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Country implementation of the international code of marketing of breast-milk substitutes: status report 2011

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Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

WHO Library Cataloguing-in-Publication Data Country implementation of the international code of marketing of breast-milk substitutes: status report 2011. 1.Breast feeding. 2.Infant food. 3.Bottle feeding. 4.Infant nutrition disorders – prevention and control. 4.Growth and development. 5.National health programs. I.World Health Organization. ISBN 978 92 4 150598 7 (NLM classification : WS 120)

© World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for non-commercial distribution – should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Cover design by Alberto March Printed in Switzerland Suggested citation WHO. Country implementation of the International Code of Marketing of Breast-milk Substitutes: status report 2011. Geneva, World Health Organization, 2013.

Contents Acknowledgements iv Abbreviations v

Executive summary vii 1. Introduction 1 2. Data on country implementation of the International Code 4 2.1 Legislative status 6 2.2 Key provisions of national legal measures 7 2.3 Specific issues and concerns 11

3. The Code: key elements for successful implementation 13 4. Why is it important to implement/monitor the implementation of the Code? 16 5. How to strengthen implementation of the Code 19 References 22

Annexes I: Legislative status and historical evolution by country or area 26 II: Key provisions in the legal measures by country 39

iii

Acknowledgements The preparation of this report was coordinated by Dr Carmen Casanovas, Department of Nutrition for Health and Development and Mr Marcus Stahlhofer, Department of Maternal, Newborn, Child and Adolescent Health under the supervision of Dr Francesco Branca, Director, Department of Nutrition for Health and Development, World Health Organization (WHO), Geneva, Switzerland. A preliminary draft was written by Mr Alessandro Iellamo and Mr Rene Raya, independent consultants from the Philippines. Most of the data presented in this document was shared directly by WHO Member States, Associate Members and other countries or areas, as articulated in individual country reports and completed questionnaires. Technical inputs were provided by Dr Juan Pablo Peña-Rosas from the Department of Nutrition for Health and Development, and Dr Bernadette Daelmans and Dr Elizabeth Mason from the Department of Maternal, Newborn, Child and Adolescent Health, WHO, and from Mr David Clark, Nutrition Specialist (Legal), Programme Division, UNICEF, New York, USA. We would like to thank internal and external reviewers, particularly Dr Peggy Henderson who edited the draft version of this report. All individuals involved in the preparation of this publication completed a WHO Declaration of Interest, and it was considered that none had a perceived or real conflict of interest.

Financial support WHO thanks the Government of Luxembourg and Micronutrient Initiative for providing financial support for this work. Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Abbreviations BMS Code CRC DoH Breast-milk substitute International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly Resolutions Convention on the Rights of the Child Department of Health

International Code International Code of Marketing of Breast-milk Substitutes IRR MoH NGO PAHO UNICEF WBTi WHA WHO Implementing rules and regulations Ministry of Health Nongovernmental organization Pan American Health Organization United Nations Children’s Fund World Breastfeeding Trends Initiative World Health Assembly World Health Organization

Executive summary Globally, breastfeeding has the potential to prevent 220 000 deaths among children under five each year. Early initiation of breastfeeding could prevent about one fifth of neonatal deaths, but less than half of infants are put to the breast within one hour of birth. WHO recommends that all infants should be exclusively breastfed for the first six months of life, but actual practice is low (38%). Only about half of children aged 20–23 months are breastfed despite the recommendation that breastfeeding continue for up to 2 years or beyond. The implementation and enforcement of the standards and recommendations contained in the International Code of Marketing of Breast-milk Substitutes and subsequent relevant Health Assembly Resolutions (the Code) are critical for ensuring an environment that supports proper infant and young child feeding and contributing to the attainment of Millennium Development Goal 4 (reduce child mortality by two thirds). This report summarizes the progress countries have made in implementing the Code. It is based on data received from WHO Member States between 2008 and 2010 and on information for 2011 from UNICEF. Thirty years after its endorsement, only 37 out of 199 countries reporting (19%) have passed laws reflecting all of the recommendations of the Code. Sixty-nine countries (35%) fully prohibit advertising of breast-milk substitutes; 62 (31%) completely prohibit free samples or low-cost suppplies; 64 (32%) completely prohibit gifts of any kind from relevant manufacturers to health workers; and 83 (42%) require a message about the superiority of breastfeeding on breastmilk substitute labels. Only 45 countries (23%) report having a functioning implementation and monitoring system. Key areas where further efforts are needed which were raised by Member States include: 1) gaps in existing national legislation; 2) clarity on processes necessary for the adaptation of the Code; 3) difficulty in gaining regulatory approval of draft measures; 4) weak implementation; 5) poor monitoring systems; and 5) reported violations by the industry. To ensure the successful implementation of the Code, the following are considered critical by government officials or national authorities: 1) political commitment and advocacy; 2) a critical mass of advocates; 3) legislation; and 4) knowledge about the Code and its implications. Actions at both international and national levels are needed to ensure full implementation of the Code. Member States need additional support from international agencies. Human rights treaty monitoring bodies must step-up reviews of Code implementation as part of States’ obligations under relevant human rights instruments. There is also a need to invest in efforts to disseminate information on Code implementation and create capacity for Code monitoring. At the national level, governments should pass legislation, set up functional monitoring and enforcement mechanisms, forge partnerships with civil society and set up documentation and reporting systems for violations. The Code remains a catalyst for change and a core element in which countries should invest to curb child mortality through improved infant and young child nutrition.

vii

Introduction

On 21 May 1981, the World Health Assembly (WHA) adopted the International Code of Marketing of Breast-milk Substitutes (hereinafter referred to as the International Code) under Resolution Number 34.22, with 118 votes for, 1 against and 3 abstentions. The International Code took into account a WHO/UNICEF report on infant and young child feeding which stressed the “importance of an adequate basis on which women can have a true and objective choice” (1). It also emphasized “the need for education and information about infant and young child feeding and for the establishment of measures at government level to protect women against misinformation”.1 The International Code also recognized that “inappropriate feeding practices lead to infant malnutrition, morbidity and mortality in all countries and that improper practice in the marketing of breast-milk substitutes [BMS] and related products can contribute to this major public health problem”. Subsequent WHA Resolutions have reaffirmed and stressed the importance of Member States promoting, protecting and supporting breastfeeding through the passage of meaningful legislation and/or regulations that would put the minimum standards recommended by the International Code in place. After 20 years of International Code implementation, the WHO/UNICEF Global strategy for infant and young child feeding (2 ) clearly indicated that: Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mothers. As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Effective implementation and monitoring of the International Code is also supported by the United Nations Convention on the Rights of the Child (CRC), and its monitoring body, the Committee on the Rights of the Child, thus providing an additional normative and legal foundation. Article 24 of the CRC – the child’s right to health and health care – requires countries to take appropriate measures to “combat disease and malnutrition” through, inter alia, the “provision of adequate nutritious foods”, and to “ensure that all segments of society, in particular parents and children, are informed (…) and supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding (…) ”. In addition, in its review of national implementation of the CRC and subsequent dialogue with governments, the Committee on the Rights of the Child consistently calls upon countries to ensure full protection, promotion and support to breastfeeding, and to give effect to the International Code and subsequent relevant WHA resolutions. This has been reiterated in General Comment No. 15, The right of the child to the enjoyment of the highest attainable standard of health (Article 24) (3 ).2 Globally, breastfeeding has the potential to prevent 220 000 under-five deaths per year (4 ). Over 30 studies from around the world, in developing and developed countries alike, have shown that breastfeeding dramatically reduces the risk of dying (5 ). A WHO pooled analysis (6 ) indicates that breastfeeding could prevent over three fourths of deaths in early infancy, and 37% of deaths during the second year of life. A cohort study in Brazil revealed that non-breastfed children, compared to those exclusively breastfed, have 14 times the risk of dying from diarrhoea, 3.6 times the risk of dying from pneumonia, and 2.5 times the risk of dying from other infections (7). A pooled analysis of studies in Ghana, India and Peru showed that non-breastfed infants are 10 times more susceptible to dying, compared to predominantly or exclusively breastfed infants. The risk of death was 2.5 times higher comparing partially breastfed infants with those predominantly or exclusively breastfed (8 ). A study in Ghana revealed that infants who were 1

