brands.

• The Albrecht brothers were known for being extremely frugal. These practices heavily influenced the way that Aldi is operated and has led to much of its success.
• The interior of Aldi stores provides a no-frills experience with food displayed in shipping boxes and no advertising. This helps to keep the cost low for consumers.
• Aldi relies on the customer to provide their own bags and labor to keep costs low. For example, customers participate in bagging their own groceries, removing empty boxes from the store, and returning shopping carts for the next customer.

The Future and Innovation of the Aldi Brand

Aldi has an ambitious goal to continue growing in the near future. This is especially true in the United States. Aldi US (Aldi Süd’s United States division) announced that it planned to become the third-largest grocery chain in the United States after Walmart and Kroger by the end of 2022. Aldi currently ranks 9th when compared by revenue to other grocery store chains in the United States. The company hopes to achieve this by focusing on new opportunities to expand services and take advantage of e-commerce. They also plan to rapidly expand the number of operating stores.

Embracing the COVID-19 Pandemic

Aldi has taken advantage of and adapted well to the COVID-19 pandemic. With workers across the globe transitioning to remote work, there has been a higher demand for groceries. While other foodservice businesses struggled, Aldi US seized the opportunity to expand their services to capture new market share including curbside pickup at hundreds of stores, alcohol sales, Instacart deliveries, and other e-commerce initiatives.

Expanding Product Lines

In 2020, Aldi announced that it would break from its approach of stocking many non-perishable food items and expand fresh food options by 40%. Due to consumer demands and changing diets, Aldi has made additional produce, meat, organic items, and prepared foods available to its customers. This is especially critical as Aldi expands into agriculture hubs like California that is known for its readily available fresh fruits and vegetables.

Creating Strategic Partnerships

Aldi is known for coming up with creative solutions to keep costs low and tackle challenges. The labor shortage coming out of the COVID-19 pandemic is no exception. With many companies laying off workers or reducing hours, Aldi partnered with the fast-food giant McDonald’s to share employee resources. This was a win-win for everyone involved — Aldi could get much-needed help with increased demand for groceries, employees would be able to maintain their income, and McDonald’s would be able to retain those employees for when economic conditions improved.

Rumors of a Consolidation

Since Aldi is privately owned, they don’t often share their strategies openly with the public. However, both Aldi Nord and Aldi Süd have made efforts in recent years to better align their product offerings to be more similar. Many speculate that this could be an indicator that the two entities plan to combine once more in the near future.

The company could potentially benefit from being publicly traded. An IPO (Initial Public Offering) could help generate some additional funding to be used toward the expansion and remodeling of existing stores.

• Aldi plans to continue to grow its market share by opening a large number of new stores by the end of 2022.
• The brand has worked diligently to adapt and capture new opportunities that came with the COVID-19 pandemic including curbside pickup, e-commerce, and labor sharing partnerships.
• Some rumors exist that Aldi could be making moves to boost its market strength by combining Aldi Nord and Aldi Süd into a single entity.

Final Thoughts and Key Takeaways

The Aldi brand is a true powerhouse in the grocery store industry. While other brands have focused their efforts on traditional approaches such as paying for expensive advertising or trying to stock the largest variety of products, Aldi has taken the opposite approach. From its frugal beginnings, the brand has captured the attention of consumers across the globe. In many cases, Aldi’s strategy has kept pricing so low that competitors have been forced to slash their prices. This has helped Aldi continue to gain a foothold in new markets around the world.

Quick Comparison of Aldi Brands

• The Aldi brand started as a small, family-owned grocery store owned by Anna Albrecht. Once her sons took over the business in the 1940s, the business grew rapidly and expanded across Germany.
• The early strategy was to offer discounts to customers before the sale. This was a new approach at the time as most consumers purchased inexpensive food products from cooperatives.
• The Albrecht brothers decided to split the business into two separate companies after a dispute over whether to sell tobacco products. The two companies would continue to operate under the combined brand Aldi (short for Albrecht Diskont).
• The two Aldi companies avoid operating in the same countries to avoid competition. The only exception is Germany and the United States. In the US, Aldi Nord operates under the Trader Joe’s brand while Aldi Süd uses the Aldi name.
• Both Aldi companies are still family-owned and have never been publicly traded.
• The Trader Joe’s brand is extremely popular in the United States and makes up a sizable portion of the brand’s annual revenue.
• Aldi gives its customers a no-frills shopping experience to keep costs low including generic brands, products displayed in original shipping boxes, and making customers bag their own groceries.
• Aldi stores are much smaller than their competitors and carry far fewer products. This allows them to focus their efforts on stocking only products that sell quickly.
• The Aldi brand plans to continue rapid expansion efforts around the globe. In the United States, the brand plans to open hundreds of new locations, securing them the number three spot after Walmart and Kroger.
• Aldi has used the pandemic to launch new initiatives and create special partnerships to strengthen and grow the brand.

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Aldi: The Dark Horse Discounter

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Aldi: the dark horse discounter description.

In 2013, Aldi-the world's 8th largest retailer-planned to accelerate its US expansion. Aldi was a German-based hard discounter that sold a limited assortment of private-label groceries and household items in barebones stores. Despite its presence with 1200 stores in 32 states, Aldi was still relatively unknown in the US. But it was often cited as one of the reasons for Walmart's exit from Germany. Could it compete with Walmart in the US, Walmart's home market?

Case Description Aldi: The Dark Horse Discounter

Strategic managment tools used in case study analysis of aldi: the dark horse discounter, step 1. problem identification in aldi: the dark horse discounter case study, step 2. external environment analysis - pestel / pest / step analysis of aldi: the dark horse discounter case study, step 3. industry specific / porter five forces analysis of aldi: the dark horse discounter case study, step 4. evaluating alternatives / swot analysis of aldi: the dark horse discounter case study, step 5. porter value chain analysis / vrio / vrin analysis aldi: the dark horse discounter case study, step 6. recommendations aldi: the dark horse discounter case study, step 7. basis of recommendations for aldi: the dark horse discounter case study, quality & on time delivery.

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Case Analysis of Aldi: The Dark Horse Discounter

Aldi: The Dark Horse Discounter is a Harvard Business (HBR) Case Study on Strategy & Execution , Texas Business School provides HBR case study assignment help for just $9. Texas Business School(TBS) case study solution is based on HBR Case Study Method framework, TBS expertise & global insights. Aldi: The Dark Horse Discounter is designed and drafted in a manner to allow the HBR case study reader to analyze a real-world problem by putting reader into the position of the decision maker. Aldi: The Dark Horse Discounter case study will help professionals, MBA, EMBA, and leaders to develop a broad and clear understanding of casecategory challenges. Aldi: The Dark Horse Discounter will also provide insight into areas such as – wordlist , strategy, leadership, sales and marketing, and negotiations.

Case Study Solutions Background Work

Aldi: The Dark Horse Discounter case study solution is focused on solving the strategic and operational challenges the protagonist of the case is facing. The challenges involve – evaluation of strategic options, key role of Strategy & Execution, leadership qualities of the protagonist, and dynamics of the external environment. The challenge in front of the protagonist, of Aldi: The Dark Horse Discounter, is to not only build a competitive position of the organization but also to sustain it over a period of time.

Strategic Management Tools Used in Case Study Solution

The Aldi: The Dark Horse Discounter case study solution requires the MBA, EMBA, executive, professional to have a deep understanding of various strategic management tools such as SWOT Analysis, PESTEL Analysis / PEST Analysis / STEP Analysis, Porter Five Forces Analysis, Go To Market Strategy, BCG Matrix Analysis, Porter Value Chain Analysis, Ansoff Matrix Analysis, VRIO / VRIN and Marketing Mix Analysis.

Texas Business School Approach to Strategy & Execution Solutions

In the Texas Business School, Aldi: The Dark Horse Discounter case study solution – following strategic tools are used - SWOT Analysis, PESTEL Analysis / PEST Analysis / STEP Analysis, Porter Five Forces Analysis, Go To Market Strategy, BCG Matrix Analysis, Porter Value Chain Analysis, Ansoff Matrix Analysis, VRIO / VRIN and Marketing Mix Analysis. We have additionally used the concept of supply chain management and leadership framework to build a comprehensive case study solution for the case – Aldi: The Dark Horse Discounter

Step 1 – Problem Identification of Aldi: The Dark Horse Discounter - Harvard Business School Case Study

The first step to solve HBR Aldi: The Dark Horse Discounter case study solution is to identify the problem present in the case. The problem statement of the case is provided in the beginning of the case where the protagonist is contemplating various options in the face of numerous challenges that Aldi Discounter is facing right now. Even though the problem statement is essentially – “Strategy & Execution” challenge but it has impacted by others factors such as communication in the organization, uncertainty in the external environment, leadership in Aldi Discounter, style of leadership and organization structure, marketing and sales, organizational behavior, strategy, internal politics, stakeholders priorities and more.

Step 2 – External Environment Analysis

Texas Business School approach of case study analysis – Conclusion, Reasons, Evidences - provides a framework to analyze every HBR case study. It requires conducting robust external environmental analysis to decipher evidences for the reasons presented in the Aldi: The Dark Horse Discounter. The external environment analysis of Aldi: The Dark Horse Discounter will ensure that we are keeping a tab on the macro-environment factors that are directly and indirectly impacting the business of the firm.

What is PESTEL Analysis? Briefly Explained

PESTEL stands for political, economic, social, technological, environmental and legal factors that impact the external environment of firm in Aldi: The Dark Horse Discounter case study. PESTEL analysis of " Aldi: The Dark Horse Discounter" can help us understand why the organization is performing badly, what are the factors in the external environment that are impacting the performance of the organization, and how the organization can either manage or mitigate the impact of these external factors.

How to do PESTEL / PEST / STEP Analysis? What are the components of PESTEL Analysis?

As mentioned above PESTEL Analysis has six elements – political, economic, social, technological, environmental, and legal. All the six elements are explained in context with Aldi: The Dark Horse Discounter macro-environment and how it impacts the businesses of the firm.

How to do PESTEL Analysis for Aldi: The Dark Horse Discounter

To do comprehensive PESTEL analysis of case study – Aldi: The Dark Horse Discounter , we have researched numerous components under the six factors of PESTEL analysis.

Political Factors that Impact Aldi: The Dark Horse Discounter

Political factors impact seven key decision making areas – economic environment, socio-cultural environment, rate of innovation & investment in research & development, environmental laws, legal requirements, and acceptance of new technologies.

Government policies have significant impact on the business environment of any country. The firm in “ Aldi: The Dark Horse Discounter ” needs to navigate these policy decisions to create either an edge for itself or reduce the negative impact of the policy as far as possible.

Data safety laws – The countries in which Aldi Discounter is operating, firms are required to store customer data within the premises of the country. Aldi Discounter needs to restructure its IT policies to accommodate these changes. In the EU countries, firms are required to make special provision for privacy issues and other laws.

Competition Regulations – Numerous countries have strong competition laws both regarding the monopoly conditions and day to day fair business practices. Aldi: The Dark Horse Discounter has numerous instances where the competition regulations aspects can be scrutinized.

Import restrictions on products – Before entering the new market, Aldi Discounter in case study Aldi: The Dark Horse Discounter" should look into the import restrictions that may be present in the prospective market.

Export restrictions on products – Apart from direct product export restrictions in field of technology and agriculture, a number of countries also have capital controls. Aldi Discounter in case study “ Aldi: The Dark Horse Discounter ” should look into these export restrictions policies.

Foreign Direct Investment Policies – Government policies favors local companies over international policies, Aldi Discounter in case study “ Aldi: The Dark Horse Discounter ” should understand in minute details regarding the Foreign Direct Investment policies of the prospective market.