International Code of Marketing of Breast-milk Substitutes. Geneva, World Health Organization, 1981 (http://www. who.int/nutrition/publications/infantfeeding/9241541601/en/index.html, accessed 26 July 2013) States are required to introduce into national law, implement and enforce internationally agreed standards concerning children’s right to health, including the International Code of Marketing of Breast-milk Substitutes (Paragraph 44, page 11).

exclusively breastfed during the first hour of life were 9 times less likely to die than those who were initiated to mixed formula and breast milk within 72 hours of birth ( 9 ). Even in the United States of America, where death from infection is relatively uncommon, there were 21% to 24% fewer deaths among children who were breastfed (10 ). Cognitive development is enhanced and the risk of some chronic diseases reduced by breastfeeding. Numerous studies, including a randomized trial (7), show that being breastfed enhances intelligence quotient; the randomized trial showed breastfeeding promotion raised intelligence quotient by about 6 points. There are also long-term benefits of breastfeeding in the form of lower blood pressure and total cholesterol, and lower prevalence of overweight/obesity and type-2 diabetes (6 ). With regard to mothers, high quality studies show that breastfeeding reduces ovarian cancer by 27% to 40% (11–13 ) and breast cancer by 40% to 80% (14–17). Exclusive breastfeeding has an effect on birth spacing that is as effective as contraceptives for the first 6 months after delivery (18 ). Breastfeeding, which releases oxytocin after delivery, also reduces uterine bleeding. Despite the overwhelming short- and long-term benefits of breastfeeding for both the child and mother, a large gap still separates current practices from accepted recommendations (19 ). Although early initiation could prevent about one fifth of neonatal deaths, less than half of infants are put to the breast within one hour of birth. Although WHO recommends 6 months of exclusive breastfeeding, current prevalence of this practice is low (36%). Only about 50% of children 20–23 months old are breastfed despite the recommendation that all children be breastfed for up to 2 years or beyond. The implementation and enforcement of the standards and recommendations contained in the International Code and subsequent WHA Resolutions (hereinafter referred to as the Code) by Member States are critical in ensuring proper infant and young child feeding practices are in place and contribute to the attainment of Millennium Development Goals 4 and 5. WHO reports to the WHA on the status of Code implementation every other year. This report is based on information provided by Member States, usually in a paragraph summarizing the situation in the six WHO regions. WHA Resolution 65.6 from May 20121 requested WHO “to support Member States in the monitoring and evaluation of policies and programmes, including those of the Global strategy for infant and young child feeding, with the latest evidence on nutrition and “to report, through the Executive Board, to the Sixty-seventh World Health Assembly on progress in the implementation of the comprehensive implementation plan, together with the report on implementation of the International Code of Marketing of Breast-milk Substitutes and related Health Assembly resolutions”. This is the first WHO publication documenting actions taken by countries; it is intended to support Member States to develop or strengthen legislative, regulatory and/or other effective measures to control the marketing of breast-milk substitutes, as requested by the WHA in May 2012.

Sixty-firth World Health Assembly. Resolution 65.6, 26 May 2012 (http://apps.who.int/gb/ebwha/pdf_files/WHA65/ A65_R6-en.pdf, accessed 26 July 2013).

Data on country implementation of the International Code

The adoption of the International Code by the WHA in May 1981 through resolution WHA34.22 marked an historical step in efforts to protect breastfeeding and contribute to the establishment and support of appropriate infant and young child feeding practices. Since the International Code was endorsed as a recommendation under resolution WHA34.22, it is not legally binding upon WHO Member States. However, Member States are expected to adhere to the aim and spirit of the International Code, and under Article 11.1 are requested to “take action to give effect to the principles and aim of this Code, as appropriate to their social and legislative framework, including the adoption of national legislation, regulation or other suitable measures…” In addition, as previously mentioned, implementation and monitoring of the Code is further supported by legal obligations under the CRC.1 After 30 years since its passage, Member States and other countries and areas from all the WHO regions have been working at different levels to translate the global recommendations into effective local measures, to be able to put the comprehensive set of standards and policies into practice. In line with Article 62 of the WHO Constitution, Member States are requested to update WHO on the status of implementation of the Code regularly and at the same time, in compliance with Article 11.7 of the International Code, WHO reports the status of implementation of the Code to the World Health Assembly. This report presents a summary of the progress made by countries in the implementation of the Code, limited to the following set of information: a) legislative status; b) specific provisions: advertising of BMS to the general public, sale or promotions to the general public, free or lowcost supplies of BMS, materials or gifts to health workers and health facilities, labelling and monitoring; and c) issues of concern. Several sources were used to review the status of Code implementation: ■■ WHO. Summary code survey for the report to the World Health Assembly on the implementation of the International Code of Marketing of Breast-milk Substitutes. Geneva, WHO, 2008. ■■ WHO. Survey for the global nutrition policy review: module 3 on the International Code of Marketing of Breast-milk Substitutes. Geneva, WHO, 2010. ■■ UNICEF. National implementation of the International Code of Marketing of Breast-milk Substitutes. New York, UNICEF, 2011. ■■ Pan American Health Organization [PAHO]. 30 Años del Código en América Latina [30 years of the Code in Latin America]. Washington DC, PAHO, 2011. ■■ World Breastfeeding Trends Initiative [WBTi]. Toolkit (2011) and website (for reports where a ministry of health is indicated as a part of the monitoring process), http://www. worldbreastfeedingtrends.org/, accessed 12 May 2012. ■■ European Union Project on Promotion of Breastfeeding in Europe. Protection, promotion and support of breastfeeding in Europe: a blueprint for action (revised). Luxembourg, European Commission, Directorate Public Health and Risk Assessment, 2008. These references were used to generate the tables in this report, including those in Annex I and Annex II, based on data for the period up to April 2011. Several issues and concerns were noted during the review and processing of the data. The survey conducted by WHO clearly shows that there is a need to clarify some of the language used in the Code, and develop a definition of terms and/or a glossary to serve as a guide in filling out the questionnaire. In some cases, contradictions between references were observed, mainly in relation to the actual legislative status of existing measures in several countries and areas, as highlighted in Annex I.

The CRC has been ratified by all but two United Nations Member States – Somalia and the United States – and thus enjoys near-universal ratification and recognition as the principal legally binding treaty on the protection and promotion of all aspects related to the overall well-being of children.

2.1 Legislative status As mentioned above, Article 11.1 of the International Code states that “Governments should take action to give effect to the principles and aim of this Code, as appropriate to their social and legislative framework, including the adoption of national legislation, regulation or other suitable measures…” Table 1 shows actual progress as reported by countries and areas in their efforts to apply the Code. Table 1 Legislative status by WHO Region Action to end free supplies only

No information

Few voluntary

Many into law

Still studying

Few into law

Full into law

No action

Voluntary

Drafted

WHO Region African Americas Eastern Mediterranean European South-East Asia Western Pacific Total

13 8 7 2 4 3 37

6 5 5 23 2 5 (1) 46 (1)

5 4 (1) 2 6 0 3 20 (1)

9 9 2 0 3 8 31

1 2 0 1 1 1 6

6 1 1 2 0 0 10

3 0 1 7 0 0 11

0 0 2 0 0 0 2

2 5 (2) 1 1 0 1 10 (2)

2 1 (1) 11 1 6 21 (1)

47 35 (3) 21 (1) 53 11 27 (1) 194 (5)

Note: The figures in parentheses indicate additional countries or areas that are not WHO Member States.

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

UNICEF categorizes the legislative status of the implementation of the Code into 10 levels (20 ), which are used in this report: 1. 2. 3. 4. 5. 6. 7. 8. 9. full into law, which means they have enacted legislation or other legal measures on all provisions of the Code; many into law, which means they have enacted legislation or other legal measures on many provisions of the Code; few into law, which means they have enacted legislation or other legal measures on a few provisions of the Code; voluntary, which means they have adopted all or most of the provisions of the Code through non-binding measures; few voluntary, which means they have adopted some but not all provisions of the Code through non-binding measures; drafted, which means that there is a final draft of a law or other measures, but it is still awaiting approval; still studying, which means they are still studying how to implement the Code; action to end free supplies onl y, which means they have taken some action to end free and low-cost supplies of BMS, but they have not implemented other provisions of the Code; no action, which means they have not taken any steps towards the implementation of the Code; and

10. no available information, which means there is no information to determine the legislative status of the Code in the country.

Total

As of April 2011, out of 199 countries reporting, 165 countries (83%) had translated the Code into a national measure, a major milestone in the efforts towards the protection of breastfeeding. Of these 165 countries, 105 (64%) have translated the Code into national legislation, but only 37 (22%) have been able to adapt in full the various recommendations of the Code. While there has been major progress in countries in adapting the Code, much still has to be done to support countries in ensuring that all its provisions are translated into national legislation.

2.2 Key provisions of national legal measures As stated earlier, Article 62 of the WHO Constitution requests Member States to update WHO on the status of implementation of the Code regularly. At the same time, in compliance with Article 11.7 of the International Code, WHO reports the status of implementation of the Code to the World Health Assembly. WHO has disseminated to all Member States the Nutrition policy review survey, in which Module 3 is dedicated to key information and data on the status of implementation of the Code as well as the key provisions of the legal measures in place in each country. The data collected from surveys carried out in 2007 (published in 2008) and 2010 helped generate the tables that present the key provisions of national legal measures. The scope of the International Code, as set out in Article 2, applies to the marketing, and practices related thereto, of the following products: breast-milk substitutes, including infant formula; other milk products, foods and beverages, including bottle-fed complementary foods, when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breast milk; feeding bottles and teats.

It also applies to their quality and availability, and to information concerning their use. Table 2 shows the age of infants to which the scope of national legal measures applies. Table 2 Scope of the Code – age range of infants (months) by WHO Region No answer/ No information 31 26 (3) 14 (1) 26 5 19 121 (4) Age (months) No age limit

0–60

0–30

0–36

0–24

WHO region African Americas Eastern Mediterranean European South-East Asia Western Pacific Total

0 0 1 1 0 1 3

2 0 0 6 1 1 10

2 2 3 12 2 2 (1) 23 (1)

4 6 3 1 3 2 19

1 0 0 0 0 0 1

4 1 0 7 0 2 14

2 0 0 0 0 0 2

1 0 0 0 0 0 1

47 35 (3) 21 (1) 53 11 27 (1) 194 (5)

Note: The figures in parentheses indicate additional countries or areas that are not WHO Member States.

Of 199 countries, 125 (63%) did not answer or did not clearly state the scope of the legal measure in terms of the age to which it applies. A total of 74 countries reported some age limit in the scope of their measures. Of these, 24 (32%) reported an age limit of 0–12 months, 19 (26%) reported an age limit of 0–24 months and 15 (20%) had an age limit of 0–36 months. The data show that country-level adaptation of the Code and subsequent development of local measures vary based on the interpretation and understanding of the recommendations of the Code.

Total

0–12

0–6

0–4

2.2.1 Prohibition of advertising and sales promotions of BMS Article 5.1 of the International Code states that “there should be no advertising or other form of promotion to the general public of products within the scope of the Code”.1 Article 5.3 further states that there should be no point-of-sale advertising, giving of samples, or any other promotion device to induce sales directly to the consumer at the retail level, such as special displays, discount coupons, premiums, special sales, loss-leaders and tie-in sales. Of 199 countries responding, only 80 (40%) provided information on advertising products within the scope of the Code ( Table 3 ). In all, 69 countries (35%) fully prohibited advertising. A total of 119 countries (60%) did not answer or did not clearly state whether there was a prohibition. Table 3 WHO Region African Americas Eastern Mediterranean European South-East Asia Western Pacific Total

Prohibition of advertising of BMS by WHO Region (21) Full 16 12 5 22 6 7 (1) 68 (1) Partial 0 0 0 4 0 1 5 No 0 1 1 4 0 0 6 No answer/ No information 31 22 (3) 15 (1) 23 5 19 115 (4) Total 47 35 (3) 21 (1) 53 11 27 (1) 194 (5)

Note: The figures in parentheses indicate additional countries or areas that are not WHO Member States.

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Table 4 shows that 199 countries also provided information on the prohibition of sales promotions, of which 68 (34%) fully prohibited them. However, 119 (60%) did not answer or did not clearly state their stand on their prohibition. Table 4 WHO Region African Americas Eastern Mediterranean European South-East Asia Western Pacific Total

Prohibition of sale promotions by WHO Region (21) Full 16 12 4 22 6 7 (1) 67 (1) Partial 0 0 0 4 0 1 5 No 0 1 2 4 0 0 7 No answer/ No information 31 22 (3) 15 (1) 23 5 19 115 (4) Total 47 35 (3) 21 (1) 53 11 27 (1) 194 (5)

Note: The figures in parentheses indicate additional countries or areas that are not WHO Member States.

The scope of the International Code as set out by Article 2 states that “the Code applies to the marketing, and practices related thereto, of the following products: breast-milk substitutes, including infant formula; other milk products, foods and beverages, including bottle fed complementary foods, when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breast milk; feeding bottles and teats. It also applies to their quality and availability, and to information concerning their use”.

2.2.2 Prohibition of free or low-cost supplies of BMS and materials/gifts to health workers and health facilities Article 6.6 of the International Code states that free or low-cost supplies of BMS to health care facilities should be prohibited. This article applies to both use of such products within a facility and to the distribution of such products for use outside of a facility. This article is further supported by WHA Resolution 47.5. Free or low-cost supplies may only be given for distribution to those infants who must be fed with BMS, and may only be distributed by the institution itself. Such donations or low-price sales should not be used by manufacturers or distributors as a sales inducement. Table 5 illustrates that out of 199 countries, 119 (60%) did not answer or did not clearly state their stand on the prohibition of free or low-cost supplies of BMS. Of the 79 that provided this information, 62 completely prohibited free samples or low-cost supplies. Only 10 countries (5%) reported that they did not prohibit free or low-cost supplies of BMS. Table 5 WHO Region African Americas Eastern Mediterranean European South-East Asia Western Pacific Total

Prohibition of free/low-cost supplies of BMS by WHO Region (21) Full/Yes 15 12 5 15 6 8 (1) 61 (1) Partial 1 0 1 6 0 0 8 No 0 1 1 8 0 0 10 No answer/ No information 31 22 (3) 14 (1) 24 5 19 115 (4) Total 47 35 (3) 21 (1) 53 11 27 (1) 194 (5)

Note: The figures in parentheses indicate additional countries or areas that are not WHO Member States.