Corporate Taxes – The rate of taxes is often used by governments to lure foreign direct investments or increase domestic investment in a certain sector. Corporate taxation can be divided into two categories – taxes on profits and taxes on operations. Taxes on profits number is important for companies that already have a sustainable business model, while taxes on operations is far more significant for companies that are looking to set up new plants or operations.

Tariffs – Chekout how much tariffs the firm needs to pay in the “ Aldi: The Dark Horse Discounter ” case study. The level of tariffs will determine the viability of the business model that the firm is contemplating. If the tariffs are high then it will be extremely difficult to compete with the local competitors. But if the tariffs are between 5-10% then Aldi Discounter can compete against other competitors.

Research and Development Subsidies and Policies – Governments often provide tax breaks and other incentives for companies to innovate in various sectors of priority. Managers at Aldi: The Dark Horse Discounter case study have to assess whether their business can benefit from such government assistance and subsidies.

Consumer protection – Different countries have different consumer protection laws. Managers need to clarify not only the consumer protection laws in advance but also legal implications if the firm fails to meet any of them.

Political System and Its Implications – Different political systems have different approach to free market and entrepreneurship. Managers need to assess these factors even before entering the market.

Freedom of Press is critical for fair trade and transparency. Countries where freedom of press is not prevalent there are high chances of both political and commercial corruption.

Corruption level – Aldi Discounter needs to assess the level of corruptions both at the official level and at the market level, even before entering a new market. To tackle the menace of corruption – a firm should have a clear SOP that provides managers at each level what to do when they encounter instances of either systematic corruption or bureaucrats looking to take bribes from the firm.

Independence of judiciary – It is critical for fair business practices. If a country doesn’t have independent judiciary then there is no point entry into such a country for business.

Government attitude towards trade unions – Different political systems and government have different attitude towards trade unions and collective bargaining. The firm needs to assess – its comfort dealing with the unions and regulations regarding unions in a given market or industry. If both are on the same page then it makes sense to enter, otherwise it doesn’t.

Economic Factors that Impact Aldi: The Dark Horse Discounter

Social factors that impact aldi: the dark horse discounter, technological factors that impact aldi: the dark horse discounter, environmental factors that impact aldi: the dark horse discounter, legal factors that impact aldi: the dark horse discounter, step 3 – industry specific analysis, what is porter five forces analysis, step 4 – swot analysis / internal environment analysis, step 5 – porter value chain / vrio / vrin analysis, step 6 – evaluating alternatives & recommendations, step 7 – basis for recommendations, references :: aldi: the dark horse discounter case study solution.

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ALDI’s marketing strategy: The key growth ingredients of the FMCG titan

A giant in the UK’s grocery industry, ALDI prides itself in selling the most economical quality items. Over the past decade, ALDI’s marketing strategy has aimed at aggressive growth globally, trying to ensure everyone has nearby ALDI stores or a nearby ALDI supermarket. This mindset has helped the company become the third-largest grocery brand in Australia and has placed it on track to become the third-largest in the U.S. by the end of 2022 .

This ALDI case study will dive into ALDI’s marketing strategy and analyze its eCommerce page to help other companies learn about marketing strategies for supermarkets and see the kind of growth that the brand has been enjoying.

Table of Contents

• > ALDI through the years: how the retail titan was created
• > ALDI marketing strategies that unlocked its growth.
• > ALDI’s eCommerce website
• > New tech that would be a service to ALDI’s customer engagement strategy
• > Engrossing technology tools that ALDI is utilizing
• > Fresh news of the supermarket retailer
• > Insightful ALDI statistics to check

ALDI through the years: how the retail titan was created

Once a small German grocery store that two brothers took over for their mother in 1945, ALDI’s brand positioning of selling quality low-cost products grew out of its environment. Since World War II had just ended, Germany’s economy was weak and many citizens couldn’t spare much money for groceries.

To reclaim money from other market leaders at the time, customers had to collect rebate stamps to send to their local co-operative at regular intervals. ALDI, then called Albrecht, thrived by subtracting the legal maximum rebate of 3% before all sales, eliminating the process to entice customers. To save costs further, the store didn’t spend on any advertising, and items that didn’t sell would promptly come off the shelves to conserve space for only what people wanted. 

By 1960, the brothers jointly owned 300 shops, leaving no one wondering why ALDI is the best.

ALDI then began expanding internationally, building its first American store in Iowa. Today, just in America, the chain has grown to over 2,000 stores across 35 states, managing more than 25,000 employees . The company has received over 1,200 product awards and recognitions since 2017, including BrandSpark American Trust Study’s most trusted Discount Grocery Store Chain.

The ALDI marketing strategies that unlocked its growth.

ALDI’s growth clearly came from 9 key factors. We’ve spotted and analyzed them below, so feel free to try the same strategies for your business.

Key Strategy #1: Omnichannel transformation

A strong, consistent omnichannel presence reduces friction along the customer journey, building and strengthening brand associations quickly. ALDI’s omnichannel strategy has been to meld its online and offline channels, investing in services like click-and-collect, letting a customer shop online and pick up their order from the store.

As a part of this effort, ALDI partnered with delivery services like Deliveroo and Instacart, which let shoppers who live far from its stores buy items as though they were physically present. Some of these services also let people access features such as click-and-collect, so they can customize their experience to best fit their needs and wants.

Key Strategy #2: Choosing the optimum target market

The grocery giant positions itself as the most cost-effective retail store to target the middle-income group worldwide. ALDI’s pricing strategy of maintaining the lowest possible prices and no-frills discounts encourages men and women in low and mid-level income groups and economical shoppers around the world to become regular customers.

To better cater to this market, ALDI continuously finds ways to reduce operational costs. For instance, it introduced a cart rental system. Shoppers would pay a quarter to unlock a cart from a corral at the front of the store, and they would get it back once they returned their cart. This added no charge to the customer but allowed ALDI to avoid hiring employees just to manage the carts.

Key Strategy #3: Creating an “As Is” map of the supply chain

ALDI maintains an “as is” map of its supply chain for some of its products to accurately pinpoint areas for expansion, as well as potential process breakdowns and risks. It also makes this information public on its website , letting its customers hold it accountable, which helps position ALDI as a transparent, trustworthy brand that values ethical product sourcing.

Key Strategy #4: Differentiation: The ‘Good Different’ new brand positioning

ALDI’s low prices make it stand out against all other major retailers. To raise consumer awareness about its uniqueness, ALDI’s marketing strategy in Australia incorporated new brand positioning, “Good Different,” which reinforced that the company’s low prices are a result of conscientious business practices — for instance, it sources products ethically and treats staff and suppliers with respect.

The “Good Different” campaign told customers that ALDI’s prices are better because the company is better, quelling any concerns over why it can charge so little.

Key Strategy #5: Social responsibility

ALDI understands the brand expectations that millennial and Gen-Z shoppers hold. They want a brand they support to take interest in its impact on the world. As a result, ALDI focuses on and constantly discusses its CSR efforts, such as sourcing all of its ALDI-exclusive chocolate bars and confectionery sustainably.

This focus also helps the brand build earned media, which is more influential than either paid or owned media. For instance, the EPA has ranked ALDI 15th on its Green Power Partnership’s “National Top 100 List” for its record-breaking green efforts. This ranking will attract more customers than ALDI Tweeting about its environmental awareness.

Key Strategy #6: Simple, cost-effective distribution

ALDI was able to open roughly one store every week in Britain, largely because its product distribution is uncomplicated. It purchases items in bulk and stores them in local warehouses, minimizing transit time and waste disposal while transporting goods.

Key Strategy #7: Ads promote USP

Though there is no ALDI marketing department in Germany, ALDI’s promotion strategy in the U.S., UK, and Australia, makes significant use of print, electronic, and display media to promote its stores. In these countries, it runs copies like “Swap and save” and “Like brands, only cheaper” to entice customers to switch from competitors’ brands to their own and build trust in its products.

Key Strategy #8: Simplified in-store layout

ALDI keeps its layout as simple as possible to drive down operational costs. Customers can generally find and pick out products on their own, reducing the number of employees necessary to assist them. ALDI’s marketing strategy also includes keeping only a limited amount of high-quality, name-brand products, so customers don’t have many options to confuse them, reducing their selection time.

Key Strategy #9: Engaging with followers

By engaging with its followers, ALDI can build brand loyalty. For instance, it has run a “Fan-Favorite Survey” since 2019 , where fans can enroll in a lottery for up to $1,000 in ALDI gift cards by voting for their favorite ALDI product. This loyalty helps the brand activate its following, turning its fans into marketers by encouraging people to use its hashtags for its products, which helps it access people its efforts hadn’t reached previously.

Social media lets a brand reach a far wider pool of potential customers than any other tool. ALDI maintains a strong social media presence — boasting 2.8 million Facebook followers, 830,000 Instagram followers, and 106,000 Twitter followers at the time of writing — to get its brand in front of the internet-savvy section of its target audience.

ALDI’s eCommerce website

ALDI is undoubtedly one of the most highly evaluated retail brands out there. To achieve this, they mastered the art of eCommerce conversions. Or not? We’ve analyzed four-page templates of their site to identify eCommerce best practices and mistakes you should avoid.

A. Analyzing ALDI’s Home Page

What we liked:

• Noninvasive offers: Pop-ups still boast an average conversion rate of 3.9% , and the main barrier preventing retailers and CRMs from using pop-up ads is their invasiveness. Because the offer appears on a bright banner that feels native to the page, it still catches a visitor’s eye but doesn’t irritate them, which can help increase conversions.
• Attractive deals: ALDI’s website reinforces the brand positioning by placing copy about ALDI’s low prices against a bold, eye-catching red background. Even if the customer doesn’t consciously register it, this reinforces the brand image in their mind.
• UX design: The page focuses strongly on user intent, letting customers start adding items to their cart directly from the home page. This removes friction between arriving at the home page and making a purchase, speeding customers along in the sales funnel.
• Search bar: A search bar is available on every page, letting the customer redirect their journey at any point if they decide they want a different item. The ubiquity of search bars reduces friction points, too. A customer can start searching for items quickly from the home page.

What we didn’t:

• Slow to load: Because it uses dynamic elements, the page loads slowly. As the user scrolls down, sections load in, freezing the page for seconds. The sidebar also sometimes fails to open when clicked. This increases the site’s bounce rate, since the probability of bounce increases by 32% if a page load time goes just from one to three seconds and by 90% if it reaches five seconds.
• Non-unique design: Though effective, the website interface is identical to Instacart’s. Visitors who have used Instacart before will automatically expect similar functionality, which may exacerbate frustration with the loading times. A website design is also an opportunity to build and reinforce brand associations and maintain consistency across platforms, which enhances the omnichannel experience.

B. Analyzing ALDI’s Category Page

• Sticky cart: The options to add an item to the cart and view the cart are conveniently available no matter where the customer scrolls on the page, empowering users to add items to their cart even if they’re unsure about buying them. A/B testing shows that sticky carts increase orders from the product page by 7.9% and all add-to-carts by 8.6%. 
• Sorting options: Letting the user customize their search helps them find the items they want more quickly, reducing churn.
• Useful information on display: By displaying deals available for items on sale and small text for other information, like if a product is gluten-free, this page enhances the customer experience, increasing retention and CLV.
• No filters: Like sorting options, filters help a user customize their search to find items more easily. This category page permits the user to reduce their options to smaller subcategories, but there is no ability to filter items based on features like brand, price, and common dietary restrictions. Adding this would reduce customer choice overload, which otherwise leads to cart abandonment.