According to Article 7.3 of the International Code, neither financial nor material inducements to promote products within the scope of the Code should be offered by manufacturers or distributors to health workers or members of their families, nor should they be accepted by health workers or members of their families. Table 6 shows that 64 countries (32%) reported completely prohibiting gifts to health workers, in full compliance with the Code, but 12 countries (6%) said they did not. Out of 199 countries, 120 did not answer or did not clearly state whether they prohibited materials or gifts to health workers and health facilities. Table 6 Prohibition of materials/gifts to health workers and health facilities by WHO Region (21) Full/yes 16 12 6 15 6 8 (1) 63 (1) No 0 1 1 10 0 0 12 Partial 0 0 0 3 0 0 3 No answer/ No information 31 22 (3) 14 (1) 25 5 19 116 (4) Total 47 35 (3) 21 (1) 53 11 27 (1) 194 (5)

WHO Region African Americas Eastern Mediterranean European South-East Asia Western Pacific Total

Note: The figures in parentheses indicate additional countries or areas that are not WHO Member States.

2.2.3 Labelling According to Article 9.2(b) manufacturers and distributors of infant formula should ensure that each container has a clear, conspicuous, easily readable and understandable message either printed on it or on a tightly-sealed label attached, in an appropriate language, which includes a statement of the superiority of breastfeeding. Table 7 shows that 83 countries (42%) reported requiring a message on the superiority of breastfeeding on BMS labels, while one country (1%) reported that there is no requirement. Of the total of 199 countries, 115 did not answer or did not clearly state whether having a message on the superiority of breastfeeding on the label was required. Table 7 WHO Region African Americas Eastern Mediterranean European South-East Asian Western Pacific Total

Labelling: message on superiority of breastfeeding by WHO Region (21) Yes 15 12 8 31 6 10 (1) 82 (1) No 0 1 0 0 0 0 1 No answer/ No information 32 22 (3) 13 (1) 22 5 17 111 (4) Total 47 35 (3) 21 (1) 53 11 27 (1) 194 (5)

Note: The figures in parentheses indicate additional countries or areas that are not WHO Member States.

As shown in Table 8, 79 countries (40%) reported that there should be a recommended age for the designated product on the label, in full compliance with the recommendations of the Code, while 4 countries (2%) reported none. Out of 199 countries, 116 did not answer or did not clearly state whether or not they require a recommended age on the label of BMS. Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Table 8 WHO Region African Americas

Labelling: recommended age for designated product by WHO Region (21) Yes 16 12 7 30 5 8 (1) 78 (1) No 0 0 1 1 1 1 4 No answer/ No information 31 23 (3) 13 (1) 22 5 18 112 (4) Total 47 35 (3) 21 (1) 53 11 27 (1) 194 (5)

Eastern Mediterranean European South-East Asian Western Pacific Total

Note: The figures in parentheses indicate additional countries or areas that are not WHO Member States.

2.2.4 Functioning implementation and monitoring system Article 11 of the International Code includes a requirement for governments to take necessary measures to give effect to the provisions of the Code within their legal and social infrastructure, including the adoption of national legislation, regulations or other appropriate measures. The responsibility for monitoring the implementation of the Code rests with governments, both individually and in collaboration with other parties (e.g. WHO, nongovernmental organizations [NGOs], professional groups). Criteria for monitoring mechanisms to ensure efficacy include: ■■ independence and transparency ■■ freedom from commercial influence ■■ empowerment to investigate code violations ■■ empowerment to impose legal sanctions.

Responses related to implementation and monitoring mechanisms are summarized in Table 9. Table 9 WHO Region African Americas Eastern Mediterranean European South-East Asian Western Pacific Total

Functioning implementation and monitoring system by WHO Region (21) Full/Yes 10 6 5 13 3 7 44 (1) Partial 1 0 0 9 0 0 10 No 4 7 2 8 3 3 27 No answer/No information 32 22 (3) 14 (1) 23 5 17 113 (4) Total 47 35 (3) 21 (1) 53 11 27 (1) 194 (5)

Note: The figures in parentheses indicate additional countries or areas that are not WHO Member States.

Only 45 countries (23%) reported having a functioning implementation and monitoring system. Twenty-seven countries (14%) reported having no such system in place. Out of 199 countries, 117 did not answer or did not clearly state whether they had a functioning implementation and monitoring system.

2.3 Specific issues and concerns Table 10 presents the specific issues and concerns raised by countries in relation to the implementation of the Code. The issues clustered into the sub-groups shown in the table. Table 10 Specific issues and concerns by WHO Region (21, 22, 23 ) Problems with provisions Laws and regulations and info dissemination Regulatory mechanisms 1 – – – – – 1

Total with report

Code monitors

WHO Region African Americas Eastern Mediterranean European South-East Asian Western Pacific TOTAL

13 14 5 3 9 9 53

10 12 5 3 9 9 48

3 – – – – – 3

6 – 1 – 3 2 12

5 1 1 – 3 4 14

2.3.1 Laws, regulations and information dissemination Of the 53 countries reporting issues and concerns, 48 mentioned the law, regulations and their dissemination. Key concerns are related to the identification of gaps in existing national legislation, which does not contain all the recommendations of the Code. Issues raised are also related to the processes and procedures necessary for the adaptation of the Code into national measures. Countries expressed difficulty in having their draft measures passed and approved for implementation. The need to review the actual implementation of the Code and identify areas that should be strengthened and updated were also identified. Generally, all countries reported poor information dissemination among health care providers as well as district officials, and a few countries added that information dissemination is insufficient

Industry 3 9 – – 1 1 14

Training

even at the level of professional groups, policy planners, law enforcers and other stakeholders. There was a call for the development of clear guidelines for service providers, as well as the design of a more effective advocacy strategy among concerned agencies. Countries voiced the need to ensure a wider target audience, with the general public included, in a systematic education programme. 2.3.2 Provisions and regulatory mechanisms Countries reported weak implementation or implementation gaps related to low technical capacity, as well as the difficulties that ministries of health (MoHs) may have in the enforcement of measures. At the same time, countries reported delays and difficulties in the setting up of national oversight committees or monitoring bodies that would support MoHs. They also noted that there is a need to obtain the support of all line ministries. Countries reported limitations in the reach/coverage of measures. Poor or weak enforcement was mentioned by several countries, and there is a clear call to identify ways to enforce or strengthen enforcement. 2.3.3 Training Countries called for the setting-up of common procedures for training, providing training to health workers and, when possible, also to other stakeholders. 2.3.4 Code monitors Weak or poor monitoring systems as well as irregular monitoring activities have been identified by countries as key issues that need to be addressed. Countries identified inadequate mechanisms for reporting violations at national, state and district levels. The causes were linked to lack of appropriate funding as well as the capacity of assigned staff to conduct monitoring activities. The majority of countries reported that NGOs have a role in advocacy, monitoring and educating legislators. 2.3.5 Industry Reported consistent, repeated, systematic violations by the industry are common concerns of countries. Very aggressive direct marketing or indirect advertisements to mothers exist. In some instances countries reported that the industry resisted all provisions of regulations, and this resistance is sometimes expressed as pressure on government to limit implementation or upgrading/updating of the law.