C. Analyzing ALDI’s Product Page

• Minimalist presentation: The above-the-fold information is minimal, stopping at the “Favorite” button. However, its design and arrangement make the page still look complete, enhancing the customer experience while reducing extra noise that could complicate their decision-making process.
• Item suggestions: Customers can look through similar products if the current one doesn’t fit their needs, so they can immediately find a better option instead of abandoning their cart. They can also check items that other users frequently buy with the current product, making it easier to pair products while expanding their final cart, increasing ALDI’s revenue.
• Add item to Favorites: The option to add an item to a “Favorites” list boosts CLV by promoting repeated use while adding value to the customer, who can find the item more easily in the future.
• Simple content copy: The product details are simple, laying out the benefits for the customer clearly and without confusing data that might distract or confuse the customer.
• Nutrition facts sometimes missing: Not all food product pages include the nutrition information of the item, which is vital in simulating an in-person grocery shopping experience. Ensuring all food items contain their nutrition facts reduces friction and improves the omnichannel experience.
• No reviews:  Almost 50% of people trust consumer reviews like they were recommendations from a family member or friend. Groceries are relatively inexpensive everyday purchases, so fewer customers may read these reviews, but giving customers the ability to leave a review would add to ALDI’s marketing objectives of portraying transparency and confidence in its products.

D. Analyzing ALDI’s Checkout Process

• Pre-checkout suggestions: The pre-checkout suggestions function like point-of-purchase marketing displays, enticing shoppers who are ready to purchase to add just one or two more items to their order.
• Simple steps: Each step in the checkout process is separate and concise, walking the customer through entering all the data necessary without overloading or tiring them.
• Savings callout: Customers who have bought items on sale see their savings in bright red under the final bill. The text color makes them focus on it, prompting them to feel more satisfied with their order even if they only saved $1.
• Multiple available delivery slots: Customers can choose from a wide selection of two-hour delivery slots throughout the day. This increases customer convenience, especially for those working long hours or those who are otherwise only able to receive their order in a specific window of time.
• Several delivery plans are available: Customers have multiple delivery options according to their needs. If they want to place an order in advance, they can set the delivery for a different day. If they need it to reach early, they can pay a small extra fee to get priority delivery within a certain time frame. Having these options available increases customer satisfaction and encourages repeat ALDI site visits.
• Pick-up option: An employee can prepare the order so the customer can simply come to pick it up, combining online and offline channels to enhance customer satisfaction.
• Google/Facebook sign-in: Internet users today expect any website that requires an account to let them connect their social media accounts, saving them the time of entering all their personal information and the trouble of remembering their username and password. If the customer already has an Instacart account, their usual settings will also auto-populate upon their login.
• No way to remove items post-checkout: Though customers can add more items to their order even after checking out, they can’t remove items they may have purchased accidentally. This can make them feel like they’re being valued less post-payment.
• No guest checkout option: However easy it is to become a member, forcing the customer to sign up adds a step in the checkout process and makes them consider the number of company emails they already receive. This increases the risk of checkout abandonment .

New tech that would be a service to ALDI’s customer engagement strategy

ALDI’s eCommerce website is effective but it could be enhanced with the help of some online tools. One tool that would significantly benefit ALDI is ContactPigeon’s Omnichannel Chat solution.

This chat feature helps a brand respond to customers immediately, preventing long waiting times and increasing customer satisfaction and brand loyalty. ALDI could use it as a way to deepen its relationship with its followers, taking a deep dive into its customers’ journey and creating smart types of automation that personalize the eCommerce experience and make users feel as though they were in a physical store.

For instance, if the chatbot recognizes a repeat customer, it can make personalized offers based on their search or order history, appealing to the specific customer’s tastes. Increased personalization is one of the best ways to boost sales effectively and access a high ROI.

Engrossing technology tools that ALDI is utilizing

Using the buildwith tool we scanned the giant’s U.K. website and we highlighted ALDI’s new website tools that we found most interesting:

• Omniture SiteCatalyst Customers: SiteCatalyst, an Adobe subsidiary, tracks visitors and conversions to provide detailed web and mobile usage analytics.
• Dynatrace: Dynatrace is an AI-powered monitoring and analytics tool that captures user journeys on a website.
• Modernizr: Modernizr lets a webpage run several tests on a user’s browser to customize the site according to the HTML, CSS, and JavaScript features they have available.

Fresh news of the supermarket retailer

Upper management at ALDI has been working hard to expand and strengthen the brand’s omnichannel experience. Here are some recent news articles that may help contextualize these efforts:

• ALDI On Track To Join ‘The Big 4’ UK Grocery Brands By 2023 ( Forbes )
• ALDI to expand store numbers in £1.3bn UK investment push ( Financial Times )
• ALDI opens first-ever cashier-less store in Greenwich ( Retail Week )
• Mold: New traffic management system introduced at ALDI store ( The Leader )

Insightful ALDI statistics to check

ALDI has experienced massive growth in multiple countries over the past few years, turning it into the grocery giant it is today. Here are some statistics that help summarize ALDI’s success story at a glance:

• ALDI’s net sales increased from $86.2 billion in 2016 to $133.9 by 2021
• ALDI expanded its UK grocery market share from 6.2% to 9% between January 2017 and January 2022
• There are over 2,100 ALDI stores across 38 states in the U.S.
• ALDI has opened over 1,000 new stores across America in the last decade, with 150 more planned for 2022, which will make it the third-largest U.S. grocery retailer by store count
• ALDI controls a 10.5% market share in Australia , rapid growth from just 4% in 2009
• ALDI was the first discount grocery store in the world

Discover more resources about FMCG retailers

• Sainsbury’s Marketing Strategy: Becoming the Second-Largest Supermarket Chain in the UK
• Tesco Case Study: How an Online Grocery Goliath Was Born
• The Marks and Spencer eCommerce Case Study: 3 Growth Lessons for Retailers
• The Ocado marketing strategy: How it reached the UK TOP50 retailers list
• ASDA’s marketing strategy: How the British supermarket chain reached the top
• Walmart Marketing Strategy: Decoding the Success of the US Multinational Retailer
• Analyzing Lidl’s Marketing Strategy: How the Discount Supermarket Leader Scaled
• FMCG Marketing Strategies to Increase YOY Revenue

Differentiate and grow like ALDI

ALDI didn’t become one of the most dominant grocery brands worldwide by luck. It identified its brand values early and built itself around them. Though this sounds simple, the difficulty comes from decades of consistency that was possible because of a consistent, brilliant, passionate, and exceptionally executed business plan that has now been successfully replicated in ALDI’s digital marketing strategy. 

The pandemic has drastically changed the world , accelerating the integration of technology into all aspects of business. It has created an opportunity for rapid growth — for companies that can quickly incorporate technology to create an omnichannel experience that improves customer satisfaction while reinforcing brand values.

Before investing in a powerful customer engagement platform , however, it’s important to conduct deep market research and evaluate the benefits of the platform’s tools. Book a free 30-minute retail customer engagement consultation with ContactPigeon’s experts and incorporate an omnichannel strategy that will bring a high ROI to your business.

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Secrets of store success: Exploring Aldi's case

Aldi has been making waves in the retail industry for years, proving that low prices don't have to come at the cost of quality. With over 10,000 stores worldwide, the German company has become a force to be reckoned with, surpassing competitors such as Walmart and Kroger in terms of growth rate. So, what's the secret to Aldi's success?

At Aldi, data is a key driver of success. The grocery retailer leverages store analytics to make informed business decisions and create a more personalized shopping experience for its customers. In this article, we will explore how Aldi uses store analytics to win at retail and gain a competitive advantage.

I. Understanding Aldi's Business Model

Aldi is a discount supermarket chain that offers high-quality products at low prices. The company operates more than 10,000 stores across 20 countries and is known for its no-frills approach to retail. Aldi's business model is built on simplicity, efficiency, and cost savings. The company achieves this by streamlining its operations, reducing overhead costs, and keeping prices low.

II. Aldi's Use of Store Analytics

Aldi's success is not just a result of its business model but also its use of store analytics. The company collects data on customer behavior, preferences, and trends to make informed decisions. This allows Aldi to tailor its product offerings and store layouts to meet customer demand.

Aldi uses a variety of analytics tools to collect data, including heat mapping, video tracking, and customer feedback. Heat mapping is used to track foot traffic and identify which areas of the store are most popular. Video tracking is used to monitor customer behavior, such as how long customers spend in certain areas of the store. Customer feedback is collected through surveys and social media to understand customer preferences and improve the shopping experience.

III. Leveraging Data to Improve the Customer Experience

Aldi uses store analytics to gain insights into customer behavior and preferences, which allows the company to create a more personalized shopping experience. By analyzing data on customer buying habits, Aldi can tailor its product offerings to meet customer demand. For example, if data shows that customers are buying more organic products, Aldi can increase its selection of organic products to meet this demand.

Aldi also uses data to optimize store layouts and improve the customer journey. By analyzing foot traffic and customer behavior, Aldi can identify areas of the store that are underutilized or overcrowded. This allows the company to make changes to the store layout to improve traffic flow and create a more seamless shopping experience.

IV. The Benefits of Store Analytics for Aldi

Aldi's use of store analytics has several benefits, including:

• Improved Customer Experience: By using data to personalize the shopping experience, Aldi can improve customer satisfaction and loyalty.
• Cost Savings: By optimizing store layouts and product offerings, Aldi can reduce waste and lower costs.
• Increased Sales: By tailoring product offerings to meet customer demand, Aldi can increase sales and revenue.
• Competitive Advantage: By leveraging data to make informed decisions, Aldi can gain a competitive advantage over other retailers.

Aldi's use of store analytics has been instrumental in the company's success. By leveraging data to make informed decisions, Aldi has been able to create a more personalized shopping experience, reduce costs, increase sales, and gain a competitive advantage. As retailers continue to face increased competition and changing consumer preferences, store analytics will become an increasingly important tool for success.

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Aldi: The Dark Horse Discounter – Case Solution

Aldi was a hard discounter based in Germany that sells a variety of private-label groceries and household items in several stores. It was the world's 8th largest retailer. In 2013, Aldi initiated moving fast with its US expansion. While it has more than a thousand stores in various states, Aldi was still not popular in the US. It is said to be the same reason why Walmart did not make it in Germany. Since the US is Walmart's home market, could Aldi make it through the competition with Walmart in the US?

​Eric Van Den Steen; David Lane Harvard Business Review ( 714474-PDF-ENG ) February 07, 2014

Case questions answered:

Case study questions answered in the first solution:

• Please identify the strategic issues and problems to be solved, describe the necessary analyses and conclusions, and present recommendations and implications. Do whatever analysis is needed to solve the problem you have identified.

C ase study questions answered in the second solution:

• What are the key business problems Aldi is facing competing in the USA?
• Who are the key stakeholders in these problems?
• What is Aldi’s business-level strategy, and what are the activities that support this strategy?
• How well is the company performing, particularly in terms of efficiency and profitability?
• Does Aldi have a source of competitive advantage relative to Walmart?
• Identify three solutions Aldi can use to address the business problems it faces, with the pros and cons of each solution.
• Which solution do you recommend, and why?

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Aldi: The Dark Horse Discounter Case Answers

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EXECUTIVE SUMMARY – ALDI

An international brand with a rich history, Aldi is known for its low prices and no-frills grocery shopping experience. While Aldi has seen substantial success in European markets, they seem to have trouble integrating into the U.S. and understanding the ideologies of the American consumer.