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

The Code: key elements for successful implementation

As stated earlier, Member States and other countries and areas have made major progress in their efforts to translate the Code into national measures. At the same time, some key issues and concerns were raised that will need to be addressed. For successful implementation, the Code needs international and national support and commitment. During the review of the data collected through various sources (see Section 2 ), key elements were identified, both at the international and national levels, to ensure successful implementation of the Code:

International level At the international level, monitoring and tracking efforts need to be systematized. The data collected by WHO in 2008 and 2010 have provided great insights on the actual status of implementation of the Code, but at the same time have shown countries’ limitations and difficulties in identifying, collecting and reporting key information. In line with the Global strategy for infant and young child feeding (2 ), international organizations need to ensure that: ■■ infant and young child feeding is placed at the top of the global public health agenda; ■■ consistent technical support is given to Member States on the implementation of the Code; ■■ the Code is “given full consideration in trade policies and negotiations”; ■■ updated research is carried out on marketing practices and the status of implementation of the Code.

National level For many countries, there are important gaps in knowledge with regard to various aspects of Code implementation. A country analysis on the status of implementation of the Code is recommended, to help guide a constructive process towards the following: ■■ Political commitment and advocacy are key elements where there is no law or rules and regulations to push for enactment and implementation, enforcement and monitoring, and where the law, rules and regulations or implementation is too weak to push for amendment and/or improved implementation, enforcement, monitoring and oversight; ■■ Creating a critical mass of Code advocates and supporters is crucial for ensuring an enabling and supportive environment for Code implementation, enforcement and monitoring. Awareness and sensitization efforts on the importance of the Code as a tool and mechanism for the protection, promotion and support to breastfeeding must be aimed at a wide audience, and be tailored to the specific responsibilities and mandates of relevant stakeholders. Efforts should be made to systematically apply existing tools for capacity building in Code implementation and monitoring processes. Such tools include training on formulation of national Code legislation organized by the International Baby Food Action Network (IBFAN), and the comprehensive e-course on the Code, developed by WHO and UNICEF (24 ). ■■ Member States need to translate the Code and subsequent relevant WHA resolutions into legislation and/or other suitable legal measures. The legislation needs to be clear, with appropriate rules and regulations complete with guidelines and/or a manual of operations, including what and how to monitor, and sanctions in terms of processes and application. ■■ Knowledge and understanding of the legal measures and the Code by health care providers (including private practitioners), relevant officials, enforcers, Code monitors and planners, including at district and other local levels, is key for the implementation, enforcement and monitoring of law. For policy-makers, this knowledge and understanding are critical to enacting a law where there is none and amending or providing oversight where the law or its implementation is weak. The public, particularly women, mothers, and private practitioners, should appreciate the law and follow it, as well as promote breastfeeding.

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

■■ Functional monitoring and enforcement mechanisms strengthen implementation, enforcement, monitoring and sanctions because weak laws and implementation and lack of or weak sanctions and monitoring result in systematic violations and aggressive marketing by the industry. ■■ Partnerships with civil society and nongovernmental organizations help governments in advocating for the enactment, implementation, enforcement and monitoring of the Code, as well as providing practical breastfeeding support at the community level. ■■ Documentation and reporting of Code violations for effective tracking, compilation and systematization of information and evidence is needed for future action and advocacy.

Why is it important to implement/monitor the implementation of the Code?

Evidence shows that advertising directly to the consumer and other marketing techniques influence mothers and families in their decisions on how to feed their infants and young children. For example, distribution of “educational materials” on breastfeeding produced by manufacturers of infant formula had a negative impact on exclusive breastfeeding (25,26 ). These “educational materials” were most likely to influence those at higher risk of stopping breastfeeding, including the mothers of first-born children and those with less formal education. The distribution of samples also had an adverse impact on breastfeeding (27). Evidence shows that nearly all mothers are able to breastfeed and will do so if they have accurate information and support. However, direct industry influence through advertisements, information packs and sales representatives, and indirect influence through the public health system, inundate mothers with incorrect and biased information. The implementation of the Code is critical towards reducing or eliminating all form of promotion of BMS, including direct and indirect promotion to pregnant women and mothers of infants and young children. At the same time, the Code can help governments to ensure that the health system is free from commercial influences, through the elimination of free sample distribution in health care facilities, as well as other gifts and inducements to health workers. The Code is instrumental in helping governments reduce risks associated with the use and distribution of infant formula in situations where there is need for them, for example for orphans after an emergency. At the same time, the implementation of the Code increases awareness by Member States and communities of the intrinsic and extrinsic risks of contamination of BMS.1 The successful implementation of the Code requires a clear and functioning monitoring mechanism for accurate assessment and tracking of the extent of implementation across countries and regions specifically for the following: ■■ determine progress and gains in the implementation of the Code ■■ validate strategies that are effective and appropriate for specific country contexts ■■ identify common issues, problems and challenges ahead ■■ identify factors that facilitate or hinder the implementation of the Code. Monitoring provides a wealth of valuable information for benchmarking practices that have been successfully carried out and institutionalized in specific countries and which can be replicated by others. It facilitates sharing of experiences and lessons and thus supports the efforts of governments and other stakeholders in the implementation of the Code. There is a need to inform all stakeholders, both government and non-government entities, to keep them updated with important issues related to the implementation of the Code. In this way, interest and vigilance about the Code can be sustained. Information about the progress and achievements made by different countries provides inspiration for others to emulate. It also encourages and strengthens the commitment of governments to pursue efforts to mainstream the implementation of the Code. Monitoring also sends a clear and strong signal to all stakeholders and the industry that the international community and governments are serious about and committed to fully implement the spirit and letter of the Code. Monitoring tracks the actions and strategies of companies and advertisers in countries and provides lessons on how to best handle different situations. The results of monitoring also provide important inputs for further developing and refining a global strategy for more effective implementation of the Code.

Contamination can occur intrinsically or from extrinsic sources. Intrinsic contamination occurs at some stage during manufacture (e.g. from the manufacturing environment, or from raw ingredients). Extrinsic contamination is possible from the person preparing the formula and the environment the formula is prepared in.

Monitoring informs policy and facilitates the following: ■■ determining policy gaps and weaknesses in communication strategy ■■ identifying needs of Members States for information and capacity building ■■ estimating resource requirements for the full implementation of the Code.

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

How to strengthen implementation of the Code

Thirty years after its endorsement by the WHA as Resolution 34.22, the International Code and subsequent WHA resolutions remain key instruments for the protection of breastfeeding globally. Since 1981, major progress has been documented in relation to the actions taken by Member States on implementation at the country level through national legislation and other measures. This report presents major milestones in the implementation of the Code globally, but more needs to be done, both at the international and national levels. The following are key practical suggestions aimed at providing a concrete direction to the global effort to protect breastfeeding, and improve infant and young child nutrition. They are based in the responses provided by 73 Member States to the WHO 2010 survey on Code implementation.

International 1. UNICEF and WHO: ■■ to establish sustainable support mechanisms for Member States in their efforts to translate the Code into national legal measures. ■■ to develop a database on national legal measures, based on an agreed standard classification for levels of compliance with all the articles of the Code. ■■ to build the capacity of their staff to support countries in the implementation and monitoring of the Code, and provide support for capacity-building activities at the country level. ■■ to provide support to the United Nations human rights mechanisms in reviewing governments’ efforts towards effective Code implementation and monitoring. 2. United Nations human rights mechanisms:

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Relevant United Nations treaty monitoring bodies (i.e. the Committee on the Rights of the Child and the Committee on Economic, Social and Cultural Rights) to pay sustained attention to Code implementation and monitoring in countries, and to issue explicit concluding observations and recommendations. The United Nations Human Rights Council to review governments’ efforts towards Code implementation and monitoring through its Universal Periodic Review process. 3. International accreditation bodies:

to incorporate key provisions of the Code as requirements for international accreditation of their health facilities and health care systems (e.g. International Standards Organization certification). 4. Donors:

to support Civil Society organizations in the independent monitoring, reporting, and dissemination of information and reports on the status of compliance to the Code, and on national measures and actions taken by manufacturers and distributors, health professionals and other concerned groups. to support the translation wherever possible into relevant local languages of all national Code, rules and regulations, research and reports. 5. Civil Society:

to conduct sustained advocacy and lobbying in countries where there is still no acceptable Code, targeting policy-makers and planners, including at local government levels.

National 1. Governments to: ■■ request WHO country offices to contribute to ensuring thorough and substantive reports on Code implementation, especially in areas where information is lacking. ■■ develop a critical mass of Code advocates to promote and disseminate information on the importance and key provisions of the Code.

■■ strengthen and strictly monitor violations and impose the corresponding sanctions to such violations; ■■ actively disseminate information concerning actions taken and sanctions imposed on Code violators for public awareness building; ■■ facilitate the mobilization of civil society organizations to support the monitoring and documentation of violations of the Code and assist in efforts for strong evidence-based advocacy; and ■■ involve national human rights institutions in Code monitoring and evaluation activities. 2. Government and other national partners to: ■■ provide in-depth training to health care providers, relevant officials, enforcers, Code monitors and planners down to local level for implementation and monitoring. ■■ provide direct sustained education and information using multimedia channels to the general public down to community level, including in schools, colleges and universities. ■■ incorporate the essential provisions of the Code into school curricula, particularly at the tertiary level for health professions. The quality of education and training on breastfeeding should be reviewed and upgraded, specifically on the law and its application and monitoring. This would require translating materials into the appropriate languages and adapting them to local cultures and practices. Through sustained public awareness, the general public may be enjoined to actively participate in community monitoring, including through the use of appropriate technology (such as email, mobile phone messaging and social networking). ■■ undertake effective tracking and documentation of violations for administrative action, legislative measures and judicial sanctions. The actions taken by industry players must be monitored and checked, especially where there are systematic violations of the Code, such as cases of aggressive resistance to compliance. ■■ link the Code and its implementation to overall public health concerns to ensure reinforcement and synergy. Member States and other countries and areas have shown that the Code is still a dynamic and critical reference even after its 30 years of existence. It remains a catalyst for change and a core element in which countries need to invest in their efforts to curb child and maternal mortality through improved infant and young child nutrition. Key gaps and limitations were identified by the countries themselves, as well as future directions and efforts. This review should help international agencies, as well as other groups and organizations, in identifying and prioritizing a key set of strategies and interventions that can support and contribute to the ongoing work being done at country level.

References

Joint WHO/UNICEF meeting on infant and young child feeding. Geneva, 9–12 October 1979: statement, recommendations, list of participants. Geneva, World Health Organization, 1979.

2. WHO/UNICEF. Global strategy for infant and young child feeding. Geneva, World Health Organization, 2003. 3. CRC/C/GC/15 General Comment No. 15, United Nations Committee on the Rights of the Child. 2013. 4. Bhutta ZA et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet, 2013, published online 6 June (http:// dx.doi.org/10.1016/S0140-6736(13)60996-4). 5. 6. León-Cava N et al. Quantifying the benefits of breastfeeding: a summary of the evidence. Washington DC, PAHO, 2002. WHO Collaborative Study Team on the role of breastfeeding on the prevention of infant mortality. Effect of breast-feeding on infant and child mortality due to infectious disease in less developed countries: a pooled analysis. Lancet, 2000, 355:451–455. Victora CG et al. Evidence for protection by breast-feeding against infant deaths from infectious diseases in Brazil. Lancet, 1987, 2:319–322. Bahl R et al. Infant feeding patterns and risks of death and hospitalization in the first half of infancy: multicentre cohort study. Bulletin of the World Health Organization, 2005, 83:418–426.

7. 8.

9. Edmond KM et al. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics, 2006, 117:380–384. 10. Chen A, Rogan W. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics, 2004, 113(5):e435–e439. 11. Ness RB et al. Factors related to inflammation of the ovarian epithelium and risk of ovarian cancer. Epidemiology, 2000, 11:111–117. 12. Whittemore AS, Harris R, Itnyre J. Characteristics relating to ovarian cancer risk: collaborative analysis of 12 US case-control studies. American Journal of Epidemiology, 1992, 136:1184–1203. 13. Gwinn ML et al. Pregnancy, breastfeeding and oral contraceptives and the risk of epithelial ovarian cancer. Journal of Clinical Epidemiology, 1990, 43:559–568. 14. Zheng T et al. Lactation reduces breast cancer risk in Shandong Province, China. American Journal of Epidemiology, 2000, 152:1129–1135. 15. Lipworth L, Bailey R, Trichopoulos D. History of breast-feeding in relation to breast cancer risk: a review of the epidemiologic literature. Journal of the National Cancer Institute, 2000, 92:302–312. 16. Romieu I et al. Breast cancer and lactation history in Mexican women. American Journal of Epidemiology, 1996, 143(6):543–552. 17. Yoo K-Y et al. Independent protective effect of lactation against breast cancer: a casecontrol study in Japan. American Journal of Epidemiology, 1992, 135(7):726–733. 18. Labbok M, Cooney K, Coly S. Guidelines: breastfeeding, family planning, and the Lactational Amenorrhea Method-LAM. Washington DC, Institute for Reproductive Health, 1994. 19. Lutter CK et al. Undernutrition, poor feeding practices and low coverage of key nutrition interventions. Pediatrics, 2011, 128: e1–e10. 20. UNICEF. National implementation of the International Code of Marketing of Breast-milk Substitutes. UNICEF, New York, 2011.

21. Survey for the global nutrition policy review: Module 3 on the International Code of Marketing of Breast-milk Substitutes. Geneva, World Health Organization, 2010. 22. PAHO. 30 Años del Código en América Latina [30 years of the Code in Latin America]. Washington DC, PAHO, 2011. 23. World Breast-feeding Trends Initiative (WBTi), 2011. WBTi. Toolkit (2011) and website, (for reports where a ministry of health is indicated as a part of the monitoring process), http:// www.worldbreastfeedingtrends.org/, accessed 12 May 2012. 24. WHO/UNICEF. Introduction to the International Code of Marketing of Breast-milk Substitutes. In press. 25. Howard C et al. Office prenatal formula advertising and its effect on breastfeeding patterns. Obstetrics and Gynecology, 2000, 95(2):296–303. 26. Shealy KR et al. The CDC guide to breastfeeding interventions. Atlanta, United States Department of Health and Human Services, Centers for Disease Control and Prevention, 2005. 27. Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mother and their healthy newborn infants. Cochrane Database of Systematic Reviews 2012. Issue 5. Art No.: CD003519. DOI: 10.1002/14651858.CD003519.pub3.

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Annexes

ANNEX I No. Country or area

Legislative status and historical evolution by country or area1 Table 1.1 Legislative status in countries and areas of the WHO African Region Legislative status Progress Source

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Congo Côte d’Ivore Democratic Republic of the Congo Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana

Few provisions of the Code into law Implementation of the Code still being studied. Full into law Full into law Full into law Measures drafted still awaiting final approval Full into law Full into law No action No action Voluntary and other national measures Measures drafted still awaiting final approval Measures drafted still awaiting final approval Few provisions into law No available information Implementation of Code still being studied Few provision of Code into law Full into law Full into law Full into law

No available information No available information No available information No available information No available information No available information

UNICEF, 2011 UNICEF, 2011 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WHO, 2008 UNICEF, 2011 UNICEF, 2011

National Code enacted UNICEF, 2011; WBTi, in 2005 2011; WHO, 2008 No available information No available information No available information No available information No available information No available information No available information – No available information No available information No available information No available information Breastfeeding promotion regulation 2000 UNICEF, 2011; WBTi, 2011; WHO, 2008 UNICEF, 2011 UNICEF, 2011 WHO, 2008 UNICEF, 2011 UNICEF, 2011 UNICEF, 2011 – UNICEF, 2011 UNICEF, 2011; WHO, 2010 UNICEF, 2011 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WBTi, 2011; WHO, 2008 & 2010

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Sources for Annex 1 are shown in Section 2 .