Aldi has developed a presence in the U.S., spreading over 32 states and 1,200 stores. Despite this, they are still virtually unknown. Looking forward, Aldi wants to expand their organic food offerings and expand their presence in the U.S.

Some of the most notable threats in the grocery industry are Walmart and Target, incredibly large brands with immense customer loyalty that can leverage their size to negotiate low prices with suppliers. With trends in the U.S. constantly evolving, niche grocery stores focused on organic and health foods and wholesale stores are prominent competitors.

A holistic analysis of the macro environment in the U.S. is necessary to understand trends and American consumer behavior. Discount retail is a very competitive industry to navigate, with revenues of the top ten retailers totaling over $1 trillion.

Aldi has unique, inimitable resources that can aid it in its mission, such as its unique staffing levels, low-cost structure, and private-label products. With this advantage, Aldi needs to implement the right global expansion strategy to succeed in the U.S., creating the core question of what specific measures Aldi must take to differentiate itself in the market.

It is recommended that Aldi emphasize their customer retention efforts with a customer loyalty program, increase its presence in urban markets, and adopt innovative technology such as self-checkout. These three strategic insights will help guide Aldi through a successful expansion in the United States.

CASE ANALYSIS

Aldi has maintained a strong sense of industry leader regarding discount grocers, attributing its success to its reputation as a frugal, consistent grocery shopping experience.

The firm has stayed committed to its value of operational excellence, with an average number of 10 employees per store and its emphasis on private label products, which make up approximately 95% of its product offerings.

Many international brands struggle with being cognizant of the local culture, often choosing the wrong global expansion strategy and ending with failure. We have seen this with Walmart and its entry into Germany.

Exhibit A outlines the market conditions of the U.S., highlighting different trends and regulations that directly affect Aldi’s operations. It is crucial to assess all trends to be proactive in identifying opportunities and threats. Failing to take into account any of these factors can be detrimental to Aldi’s expansion.

This analysis shows that the grocery industry in the U.S. is relatively stable, and with groceries being a necessity, the industry will still thrive through economic boom and bust cycles. The firms that can adapt to trends quickly are the ones that succeed.

One prevalent trend is that of online ordering and self-checkout, feeding into the sensation of instant gratification that is common in the American consumer.

The scope of Aldi’s expansion efforts is incredibly ambitious, aiming to open 650 new stores by 2018. While they are trying to replicate initiatives that have been successful overseas, such as their successful expansion into Australia with over 270 stores, Aldi needs to tailor their expansion efforts to the U.S.’ unique business environment. What specific measures can Aldi take to differentiate itself in the market?

Industry Analysis

Exhibit B addresses various parameters of the competitive structure of the grocery industry and how they affect Aldi. There is a high barrier to entry due to the tremendous number of competitors and the high start-up costs associated with building an effective distribution network and establishing a brick-and-mortar store.

With various big players already in the space, it is…

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Can music education boost grades, attendance? A new case study suggests it might

A new case study that included hundreds of Tennessee public schools suggests that music education may be tied to better math and reading scores, along with better attendance and positive social, emotional and behavioral effects.

The study, titled "Face the Music: A Case Study for Expanding Music and Arts in Schools," was the result of a joint effort between the CMA Foundation and the Mr. Holland's Opus Foundation. It examined the challenges and benefits stemming from music and arts education across 589 schools and 23 districts in Tennessee, and also included feedback from music and arts teachers, students and lifelong learners.

“Music and arts education are playing a key role in helping students catch up after the pandemic, from helping with math and reading proficiency to coping with stress and trauma. The research is clear: arts and music classes are a must-have, not a nice-to-have," CMA Foundation Executive Director Tiffany Kerns said in a news release.

The foundations behind the study hope it will serve as a model for other states to boost music and arts education at the state and district level, along with gaining support from nonprofit organizations and philanthropy.

Here are key takeaways from the study.

Related: TN high school band gets surprise invite to perform at CMA Fest as director wins award

A connection between music, arts, math and reading

Data from the majority of districts in the study showed that students enrolled in music and arts programs demonstrated significantly higher proficiency rates in math and literacy. The majority of districts also saw better attendance rates from music and arts students, compared to schoolwide averages. These outcomes align with a handful of other studies. However, the case study report did note an important caveat: Most studies on music and arts participation don't prove it's the cause of improved academics.

Here's a look at the proficiency and attendance numbers the study revealed:

• Roughly 1-in-4 school districts reported 47% of students enrolled in music and arts programs showed reading proficiency, compared to an overall school average of 36%.
• Roughly 7-in-10 school districts reported 46% of students enrolled in music and arts programs excelled in math, compared to an overall school average of 35%.
• Roughly 3-in-4 districts reported increased attendance rates for students enrolled in music and arts programs. The study noted that schools where music and arts students outpaced the school average for attendance saw an average attendance boost of 12%.

Systemic barriers to music and arts education

The case study also outlined factors that hamper access to music and arts education for students and schools. They largely align with trends reported in the most recent National Arts Education Status Report and historical data from the Tennessee Arts Education Data Project, the study said.

The barriers for students identified in the study are:

• Participation requirements, including after-school attendance and prerequisites or auditions
• Housing insecurity
• Transportation challenges
• Participation fees
• Equipment costs

The study also showed that curriculum scheduling is a primary issue facing schools. That can disrupt the ability to offer sequential music and arts classes in every grade, allowing students to explore a variety of options and build upon their skills each year.

Recommendations for action

The study mapped out a series of recommendations for how everyone from parents and students to educators and lawmakers can take action to bolster music and arts education in Tennessee.

For school community members like parents, students and educators, that can range from simply attending music and arts events to show support to advocating for more funding for programs. The study also calls on school and state leaders to partner to fund music and arts education, train teachers and develop partnerships that help sustain those programs in schools. It also challenges philanthropic organizations to fund grants, promote advocacy and awareness and take other steps to partner with and support schools.

"Each of us can support a system of change to enhance music and arts education for a more well-rounded education for our students," the study stated.

A look at the demographics and schools

The demographics of the schools that participated were similar to the state of Tennessee as a whole, but they differed slightly when it came to the population of public school students statewide. Students in the study were:

• 16% Black or African American
• 9% Hispanic or Latino
• 2% other racial identities
• 24% socioeconomically disadvantaged
• 13% engaged in special education services
• 9% English language learners
• 2% experiencing homelessness or in foster care
• 1% identified as migrants or refugees

According to 2022-23 academic year data from the Tennessee Department of Education, here's how Tennessee schools demographics broke down:

• 24% Black and African American
• 14% Hispanic
• 3% other racial identities
• 30% economically disadvantaged
• 14% students with disabilities
• 8% English learners
• Less than 1% in foster care
• 2% experiencing homelessness
• Less than 1% identified as migrants

Here's the full list of districts that participated in the case study:

• Arlington Community Schools
• Bartlett City Schools
• Benton County Schools
• Chester County School District
• Clarksville-Montgomery County School System
• Coffee County School District
• Germantown Municipal School District
• Giles County School System
• Greene County Schools
• Hamilton County Schools
• Jackson-Madison County School District
• Knox County Schools
• Lincoln County Schools
• Marion County Schools
• Maury County Public Schools
• Metro Nashville Public Schools
• Paris Special School District
• Robertson County Schools
• Rutherford County Schools
• Tullahoma City Schools
• Weakley County Schools
• Williamson County School 
• Wilson County Schools

The CMA Foundation is the philanthropic arm of the Country Music Association. More information, along with the foundation's extensive research and initiatives, can be found at cmafoundation.org . Learn more about the Mr. Holland's Opus Foundation at mhopus.org .

• Open access
• Published: 30 May 2024

Health workers’ adherence to malaria case management protocols in Northern Sudan: a qualitative study

• Sahar Khalid Mohamed 1 , 2 ,
• Duha Khalid Mohamed 1 ,
• Khansaa Ahmed 1 ,
• Fadwa Saad 1 &
• Dejan Zurovac 3  

Malaria Journal volume  23 , Article number:  170 ( 2024 ) Cite this article

Metrics details

Nonadherence to national standards for malaria diagnosis and treatment has been reported in Sudan. In this study, qualitative research examined the clinical domains of nonadherence, factors influencing nonadherent practices and health workers’ views on how to improve adherence.

In September 2023, five Focus Group Discussions (FGDs) were undertaken with 104 health workers from 42 health facilities in Sudan’s Northern State. The participants included medical assistants, doctors, nurses, laboratory personnel, pharmacists and public health officers. The FGDs followed a semi-structured guide reflecting the national malaria case management protocol. Qualitative thematic analysis was performed.

Nonadherent practices included disregarding parasitological test results, suboptimal paediatric artemether–lumefantrine (AL) dosing, lack of counselling, use of prohibited artemether injections for uncomplicated and severe malaria, artesunate dose approximations and suboptimal preparations, lack of AL follow on treatment for severe malaria; and rare use of primaquine for radical Plasmodium vivax treatment and dihydroartemisinin-piperaquine as the second-line treatment for uncomplicated malaria. Factors influencing nonadherence included stock-outs of anti-malarials and RDTs; staff shortages; lack of training, job aids and supervision; malpractice by specialists; distrust of malaria microscopy and RDTs; and patient pressure for diagnosis and treatment. Health workers recommended strengthening the supply chain; hiring personnel; providing in-service protocol training including specialists; establishing external quality assurance for malaria diagnosis; and providing onsite supportive supervision and public health campaigns.

Conclusions

This study revealed a broad spectrum of behavioural and systemic challenges in malaria management among frontline health workers in Northern Sudan, including nonadherence to protocols due to resource shortages, training gaps, a lack of supportive supervision and patient pressure. These insights, including health workers’ views about improvements, will inform evidence-based interventions by Sudan’s National Malaria Control Programme to improve health systems readiness and the quality of malaria case management.

Malaria, a significant public health concern, continues to cast a shadow over Sudan’s healthcare landscape. The malaria burden in Sudan was estimated to be 3.7 million cases, and 1760 deaths accounted for 17.0% of the number of outpatients admitted and 14.7% of the total number of hospital admissions in 2021 [ 1 , 2 ]. Plasmodium falciparum accounts for 87.6%, Plasmodium vivax accounts for 8.1%, and other Plasmodium species account for approximately 4.3% of malaria infections [ 2 ]. The country’s struggle with malaria is further complicated by the COVID-19 pandemic [ 3 ], the persistent spectre of war [ 4 ] and the ensuing internal displacement of populations [ 5 ]. In this fragile environment, effective evidence-based management of malaria cases is paramount, safeguarding the well-being of communities and alleviating the economic burden associated with the disease. Sudan malaria case management standards reflect the WHO 2010 “test and treat” recommendations [ 6 ], and promote a shift from presumptive treatment of fevers to confirmed malaria diagnosis with either malaria microscopy or rapid diagnostic tests (RDT) and targeted treatment with artemisinin-based combination therapy (ACT) with appropriate weight-based dosing, drug dispensing and patient counselling [ 7 ]. Artemether–lumefantrine (AL) and dihydroartemisinin–piperaquine (DHAP) are the recommended first- and second-line artemisinin-based combinations for both P. falciparum and P. vivax uncomplicated malaria, while patients with P. vivax should also receive radical primaquine treatment. Regarding severe malaria management, the 2023 protocols have unambiguously recommended the use of artesunate injections and reserved parenteral quinine only when artesunate is contraindicated or unavailable [ 8 ]. Injectable artemether has been policy discontinued and banned since 2017 due to its prior irrational use [ 7 , 9 ].