No.

Country or area

Legislative status

Progress

Source

21 22

Guinea Guinea-Bissau

Few provisions of Code into law Few provisions of Code into law

No available information Decree passed in April 2005 Country reported voluntary measures as of 2007. Since 2008, a law was being drafted but is not yet enacted. No available information No available information No available information Public Health Act (34:01), no date available No available information No available information

UNICEF, 2011; WHO, 2008 UNICEF, 2011; WHO, 2008 & 2010 UNICEF, 2011; WHO, 2008 & 2010

Kenya

Voluntary measures

Lesotho

Implementation of the Code still being studied Some provisions of the Code translated into voluntary measures Full into law Many provisions of the Code into law Many provisions of the Code into law Voluntary and other national measures. Implementation of the Code still being studied Voluntary and other national measures. Implementation of the Code still being studied

UNICEF, 2011 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WBTi, 2011 UNICEF, 2011

25 26 27 28

Liberia Madagascar Malawi Mali

Mauritania

UNICEF, 2011; WHO, 2008

Mauritius

No available information Law was passed 18 November 2005 (Diploma Ministerial No. 129/2007 de 3 de Outubro, Código de Comercialização dos Substitutos do Leite Materno) No available information

UNICEF, 2011; WHO, 2008 & 2010

Mozambique

Full into law

UNICEF, 2011; WBTi, 2011; WHO, 2008 & 2010;

Namibia

Measures drafted still awaiting final approval Many provisions into law

UNICEF, 2011

Niger

Law was passed 27 July 1998 (Arrete UNICEF, 2011; WHO, No. 00215/msp/ 2008 & 2010 portant reglementation) Country passed the Marketing of BMS Act 41 of 1990, then amended by Act 22 of 1999. Act was replaced by NAFDACMarketing of Infant and Young Children Food and Other Designated Products (Registration, Sales, etc.) Regulations 2005

Nigeria

Many provisions into law

UNICEF, 2011; WHO, 2010

No.

Country or area

Legislative status

Progress

Source

35 36 37 38

Rwanda Sao Tome and Principe Senegal Seychelles

Measures drafted still awaiting final approval Voluntary and other national measures Many provisions of Code translated into law Voluntary and other national measures Voluntary and other national measures. Drafted measures still awaiting approval Voluntary measures Voluntary measures Not clear from survey response. Drafted measures for approval

No available information No available information No available information No available information No available information No available information No available information Government adopted the Code in 2003.

UNICEF, 2011 WHO, 2008 UNICEF, 2011 WHO, 2008 UNICEF, 2011; WHO, 2008 UNICEF, 2011 UNICEF, 2011; WBTi, 2011 UNICEF, 2011; WHO, 2010

Sierra Leone

40 41 42

South Africa Swaziland Togo

Uganda

Full into law

Adopted the Code in the Food and Drugs Act of 1997 (Marketing of Infant and Young Child Foods) and a WBTi, 2011 draft amendment in the Food Safety Act of 2005, but not yet enacted No available information Adopted a voluntary measure in 1982 which was revised in 1994. In 2006 the country passed the Food & Drugs, Marketing of Breast Milk Substitutes, Regulations No available information UNICEF, 2011; WHO, 2008

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

United Republic Full into law of Tanzania

Zambia

Many provisions into law

UNICEF, 2011; WBTi, 2011; WHO, 2008

Zimbabwe

Full into law

UNICEF, 2011; WHO, 2008

Table 1.2 Legislative status in countries and areas of the WHO Region of the Americas No. Country or area Legislative status Progress Source

1 2

Antigua and Barbuda Argentina

No action Many provisions into law

No available information Has been active in regulating the production of BMS since 1969. In 1997, MoH signed Resolution No. 54/97 approving implementation of the Code. This new resolution needed joint support of other ministries, which was provided with Resolutions No. 97 and 301 of 2007. – No available information No available information

WHO, 2010 PAHO, 2011; UNICEF, 2011; WHO, 2008

3 4 5

Bahamas Barbados Belize

No available information No action Voluntary and other national measures Many provisions into law

UNICEF, 2011 WHO, 2010 WHO, 2008

Bolivia (Plurinational State of) Brazil

Law passed 15 August 2006. Working on a regulation to impose sanctions that for now are not yet part of the law.

PAHO, 2011; UNICEF, 2011; WBTi, 2011; WHO, 2010

Full into law

Regulation for the Marketing of PAHO, 2011; UNICEF, Infant Food (NCAL) approved in 2011; WBTi, 2011; 1988. This was later amended WHO, 2008 into the Brazilian Regulation for Marketing of foods for infants (NBCAL) in October 1992. Due to the increased number of reports of alleged violations of the regulation, in 2000, the MoH established a technical working group to strengthen it. In 2001, a Ministerial Order was issued. On 4 January 2006 a law (Ley 11.265) was passed that aims at regulating the marketing of products for infants and young children. No available information No available information Not all provisions of Code are law. Recently, the President vetoed a provision in a new nutrition law that aimed at prohibiting promotion of BMS. Before the WHA in 1980, a proposal to regulate marketing of BMS was made, with Ministerial Decree 1220, but it was not approved. In 1992, the proposed decree was amended into Decree 1397 and eventually approved. WHO, 2010 UNICEF, 2011 PAHO, 2011; UNICEF, 2011; WHO, 2008 & 2010

8 9 10

British Virgin Islands Canada Chile

No action taken Few provisions into law Mainly voluntary measures. Few provisions into law. Many provisions into law

Colombia

PAHO, 2011; UNICEF, 2011; WBTi, 2011

No.

Country or area

Legislative status

Progress

Source

Costa Rica

Full into law

A technical working group was UNICEF, 2011; WBTi, created in 1985 to work on 2010; WHO, 2008 & implementation of the Code. Its 2010 proposal was rejected by the Legislative Assembly. Law 7430 of 1992, to foster and support breastfeeding, and Regulation Nº 24576-S, 1995, were not approved immediately. It took the intervention of the First Lady to convince the legislative body to support and endorse the proposed law. It was eventually passed in September 1994 and gazetted in October 1994, as law No. 7430. Its regulations were published in September 1995. No available information PAHO, 2011; UNICEF, 2011

13 14

Cuba Dominica

Few provisions into law Few provisions into law. Voluntary measures Full into law

Breastfeeding policy adopted in WHO, 2008 & 2010 1993 and revised in 1999. Law 8-95 passed 19 September 1995, and its regulations 20 January 1996. First regulation of marketing of BMS, limited to infants, approved in 1983. In 1993, manufacturers signed Code of Conduct, voluntary measure to self-regulate their own marketing activities. Law 101 of 1995, for the promotion, support and protection of breastfeeding, does not contain any article of the Code. Since 2002, a drafted law has been supported by civil society and international organizations, but still not approved. No available information PAHO, 2010; UNICEF, 2011; WBTi, 2011; WHO, 2008 PAHO, 2011; UNICEF, 2011; WBTi, 2011; WHO, 2010

Dominican Republic Ecuador

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Mainly voluntary measures (Code of conduct). Existing law for support of breastfeeding does not contain any article of the Code.