Despite evidence-based policies and recommendations, health worker adherence to national guidelines is the key factor determining the real-world cost-effectiveness of the “test and treat” policy for malaria [ 10 ]. Improved adherence to malaria guidelines decreases malaria mortality [ 11 ] and highlights the importance of poor quality of care as a major contributor to mortality in low- and middle-income countries [ 12 ]. The levels, trends and factors of healthcare providers’ adherence to national malaria guidelines have been studied across Africa [ 13 , 14 , 15 , 16 ]. Despite some improvements, adherence was found to be insufficient in many settings [ 17 , 18 , 19 , 20 ] with series of studies evaluating outpatient malaria case management and observing deviations from testing indications [ 21 , 22 ]. Additionally, a tendency to prescribe non-recommended anti-malarials even for confirmed cases [ 23 , 24 ] and provide irrational anti-malarial treatments to patients who test negative for malaria has commonly been reported [ 25 , 26 ]. Furthermore, a number of studies highlighted missed opportunities in delivering timely anti-malarial treatment at healthcare facilities [ 27 , 28 ]. With respect to inpatient management, suboptimal quality-of-care has also been observed. Specifically, low testing rates of febrile patients on admission, persistence of presumptive anti-malarial treatment without testing or despite negative malaria tests, lack of parasitological monitoring, use of non-recommended anti-malarials and incomplete treatments are only few of the clinical deficiencies observed [ 29 , 30 , 31 , 32 , 33 ].

In Sudan, the quality of malaria case management, characterized by health workers’ adherence to national protocols, has been a challenge [ 2 ]. Nonadherence to standards for diagnosing and treating uncomplicated and severe malaria has been reported in different settings [ 9 , 34 , 35 , 36 ]. For instance, despite the availability of test and treat commodities for malaria, a national outpatient survey revealed that 67% of febrile patients tested, 64% of confirmed cases treated with ACT, 17% of test-negative patients treated for malaria, 6% of prescribed ACT patients weighed, 3% promptly administered the first ACT dose and 87%, 61% and 3% of patients, respectively, counselled on dosing, treatment completion and vomiting [ 9 ]. Inpatient management of severe malaria was less commonly evaluated, however a 20-hospital survey in Gezira State suggested that only 54% of severe malaria patients received the correct dose and dosing regimen [ 36 ].

Quantitative research can estimate the magnitude of the problem, but there is a need for qualitative research to understand the subtle factors and provide more nuanced recommendations for policy implementers to improve adherence. In the absence of such data in Sudan, this qualitative study embarks on an exploration of nonadherence among healthcare providers to malaria case management protocols in the Northern State of Sudan. Delving into the intricate web of healthcare practices, this research endeavours to unearth factors undermining adherence, as perceived by the very individuals entrenched in the frontline of healthcare delivery. Furthermore, it seeks to harness their collective wisdom by capturing their recommendations, thereby paving the way towards enhanced adherence.

Study design

This study utilized a qualitative research design with focus group discussions (FGDs) to explore healthcare providers’ adherence to national malaria case management protocols, specifically to identify nonadherent practices, factors influencing such practices, and gather health workers’ views on how to improve adherence to national protocols.

Northern State, one of Sudan’s 18 states, covers 348,765 km, with Dongola as its capital. Comprising seven localities, it is home to an estimated population of 1,511,442 primarily residing in rural areas along the River Nile [ 37 ]. Malaria transmission is hypoendemic, and the Sahara Desert is constrained, with an estimated incidence of 175 cases per 1000 population [ 37 ]. The selection of Northern State for the study area involved the delivery of in-service malaria case management training for health workers, an implementation platform conveniently used for the conduct of FGDs prior to training sessions. The state hosts 314 health facilities and 2345 healthcare providers distributed across various levels of care, including family health units, primary health centres, primary hospitals, and secondary and tertiary facilities [ 38 ]. At primary healthcare (PHC) facilities, RDTs serve as the exclusive diagnostic method, especially at the family health units, where the lower PHC level is operated by medical assistants (clinical practitioners with basic medical training). Health centres, representing the higher PHC levels, provide malaria microscopy services conducted by medical laboratory technologists and outpatient services provided by medical doctors. Malaria microscopy is also available at laboratories in local, general, referral, and teaching hospitals, encompassing secondary and tertiary levels of care, where outpatient and inpatient curative services are overseen by medical doctors [ 39 ]. Malaria services are supervised by the Federal and State Ministries of Health, which also oversee tasks such as updating protocols and providing training on them. The Ministry of Health also ensures the provision of essential supplies, including malaria RDTs and anti-malarial medications, most of which are free of charge. However, malaria microscopy services are still subject to charges. In 2023, a significant increase in population and healthcare providers occurred with the influx of internally displaced people, many of whom were originally from regions with high malaria transmission [ 40 , 41 ].

Study participants

A total of five FGDs were held at Primary Health Care Directorate venues in five out of seven localities within Sudan’s Northern State in September 2023. Healthcare providers from 42 health facilities participated in the FGDs (Fig.  1 ). The participants, who had diverse professional backgrounds, were chosen by the state and locality malaria control programmes to attend orientation training sessions (total of 8 training sessions for 200 health workers) on the updated malaria case management protocol [ 8 ]. The FGDs included all health workers attending an orientation session, and all study participants provided informed consent. The point of saturation through iterative data analysis after each FGD was reached after the completion of five FGD sessions, which included 104 participants in total (Fig.  2 ).

Map of Sudan showing Northern State and participant’s health facilities along the River Nile

Schematic flow of the sampling process

Data collection

At the initiation of the orientation sessions, the collection of demographic data were collected, encompassing participants’ occupations, gender, and workplace locations. FGDs were purposefully directed toward understanding healthcare providers’ adherence to the national case management protocol, unravelling factors influencing nonadherence, and soliciting recommendations to enhance adherence. Each session of these FGDs was conducted in the Arabic language, spanning approximately 2 to 3 h, punctuated with breaks and composed of a total of 104 healthcare providers and 19 to 25 participants at each FGD. The manuscript author (SKM), following semistructured guide tailored to reflect on the study objectives on adherence to malaria case management protocols, factors affecting adherence, and recommendations to improve adherence [ 8 ], moderated the discussions. The guide, with respect to the management of uncomplicated malaria, included inquiries into participants’ knowledge regarding malaria symptoms, diagnostic procedures, first- and second-line treatments, dosage specifics, and patient counselling. Regarding severe malaria management, the guide comprised inquiries on symptoms, signs, laboratory findings, diagnostic criteria, initial management strategies, treatment locations, dosage calculations, drug preparation and administration techniques, treatment duration, discharge protocols, and second-line management. Additional questions delved into the diagnosis and management of malaria in pregnant women. Prior to its use, the guide was pretested with health workers not involved in the study (Additional file 1 ). Finally, participant responses prompted exploration of the underlying causes of nonadherence to the protocols, eliciting valuable suggestions to improve the training at which focus group discussions were conducted and to provide potential improvement recommendations to the Federal Ministry of Health. During the discussions, the moderator preserved neutrality and ensured that all participants felt comfortable and similarly engaged. Simultaneously with discussions, notes were taken in Arabic language, which subsequently underwent dual forward translation by two investigators (SKM and DKM) into English and transcription for comprehensive analysis.

Data analysis

Qualitative thematic analysis was conducted [ 42 ]. It comprised seven sequential stages leveraging transcripts from FGDs and handwritten notes. Initially, all transcripts and notes were collected. Subsequently, the researcher thoroughly reviewed sample files, identifying words, phrases, or sentences pertaining to adherence to malaria diagnosis and treatment protocols. Following this, coding categories were developed using a deductive approach, with the protocol serving as the analytical framework. The fourth stage involved the coding of all files and text. The fifth stage encompassed scrutiny of the consistency in code, subthemes, and theme utilization. The sixth step entailed the interpretation of themes, drawing inferences from observed patterns, relationships, and codes, subthemes, and theme attributes. Finally, the seventh stage encompassed the presentation of findings, complemented by supporting quotes and verbatim quotes. A total of four to five themes was identified answering the research questions on healthcare providers’ adherence, factors and recommendations (Additional file 2 ).

Characteristics of participants

Of 104 participants across five FGDs, most of them were males (68.2%) and most worked at the primary health care facilities (75.5%). The number of participants ranged between FGDs from 19 in Al-Golead to 25 in Dongola locality (Table  1 ). Healthcare providers from various backgrounds participated in the study, most commonly medical assistants (59; 56.7%), followed by doctors (13; 12.5%), public health officers (13; 12.5%), nurses (9; 8.7%), laboratory personnel (7; 6.7%) and pharmacists (3; 2.9%).

Nonadherence to national malaria protocols

Four main themes reflecting health worker clinical practices nonadherent with national malaria case management protocols were identified in the analysis (Table  2 ). These included malaria diagnosis practices based on parasitological tests and clinical practices related to the treatment of uncomplicated malaria, severe malaria and patients harbouring P. vivax and mixed malaria infections.

Nonadherence to malaria diagnosis based on parasitological tests

Universal testing of fevers and targeted anti-malarial treatment is the backbone of malaria case management in Sudan. Healthcare providers reported common ordering of a parasitological test upon suspecting malaria but highlighted distrust in the test results and many reported practicing presumed malaria diagnosis. Specifically, regarding uncomplicated malaria, several health workers reported that patients with negative test results are still diagnosed presumptively and treated for malaria:

“Sometimes the test result comes negative for malaria, I test other causes of fever, and if all of them come negative I presume that patient has malaria” (Medical assistant)

Higher cadres of health workers also reported presumptive treatment practices, as medical officer managing hospital outpatients similarly observed.

“After excluding other causes of fever, even if the parasitological test is negative I treat patients as malaria and prescribe Coartem” (Medical doctor)

Regarding the management of severely ill patients, most health workers did not mention parasitological testing and reported that anti-malarial treatment is the standard management for severe disease, as observed by medical officer working at a secondary hospital.

“Febrile comatose patients are treated with broad spectrum antibiotic, antiviral therapy and anti-malarial treatment usually quinine, this is an umbrella approach commonly used” (Medical doctor)

Nonadherence to uncomplicated malaria treatment

The AL treatment of uncomplicated malaria was highly accepted by health workers, and most participants were knowledgeable about adult doses and schedules, particularly about the importance of the second dose administration 8 h after the first dose and the third dose administered 24 h after the first dose. However, some healthcare providers have shown little knowledge about paediatric dosage schedules potentially resulting in the underdosing and overdosing of malaria patients, as demonstrated by medical assistant practicing at outpatient health centre.

“From five to ten kilograms that is one tab of Coartem, from ten to twenty that is two tabs of Coartem, from twenty to thirty that is three tabs of Coartem” (Medical assistant)

Most health workers during the FGDs acknowledged a lack of AL dispensing and counselling knowledge on the administration of the first dose under observation, AL dosing with a fatty meal, repeating the dose if the patient vomited within 30 min and stressing the point of taking the dose as prescribed. Some, however, highlighted that forgetfulness and unclear counselling responsibilities between different health worker cadres encountering malaria patients within health facilities contribute to poor practices. Hospital doctor and pharmacist echoed these observations.

“I try my best to counsel all the patients but sometimes I forget” (Medical doctor). “Usually we do not counsel patients and we presume that their doctor told them how to take the drug” (Pharmacist)

Oral administration of dihydroartemisinin–piperaquine is the recommended second-line treatment for uncomplicated malaria in Sudan. However, its availability is scarce, dosing knowledge is low and health workers do not prescribe it. A healthcare provider humorously remarked on DHAP:

“DHAP (dihydroartemisinin–piperaquine) is as rare as gold (referring to the literal meaning of Dhap in Arabic), and it is nowhere to be found” (Medical assistant)

In this context, patients considered to have AL treatment failure are often prescribed artesunate injections reserved for severe malaria—the practice justified by the scarcity and unavailability of DHAP in the public and private sectors, as highlighted by the hospital doctor:

“Patients may present with recurrent malaria even after taking Coartem, DHAP is not available, we have no other choice but to prescribe artesunate injections” (Medical doctor)

Finally, despite high acceptance of AL by health workers, healthcare providers at lower levels of care (PHCs and family health units) reported the use of artemether injections as a treatment for uncomplicated malaria upon patient request:

“Sometimes the patient refuse it when I prescribe them tabs and insist that they want the oily injections (known name for artemether injections in Sudan) and I have no other choice but to prescribe it to them” (Medical assistant)

Nonadherence to severe malaria treatment

Health workers reported several treatment practices nonadherent to protocols for the management of severe malaria. Such practices spanned from the selection of non-recommended parenteral anti-malarial treatments to the lack of weight-based dosing; poor parenteral solution preparation, administration and disposal; and compromised completion of follow on ACT treatment after parenteral therapies. Participants acknowledged the frequent use of artemether injections, partly due to the patients’ pressure but also due to a lack of understanding of why artemether was prohibited while remaining available on the market. Most significantly, continued artemether use by consultants and specialists acting as supervisors and role models for front-line clinicians further undermined the treatment policy, as clearly stated by several participants of different cadres:

“I know we should not use artemether injections, but I should do what my boss says” (Medical doctor)

A medical assistant added,

“When a specialist prescribes artemether injections, I find myself wondering, who am I not to do the same?”

Most participants acknowledged not weighing adult patients but uniformly administering a 120 mg dose corresponding to a single vial of artesunate, which in turn, based on artesunate dosing recommendations of 2.4 mg/kg, results in dosing needs for patients weighing 50 kg. A lack of weighing practice in adults was well observed by the hospital doctor:

“Usually we prescribe 120 mg to all adults, we don’t weigh them and calculate the dose accordingly, weight dependant dosage are common in paediatrics but not the common in adults” (Medical doctor)

While weighing was probably more common in children, some healthcare providers acknowledged that the lack of weight-based artesunate dosing may also occur among paediatric patients:

“I usually weigh the child before prescribing any medication not just malaria medications, but sometimes, when the load is heavy in the ER or the clinic I just estimate the child’s weight” (Medical doctor)

Most participants reported uncertainties about how to prepare and administer injectable artesunate, particularly clinicians whose responsibility was related to prescribing artesunate but not to the preparing and administering of parenteral therapy:

“We don’t prepare artesunate since it’s a nurse responsibility, but when we find ourselves in a position to do this, when nurses aren’t available, we check the directions in the box, but we weren’t trained on this before” (Registrar)

Nurses were, however, less comfortable with IM artesunate preparations as well as with determining the number of vials needed for preparation, preparing solutions other than 120 mg for adults and disposing of unused solutions. The following remarks from hospital nurses illustrate these concerns:

“We usually prepare IV artesunate solutions but we are not familiar with IM preparations” (Nurse) “We are used to a standard dose of 120mg of artesunate injection, mixing vials to accommodate it to the patient needed dose isn’t a regular practice for us” (Nurse) “We usually use the remaining solution for the next dose, we don’t dispose it and we think it will be better to save it in the refrigerator” (Nurse)

The full course of AL should follow on IV artesunate treatment, which is administered to severe malaria patients upon admission, repeated minimally at 12 h and 24 h, and thereafter once a day until the patient can tolerate oral medicines and be discharged on oral AL therapy. Most participants, however, expressed a lack of awareness about AL follow on treatment, as clearly noted by the medical doctor:

“I didn’t hear about this before, but if it’s in the protocol then I will do it” (Medical doctor)

Moreover, incompletion of three minimally required IV artesunate doses at the hospital was common and discharge on injectable artesunate treatments for home administration was commonly reported:

“I’m used to neighbours knocking my door asking me to give a patient artesunate injections at home” (Medical assistant) “It’s true, I get the same neighbours asking for similar favours, and to be honest, if the patient is vitally stable we discharge him on artesunate at home” (Medical doctor)

Nonadherence to P. vivax and mixed infection treatments

While most participants were aware of radical P. vivax treatment with primaquine, the scarcity of primaquine on the market contributed to the low number of prescriptions. When primaquine is prescribed, health workers often have limited knowledge about primaquine doses, glucose-6-phosphate dehydrogenase (G6PD) risks, and adjusted dosing schedules for G6PD-deficient patients, as shown below:

“If a patient has P. vivax I prescribe them with 15 mg primaquine tabs twice daily for 2 weeks, I don’t ask specific questions to get a clue if the patient has G6PD honestly” (Medical assistant) “I didn’t know about the contraindication of primaquine with G6PD, even the paediatric weight dependant dose, I’m used to prescribe 7.5 mg tabs once per day for 14 days to all paediatric patients” (House officer)

Moreover, heath workers were less familiar with the possibility of mixed infections, particulary with test result interpretations, as observed by medical assistant below:

“Sometimes the RDT shows both P. falciparum and P. vivax, I don’t know what the meaning of this is, I presume that the RDT is not working well and I diagnose the patient with having P. falciparum infection” (Medical assistant)

Factors influencing nonadherence to protocols

Four broad themes describing factors influencing nonadherence to case management protocols were identified (Table  3 ). These included lack of commodities and shortage of human resources, poor knowledge of health workers about case management protocols, distrust in parasitological test results and patient pressure on modalities of clinical malaria management.

Lack of commodities and shortage of human resources

The absence of diagnostics and medicines precludes adherence to case management protocols. Common stock-outs of anti-malarials and RDTs at public health facilities, the reliance upon the private sector for costly purchases and the nearly universal absence of primaquine and DHAP from the market have been commonly reported by most participants, as illustrated by the hospital doctor:

“Malaria medications and RDTs aren’t always available in the hospital, most can be found in the private pharmacies and laboratories, except for primaquine and DHAP, they are hard to find” (Medical doctor)

The lack of commodities is limited not only to medicines and diagnostics but also to basic facility equipment, such as weighing scales, which are required to implement appropriate weight-based dosing of patients. The majority of participants seconded the frustrations highlighted by the medical assistant:

“I don’t have a weight scale in my centre, how am I supposed to adopt a weight dependent approach?!” (Medical assistant)

Moreover, even when commodities are available a major effort may be required to adhere to the protocols due to high patient workloads in the face of staff shortages, as also well observed by the hospital nurse:

“Now I understand I should prepare quinine dose just before administration, but I’m working alone and usually I have many patients to observe, this will definitely be a challenge” (Nurse)

Lack of training and lack of continuous support for protocol adherence

Participants commonly attributed nonadherence to a lack of knowledge and information transfer through interventions such as regular in-service training and supportive supervision, including the delivery of reminders about good practices. For instance, the role of job aids such as poster wall charts and protocol booklets was repeatedly emphasized by the participants:

“If I have a poster in my centre it will remind me if I forget” (Medical assistant)

This was similarly echoed by medical doctors in hospital settings:

“Posters help us train our house officers and as he said it helps reminding us if we forget” (Registrar)

With respect to more formal capacity building, in-service training has been acknowledged as a valuable intervention in transmitting knowledge and enhancing case management readiness for all health workers, however, it appears that consultants and specialists have not been sufficiently reached:

“When prestigious consultants treat malaria differently than us, we lose patients trust” (Medical assistant)

Finally, most participants acknowledged that the lack of supportive supervision to address the availability of commodities and provide on-job support and problem solving for front-line health workers may further facilitate nonadherent practices:

“You ask us to do things but at the same time you don’t avail the needed requirements for us, why don’t you come and see the setting at which we are practicing first?” (Medical assistant)

Distrust in parasitological test results

Treatment nonadherent to malaria test results due to the distrust of malaria microscopy and doubtful quality of laboratory services was a recurrent theme among the participants:

“Sometimes a patient presents with fever, we exclude all other causes, but if the microscopic test results come back negative from the lab, we do not trust, we manage as malaria, and we observe dramatic improvement in patients.” (Medical officer)

Notably, clinicians’ distrust in malaria microscopy has been exclusively directed towards negative test results, as well remarked by laboratory specialist:

“If I provide a negative result, the healthcare provider will not trust me, and they will send the patient to another lab that gives them positive results” (Laboratory specialist)

Discontinuation of external quality assurance systems for laboratories and a lack of recent refresher training for malaria microscopists does not mitigate the distrust in test results:

“Previously the program used to take slides from our lab for verification and provide training if the staff is giving wrong readings, but now this is not happening!” (Laboratory specialist)

Finally, similar levels of distrust were reported with respect to malaria RDT results. Furthermore, much of the confusion was reported in the PHC facilities with regard to the appropriate performance and interpretation of RDTs produced by different companies:

“The RDTs I have only gives me a negative result no matter what, I suspect it might be due to storage conditions” (Medical assistant) “I don’t understand how to use RDTs, some companies require waiting for 15 min, some for more or less, having RDTs from different companies each time is tiring and exhausting because I’m already overworked” (Medical assistant)

Patient pressure

In addition to health worker and health system factors, patient pressure may also influence health worker adherence to malaria case management protocols and alter health worker clinical practices. For instance, some health workers illustrated how patients may influence diagnosing practices for malaria:

“When you ask the patient what are you complaining from he says malaria! And when I try to explain that I’m asking about the symptoms he says I know my malaria just order me the test” (Medical doctor) “Patients insist it’s malaria even if the test is negative” (Medical assistant)

The other participants illustrated how patients may influence treatment practices:

“Patients insist its malaria even if the test is negative, they insist on being treated for malaria and if I didn’t write the drug they will buy it themselves” (Medical assistant) “Sometimes the patient have malaria but he demands injectable treatment although they should just take tabs, some insist on taking artemether injections even after I counsel them about it” (Medical doctor)

Health worker recommendations to improve adherence

The participants provided valuable insights into what could be done to address the identified challenges and improve adherence to malaria case management protocols, as summarized in Table  4 .

Ensuring the availability of case management commodities

Health workers emphasized the responsibility of the Ministry of Health to strengthen the effective supply chain for malaria commodities and ensure the universal, continuous and affordable availability of malaria diagnostic and treatment commodities. Such steps would present a basic prerequisite for adherence improvements:

“If RDTs are free and available we can take a step towards accurate diagnosis of malaria” (Medical assistant) “I don’t prescribe primaquine for patients with P. vivax because it’s not available, same goes for DHAP” (Medical assistant)

Improving the balance between human resources and workload

Quality of care is dependent on adequate human resources and calls for additional personnel to balance heavy workloads were the theme of transpiring discussions across the cadres of participants:

“Now I understand I should prepare quinine dose just before administration, but I’m working alone and usually I have many patients to observe, this will definitely be a challenge, I need more people to work with me” (Nurse) “Being overworked and not have much sleep can alter your cognitive skills! This is scientifically proven! The Ministry of Health should decrease our workload because this isn’t just affecting malaria management, this is affecting all patient’s health outcome” (Medical doctor)

In-service training on case management protocols

Participants emphasized the importance of continuous training for all health workers. Recognizing the influential role played by specialists and consultants in hospital settings, they also underscored the importance of targeted training and interventions for these professionals:

“Now, I know the updated protocol, but my boss doesn’t, I may adhere to it in my private outpatient clinic but in the hospital it’s the consultant’s decision, not mine, you have to orient him too with the protocol” (Medical officer)

Moreover, whether implemented during training or through separate communication channels, health workers expected clarifications about the reasons for artemether injection prohibitions:

“The consultant in my unit is prescribing artemether injection, I do too since I don’t understand why is it prohibited at the first place, if you are afraid of the resistance because of the mono-therapies, why would you put artesunate injection in the protocol?” (Medical doctor)

Quality assurance for malaria diagnosis and supervision activities

Most of the participants called for external quality assessments at public laboratories through onsite supervisory visits for malaria microscopy and RDTs:

“I don’t trust the lab results, supervising the lab and making sure it’s well equipped and its staff is qualified will be great” (Medical doctor) “The RDTs I have only give a negative result, I would like if the Ministry of Health came and saw if it’s working or not or if its storage is well or not” (Medical assistant)

Some hospital clinicians further emphasized MoH supervision at public pharmacies and laboratories with respect to the enforcement of free policy for government procured RDTs and artesunate vials:

“When artesunate is available in the hospital, only the first dose is free, the patient has to buy other doses from the private pharmacy, you should talk to them to make sure they provide all doses for free” (Medical officer)

Finally, participants highlighted the importance of extending supervision to the private pharmacies to ensure the delivery of quality products and compliance with artmether injection prohibition:

“If artemether is prohibited then why the government doesn’t enforce its prohibition by law? Supervise the private pharmacies!” (Medical assistant) “Artesunate injection isn’t available in the public hospital, patients buy it from the private pharmacies and the quality of the drug available isn’t good” (Medical doctor)

Health promotion campaigns

Participants emphasized that public campaigns are necessary to promote malaria diagnosis based on parasitological test results and to increase the understanding of the rational use of anti-malarial medicines:

“Patients and co-patients don’t trust the parasitological test and insist on the malaria diagnosis, the concept “I know my Malaria” needs to be fought” (Medical assistant) “Patients insist on being treated for malaria even they don’t have malaria, and if they do they insist on being treated through injections rather than tabs, let alone those who request artemether injections” (Medical doctor)

Sudan health workers from Northern State revealed a broad spectrum of protocol nonadherent malaria case management practices, factors influencing such practices and recommendations of relevance for policy implementers to improve the adherence to and quality of malaria care. The problem of malaria diagnosis transpired throughout the study. Stock-outs of diagnostic commodities such as RDTs, distrust of malaria microscopy, but also RDTs, limited in-service training and lack of supportive supervision for laboratories and clinicians have been highlighted in this study, as similarly observed in various settings across Africa [ 26 , 27 , 28 , 29 , 43 , 44 ]. More recently, compliance with test negative test results and the rational use of anti-malarials have improved in other countries [ 14 , 25 ], and many of these achievements have been attributed to the implementation of quality assurance programmes for malaria diagnosis supported with systems readiness and case management monitoring [ 15 , 45 ]. In Sudan, as also suggested by the study findings, the quality assurance programmes traditionally targeting malaria microscopy should be re-established but also expanded to include RDTs through the onsite supervision of non-laboratory personnel, in line with recently developed quality assurance guidelines [ 46 ]. To mitigate human resource issues, outpatient use of RDTs for initial febrile visits should be promoted at all levels of care, including hospitals, while complex to perform malaria microscopy should be reserved for follow-up of treatments and monitoring of parasitaemia for severely admitted patients [ 47 , 48 ].

Another quality of care aspect severely compromising the effectiveness of malaria case management is nonadherence to treatment recommendations [ 47 ]. Health workers revealed several suboptimal treatment practices. First, lack of patients’ weighing and the practice of dose approximations, the clinical deficiencies not unique to Sudan [ 29 , 33 ], are widespread and inevitably result in overdosed and underdosed treatments. Although the lack of weighing scales may provide a plausible explanation, uniformed artesunate prescriptions for adults based on a single 120 mg vial may also reflect cost considerations, ease of administration and waste minimization. Second, paediatric anti-malarial misdosing reported by health workers may not only be due to the absence of weighing scales but also due to deficient dosing knowledge. Third, suboptimal counselling practices, as similarly observed for outpatients in other settings [ 9 , 28 , 34 ], are important components of malaria case management, compromising the promptness of the treatment, patient adherence, cure rates, and follow-up needs [ 49 , 50 ]. While acknowledged in the protocols, patient counselling has been a neglected topic and has indeed not been addressed during case management in-service trainings for health workers in Sudan [ 51 ]. Fourth, while the first-line treatment recommendations for uncomplicated malaria are highly accepted by health workers, the use of injectable artemether due to patient pressure seems to compromise the implementation of the treatment policy. This irrational treatment pattern was observed during earlier national surveys [ 9 , 40 ], raised concerns about drug resistance and ultimately led to the prohibition of injectable artemether in Sudan [ 7 ]. Although the findings of this study suggest persistent artemether use for uncomplicated malaria, quantitative assessments are required to estimate the scale of this malpractice. Fifth, regarding the treatment of severe malaria, the widespread use of injectable artemether, the inferior anti-malarial choice for this category of patients, as well as incomplete ACT follow on treatments are the nonadherent aspects of care described previously [ 29 , 30 ], and are perhaps the most concerning since they directly compromise patient outcomes [ 52 , 53 ]. Artemether preferences, especially common among role model cadres such as consultants and specialists, might reflect a lack of updates about treatment effectiveness but also weak regulatory enforcements given the banned status of the product on the market. Finally, the recommended management of the treatment failures and radical treatment of P. vivax infections is uncommon in Sudan due to the very low availability of respective treatments for these special patient groups, DHAP and primaquine.

Quality improvement initiatives targeting the readiness of health systems and the adherence of health workers to evidence-based case management protocols are malaria control priorities in Sudan [ 36 ]. Reinforcement of the test and treat practices is important not only for delivering quality of care and curbing malaria mortality but also for establishing reliable disease surveillance and malaria elimination foundations to which the country, and in particular the northern states of Sudan, are aspiring to. The study health workers in the Northern State suggested several valuable interventions that concur with broad strategic plans of the National Malaria Control Program (NMCP) [ 37 ]. Quality assurance for malaria diagnosis, the programmatic intervention mentioned earlier, is one of the control priorities. Regarding the initiatives targeting clinicians, only smaller-scale, multifaceted projects have been piloted [ 54 ], while programmatic interventions focusing mainly on supply, protocols and training have had limited reach [ 2 ]. In the following years, the Sudan NMCP plans to implement a package of multifaceted, evidence-based, country-adapted, quality improvement interventions focusing on the provision of diagnostics and medicines; supportive supervision, including audit, feedback and mentorship; and in-service training coupled with monitoring and group problem solving, interventions that have been shown to have significant positive effects [ 55 ]. Clinical algorithms in the format of job aids will be integral components of the multifaceted training and supervision interventions, required to remind health workers but also policy makers about key case management standards. However, it should be emphasized that improved performance through health worker supportive interventions such as job aids, training and supervision can be realized only if basic prerequisites are in place, i.e., universal and continuous availability of “test and treat” commodities and services for malaria [ 56 ]. Finally, regular assessments of the quality of care will be established to provide reliable quantitative indicators to inform progress in health system readiness and adherence to outpatient and inpatient malaria case management protocols [ 9 , 33 , 57 ].

In addition to health system interventions, health campaigns have been suggested for Sudan’s Northern State to mitigate patient pressure by increasing public awareness of parasitological diagnosis and decreasing demand for injectable medicines, especially for artemether injections. Other countries reported differing effects of patient pressure on anti-malarial prescriptions [ 58 ]. In Sudan, further quantitative research is needed to assess relation between appropriate counselling, patient pressure and patient satisfaction level. Finally, while staff shortages are a pertinent health system problem in Sudan and additional hiring, as requested by health workers, is a long-term solution, more effective use of available resources such as task shifting of RDT performance is a more realistic palliative solution in the short term.

Several study limitations should be acknowledged. First, while the study findings represent Northern State health workers, they may not be generalizable to other parts of Sudan. Second, the study did not include policy makers and implementers what limited insights into adherence factors only to the recipients of the case management interventions. Third, while the social desirability bias in reporting clinical behaviour cannot be excluded, this bias appeared to be controlled given the extent of reported nonadherent practices. Finally, the identification and exploration of nonadherent topics were guided by case management protocols and not by quantitative adherence data in the study area. Future studies exploring adherence to protocols should deploy mixed methods designs.

This study revealed a broad spectrum of behavioural and systemic challenges in malaria management among Northern Sudan’s frontline health workers, including nonadherence to protocols due to resource shortages, training gaps, lack of supportive supervision and patient pressure. These insights, including health workers’ views about improvements, will inform evidence-based interventions by Sudan’s National Malaria Control Programme to improve health system readiness and the quality of malaria case management.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author upon reasonable request.

WHO. World malaria report 2023. Geneva: World Health Organization; 2023.

Google Scholar  

Federal Ministry of Health—Sudan. Malaria program review, 2023. National Malaria Control Program; 2023.

World Bank. Socioeconomic impact of COVID-19 on Sudanese households. Central Bureau of Statistics—Sudan. December 2020. https://documents1.worldbank.org/curated/en/394981620725892919/pdf/Socioeconomic-Impact-of-COVID-19-on-Sudanese-Households.pdf . Accessed 24 Feb 2024.

WHO. Three months of violence in Sudan: health hanging in the balance. WHO—Regional Office for Africa; 2023. https://www.afro.who.int/news/three-months-violence-sudan-health-hanging-balance . Accessed 10 Dec 2023.

WHO. Health needs heighten as Sudan conflict displaces millions of people. WHO—Eastern Mediterranean region; 2023. http://www.emro.who.int/media/news/health-needs-heighten-as-sudan-conflict-displaces-millions-of-people.html . Accessed 10 Dec 2023.

WHO. Guidelines for the treatment of malaria, 2nd edition. Geneva: World Health Organization; 2010. https://www.paho.org/en/documents/guidelines-treatment-malaria-second-edition-2010 . Accessed 10 Dec 2023.

Federal Ministry of Health—Sudan. Sudan malaria case management protocol. National Malaria Control Programme; 2017.

Federal Ministry of Health—Sudan. Sudan malaria case management protocol. National Malaria Control Program; 2023.

Abdelgader I, Elmardi KA, Githinji S, Zurovac D, Snow RW, Noor AM. Quality of malaria case-management in Sudan. BMC Public Health. 2012;12:11.

Article   PubMed   PubMed Central   Google Scholar  

Lubell Y, Reyburn H, Mbakilwa H, Mwangi R, Chonya K, Whitty CJM, et al. The cost-effectiveness of parasitologic diagnosis for malaria-suspected patients in an era of combination therapy. Am J Trop Med Hyg. 2007;77:128–32.

Article   PubMed   Google Scholar  

Biai S, Rodrigues A, Gomes M, Ribeiro I, Sodemann M, Alves F, et al. Reduced in-hospital mortality after improved management of children under 5 years admitted to hospital with malaria: randomised trial. BMJ. 2007;335:862.

Kruk M, Gage A, Joseph N, Danaei G, García-Saisó S, Salomon J, et al. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018;392:2203–12.

Amboko B, Stepniewska K, Malla L, Machini B, Bejon P, Snow RW, et al. Determinants of improvement trends in health workers’ compliance with outpatient malaria case-management guidelines at health facilities with available “test and treat” commodities in Kenya. PLoS ONE. 2021;16: e0259020.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Amboko B, Stepniewska K, Macharia PM, Machini B, Bejon P, Snow RW, et al. Trends in health workers’ compliance with outpatient malaria case-management guidelines across malaria epidemiological zones in Kenya, 2010–2016. Malar J. 2020;19:406.

Amboko B, Stepniewska K, Machini B, Bejon P, Snow RW, Zurovac D. Factors influencing health workers’ compliance with outpatient malaria ‘test and treat’ guidelines during the plateauing performance phase in Kenya, 2014–2016. Malar J. 2022;21:68.

Bawate C, Callender-Carter ST, Nsajju B, Bwayo D. Factors affecting adherence to national malaria treatment guidelines in management of malaria among public healthcare workers in Kamuli District, Uganda. Malar J. 2016;15:112.

Muhindo Mavoko H, Ilombe G, Inocêncio da Luz R, Kutekemeni A, Van Geertruyden J-P, Lutumba P. Malaria policies versus practices, a reality check from Kinshasa, the capital of the Democratic Republic of Congo. BMC Public Health. 2015;15:352.

Salomão CA, Sacarlal J, Chilundo B, Gudo ES. Prescription practices for malaria in Mozambique: poor adherence to the national protocols for malaria treatment in 22 public health facilities. Malar J. 2015;14:483.

Bulafu D, Nagawa Tamale B, Ninsiima LR, Baguma JN, Namakula LN, Niyongabo F, et al. Adherence to malaria treatment guidelines among health care workers in private health facilities in Kampala’s informal settlements, Uganda. PLoS Global Public Health. 2023;3: e0002220.

Baraka V, Nhama A, Aide P, Bassat Q, David A, Gesase S, et al. Prescription patterns and compliance with World Health Organization recommendations for the management of uncomplicated and severe malaria: a prospective, real-world study in sub-Saharan Africa. Malar J. 2023;22:215.

Plucinski MM, Ferreira M, Ferreira CM, Burns J, Gaparayi P, Joao L, et al. Evaluating malaria case management at public health facilities in two provinces in Angola. Malar J. 2017;16:186.

Plucinski MM, Guilavogui T, Camara A, Ndiop M, Cisse M, Painter J, et al. How far are we from reaching universal malaria testing of all fever cases? Am J Trop Med Hyg. 2018;99:670–9.

Bruxvoort KJ, Leurent B, Chandler CIR, Ansah EK, Baiden F, Bjorkman A, et al. The impact of introducing malaria rapid diagnostic tests on fever case management: a synthesis of ten studies from the ACT Consortium. Am J Trop Med Hyg. 2017;97:1170–9.

O’Boyle S, Bruxvoort KJ, Ansah EK, Burchett HED, Chandler CIR, Clarke SE, et al. Patients with positive malaria tests not given artemisinin-based combination therapies: a research synthesis describing under-prescription of antimalarial medicines in Africa. BMC Med. 2020;18:17.

Boyce MR, O’Meara WP. Use of malaria RDTs in various health contexts across sub-Saharan Africa: a systematic review. BMC Public Health. 2017;17:470.

Kabaghe AN, Visser BJ, Spijker R, Phiri KS, Grobusch MP, van Vugt M. Health workers’ compliance to rapid diagnostic tests (RDTs) to guide malaria treatment: a systematic review and meta-analysis. Malar J. 2016;15:163.

Namuyinga RJ, Mwandama D, Moyo D, Gumbo A, Troell P, Kobayashi M, et al. Health worker adherence to malaria treatment guidelines at outpatient health facilities in southern Malawi following implementation of universal access to diagnostic testing. Malar J. 2017;16:40.

Steinhardt LC, Chinkhumba J, Wolkon A, Luka M, Luhanga M, Sande J, et al. Quality of malaria case management in Malawi: results from a nationally representative health facility survey. PLoS ONE. 2014;9: e89050.

Ojo AA, Maxwell K, Oresanya O, Adaji J, Hamade P, Tibenderana JK, et al. Health systems readiness and quality of inpatient malaria case-management in Kano State. Malar J. 2020;19:384.

Signorell A, Awor P, Okitawutshu J, Tshefu A, Omoluabi E, Hetzel MW, et al. Health worker compliance with severe malaria treatment guidelines in the context of implementing pre-referral rectal artesunate in the Democratic Republic of the Congo, Nigeria, and Uganda: an operational study. PLoS Med. 2023;20: e1004189.

Achan J, Tibenderana J, Kyabayinze D, Mawejje H, Mugizi R, Mpeka B, et al. Case management of severe malaria-a forgotten practice: experiences from health facilities in Uganda. PLoS ONE. 2011;6: e17053.

Shah MP, Briggs-Hagen M, Chinkhumba J, Bauleni A, Chalira A, Moyo D, et al. Adherence to national guidelines for the diagnosis and management of severe malaria: a nationwide, cross-sectional survey in Malawi. Malar J. 2016;15:369.

Zurovac D, Machini B, Kiptui R, Memusi D, Amboko B, Kigen S, et al. Monitoring health systems readiness and inpatient malaria case-management at Kenyan County Hospitals. Malar J. 2018;17:213.

Elmannan AAA, Elmardi KA, Idris YA, Spector JM, Ali NA, Malik EM. Anti-malarial prescribing practices in Sudan eight years after introduction of artemisinin-based combination therapies and implications for development of drug resistance. BMC Pharmacol Toxicol. 2015;16:3.

Bilal JA, Gasim GI, Abdien MT, Elmardi KA, Malik EM, Adam I. Poor adherence to the malaria management protocol among health workers attending under-five year old febrile children at Omdurman Hospital Sudan. Malar J. 2015;14:34.

Elnour FA, Alagib MEA, Bansal D, Farag EABA, Malik EM. Severe malaria management: current situation, challenges and lessons learned from Gezira State, Sudan. Malar J. 2019;18:170.

Federal Ministry of Health—Sudan. Sudan malaria strategic plan 2021–2026, update March 2023. National Malaria Control Programme; 2023.

WHO. Understanding the labour market of human resources for health in Sudan. Working Paper, November 2013. https://www.who.int/publications/m/item/2013-sudan-hrh-labour-market . Accessed 15 Dec 2023.

Ebrahim EMA, Ghebrehiwot L, Abdalgfar T, Juni MH. Health care system in Sudan: review and analysis of strength, weakness, opportunity, and threats (SWOT analysis). Sudan J Med Sci. 2017;12:133–50.

Article   Google Scholar  

Federal Ministry of Health—Sudan. Sudan malaria indicator survey 2016. Directorate of Communicable and Non-communicable Diseases Control; 2017.

Office for the Coordination of Humanitarian Affairs. Sudan situation report, 2 November 2023. https://www.unocha.org/publications/report/sudan/sudan-situation-report-2-november-2023-enar . Accessed 16 Dec 2023.

Nowell LS, Norris JM, White DE, Moules NJ. Thematic analysis: striving to meet the trustworthiness criteria. Int J Qual Methods. 2017;16:160940691773384.

Hanson K, Goodman C. Testing times: trends in availability, price, and market share of malaria diagnostics in the public and private healthcare sector across eight sub-Saharan African countries from 2009 to 2015. Malar J. 2017;16:205.

Kuupiel D, Bawontuo V, Drain PK, Gwala N, Mashamba-Thompson TP. Supply chain management and accessibility to point-of-care testing in resource-limited settings: a systematic scoping review. BMC Health Serv Res. 2019;19:519.

Ashton RA, Worges M, Zeh Meka A, Yikpotey P, Domkam Kammogne I, Chanda-Kapata P, et al. Can outreach training and supportive supervision improve competency in malaria service delivery? An evaluation in Cameroon, Ghana, Niger, and Zambia. Am J Trop Med Hyg. 2023;4: tpmd230150.

Federal Ministry of Health—Sudan. Sudan quality assurance guide for parasitological diagnosis of malaria (draft). National Malaria Control Programme; 2023.

WHO. Malaria microscopy—quality assurance manual. Geneva: World Health Organization; 2016.

Galactionova K, Tediosi F, de Savigny D, Smith T, Tanner M. Effective coverage and systems effectiveness for malaria case management in sub-Saharan African countries. PLoS ONE. 2015;10: e0127818.

Mace KE, Mwandama D, Jafali J, Luka M, Filler SJ, Sande J, et al. Adherence to treatment with artemether–lumefantrine for uncomplicated malaria in rural Malawi. Clin Infect Dis. 2011;53:772–9.

Article   CAS   PubMed   Google Scholar  

Talisuna AO, Oburu A, Githinji S, Malinga J, Amboko B, Bejon P, et al. Efficacy of text-message reminders on paediatric malaria treatment adherence and their post-treatment return to health facilities in Kenya: a randomized controlled trial. Malar J. 2017;16:46.

Federal Ministry of Health—Sudan. Malaria case management training manual. Directorate of Communicable and Non Communicable Disease; 2023.

Phu NH, Tuan PQ, Day N, Mai NT, Chau TT, Chuong LV, et al. Randomized controlled trial of artesunate or artemether in Vietnamese adults with severe falciparum malaria. Malar J. 2010;9:97.

Hetzel MW, Okitawutshu J, Tshefu A, Omoluabi E, Awor P, Signorell A, et al. Effectiveness of rectal artesunate as pre-referral treatment for severe malaria in children under 5 years of age: a multi-country observational study. BMC Med. 2022;20:343.

Mohammed NMA. Impact of multifaceted clinical pharmacist interventions on implementation of national malaria protocol, in Wad Madani Maternity Hospital, Gezira State, Sudan (2020). PhD Thesis—University of Gezira; July 2022.

Rowe AK, Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D. Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. Lancet Glob Health. 2018;6:1163–75.

Bernard YM, Ahmed J, Mostel J, Ba T, Ciceron AC, Busiga M, et al. Clinical outreach training and supportive supervision quality-of-care analysis: impact of readiness factors on health worker competencies in malaria case management in Cameroon, Mali, and Niger. Am J Trop Med Hyg. 2023;26: tpmd230479.

Zurovac D, Githinji S, Memusi D, Kigen S, Machini B, Muturi A, et al. Major improvements in the quality of malaria case-management under the “test and treat” policy in Kenya. PLoS ONE. 2014;9: e92782.

Chandler CI, Mwangi R, Mbakilwa H, Olomi R, Whitty CJ, Reyburn H. Malaria overdiagnosis: is patient pressure the problem? Health Policy Plan. 2008;23:170–8.

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Acknowledgements

The authors would like to thank all the health workers who participated in the study. The authors are grateful to Dr. Mujahid Abdin for the creation of the study area map and Dr. Mariam Adam Babiker for comments on the manuscript. The authors express their sincere gratitude to the Primary Health Care Directorate which funded orientation training for health workers which were used as operational avenues for the study FGDs. Special thanks to the Federal Ministry of Health, the Northern State Ministry of Health and the National Malaria Control Programme for continued study support.

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Sahar Khalid Mohamed, Duha Khalid Mohamed, Khansaa Ahmed & Fadwa Saad

Department of Community Medicine, Faculty of Medicine, Al-Neelain University, Khartoum, Sudan

Sahar Khalid Mohamed

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SKM conceived and designed the study, collected the data, performed the analyses, interpreted the study findings and wrote the first draft of the manuscript. KA, DKM, FMS and DZ contributed to the interpretation of the study findings and revision of the manuscript. All the authors have read and approved the final manuscript.

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Correspondence to Sahar Khalid Mohamed .

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Khalid Mohamed, S., Khalid Mohamed, D., Ahmed, K. et al. Health workers’ adherence to malaria case management protocols in Northern Sudan: a qualitative study. Malar J 23 , 170 (2024). https://doi.org/10.1186/s12936-024-04998-9

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Received : 17 March 2024

Accepted : 23 May 2024

Published : 30 May 2024

DOI : https://doi.org/10.1186/s12936-024-04998-9

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