El Salvador

Measure drafted

PAHO, 2011; UNICEF, 2011; WHO, 2008 & 2010 WHO, 2010

Grenada

No action taken. Voluntary measures limited to guidelines. Full into law, with other voluntary measures Some provisions voluntary Drafted measures awaiting final approval

Guatemala

Law No. 66-83 of 7 June 1983

UNICEF, 2011; WBTi, 2011; WHO, 2008 & 2010 UNICEF, 2011 UNICEF, 2011

20 21

Guyana Haiti

No available information No available information

No.

Country or area

Legislative status

Progress

Source

Honduras

Norm, regulation, voluntary measures

Norm (Agreement 4780) for promotion and protection of breastfeeding passed 8 November 2005. Instrument (it is not a law) does not contain any sanctions or legal procedure for prosecuting alleged violations. No available information

PAHO, 2011; UNICEF, 2011; WHO, 2008 & 2010

23 24

Jamaica Mexico

Some provisions voluntary Many provisions into laws and regulations

UNICEF, 2011; WHO, 2008

In 1992, manufacturers of PAHO, 2011; UNICEF, BMS and MoH entered 2011; WBTi, 2011; into agreement to regulate WHO, 2008 & 2010 promotion and distribution of BMS to health workers. Agreement was ratified in 1995 and 2000. Law on Health (amended 31 May 2009) clearly adopts some standards of the Code in relation to promotion to the general public. No available information On 12 December 1981, first to pass Decree on promotion, support and protection of breastfeeding after WHA endorsement of the Code. Law No. 295 passed in 1999. MoH studying possibility of strengthening law. Law No. 50 was passed 23 November 1995. Law 1478 on marketing of BMS passed 8 October 1999. Decree No. 020-82-SA approved in 1982, making it a leading country in adopting the Code. After several years and some reviews, proposals for its amendment were made, and a new Decree No. 0072005-SA was created. Despite being approved, industry exerted major efforts calling for government to negotiate the decree and amend it again. Finally, decree 009-2006 SA was approved. WHO, 2010 PAHO, 2011; UNICEF, 2011; WBTi, 2010

25 26

Montserrat Nicaragua

No action Many provisions into law

27 28 29

Panama Paraguay Peru

Full into law Few provisions into law Full into law

PAHO, 2011; UNICEF, 2011; WHO, 2008 PAHO, 2011; UNICEF, 2011; WHO, 2008 UNICEF, 2011; WBTi, 2011; WHO, 2008 & 2010

Puerto Rico

Few provisions Law 79 passed in 2004. into law. No law or regulations deal with marketing of BMS. Voluntary and other national measures No action No available information

PAHO, 2011

Saint Kitts and Nevis Saint Lucia

WHO, 2008

No available information

WHO, 2010

No.

Country or area

Legislative status

Progress

Source

Saint Vincent and the Grenadines Suriname

Voluntary measures (guidelines) Voluntary and other national measures Voluntary and other national measures

No available information

WHO, 2010

No available information

WHO, 2008

Trinidad and Tobago

No available information

UNICEF, 2011; WHO, 2008 UNICEF, 2011; WHO, 2010 PAHO, 2011; UNICEF, 2011; WBTi, 2011; WHO, 2010

36 37

United States of No action America Uruguay Full into law

No available information Decree 315 passed in 1994. In 2009, MoH issued Ministerial Ordinance containing one provision regarding role of MoH in relation to monitoring practices of manufacturers. Resolution No. 405 issued on 17 August 2004 requiring mandatory labelling for BMS. In same year, Resolution No. 444, calling for promotion, support and protection of breastfeeding was signed. Law for promotion, support and protection of breastfeeding passed in 2007.

Venezuela (Bolivarian Republic of)

Full into law

PAHO, 2011; UNICEF, 2011

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Table 1.3 Legislative status in countries and areas of the WHO Eastern Mediterranean Region No. Country or area Legislation status Progress Source

Afghanistan

Full into law

No available information

UNICEF, 2011; WBTi, 2011; WHO, 2008 UNICEF, 2011 UNICEF, 2011 UNICEF, 2011; WBTi, 2011; WHO, 2008 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WHO, 2008

2 3 4

Bahrain Djibouti Egypt

Full into law Many provisions into law Many provisions into different laws and decrees Full into law with voluntary and other national measures Voluntary and other national measures. Measures drafted still awaiting approval. Many provisions into law Voluntary measures

No available information No available information No information available

Iran (Islamic Republic of) Iraq

No information available

No available information

7 8

Jordan Kuwait

No available information Set of standards only implemented in MoH facilities. Ongoing initiative to integrate the Code into Kuwait child rights law.

UNICEF, 2011; WHO, 2008 UNICEF, 2011; WBTi, 2011

9 10 11 12

Lebanon Libya Morocco Oman

Full into law Action limited to end free supplies Drafted measures awaiting approval Many provisions into law. Voluntary and other national measures. Full into law

Law enacted 11 December UNICEF, 2011; 2008 WBTi, 2011 No available information No available information UNICEF, 2011 UNICEF, 2011

Code of Marketing of BMS UNICEF, 2011; passed 16 March 1998. WHO, 2008 & 2010 Breastfeeding ordinance passed in 2002, but its rules and regulations only in 2009. No available information No available information No available information No available information UNICEF, 2011; WBTi, 2011

Pakistan

14 15 16 17

Qatar Saudi Arabia Somalia Sudan

Few provisions into law Full into law No action Only actions limited to end free supplies. Voluntary and other national measures. Measures being studied Many provisions into law Few provisions into law No available information Full into law

UNICEF, 2011 UNICEF, 2011 UNICEF, 2011 UNICEF, 2011; WHO, 2008

18 19 20 21 22

Syrian Arab Republic Tunisia United Arab Emirates West Bank and Gaza Strip Yemen

No available information No available information No available information – No available information

UNICEF, 2011 UNICEF, 2011 UNICEF, 2011 – UNICEF, 2011

Table 1.4 Legislative status in countries and areas of the WHO European Region No. Country or area Legislation status Progress Source

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco

Full into law No available information Few provisions into law Many provisions into law Many provisions into law Measures being studied Many provisions into law Drafted measures awaiting approval No available information Measures being studied No available information Many provisions into law Few provisions into law Many provisions into law Many provisions into law Full into law Many provisions into law Many provisions into law Many provisions into law No available information Many provisions into law Few provisions into law Many provisions into law No action Many provisions into law Many provisions into law Measures being studied Many provisions into law Drafted measures awaiting approval No available information

No available information – No available information No available information No available information No available information No available information No available information – No available information No available information No available information No available information No available information No available information No available information No available information No available information No available information No available information – No available information No available information No available information No available information No available information No available information No available information No available information No available information

UNICEF, 2011; WHO, 2008 & 2010 UNICEF, 2011 UNICEF, 2011; WHO, 2010 UNICEF, 2011; WHO, 2008 & 2010 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WHO, 2008 & 2010 UNICEF, 2011; WHO, 2008 & 2010 WHO, 2008 UNICEF, 2011; WHO, 2008 & 2010 – UNICEF, 2011 UNICEF, 2011 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WHO, 2008 & 2010 UNICEF, 2011 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WHO, 2008 & 2010 UNICEF, 2011; WHO, 2008 & 2010 WHO, 2008 UNICEF, 2011; WHO, 2010 UNICEF, 2011 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WHO, 2008 UNICEF, 2011 UNICEF, 2011; WHO, 2010 UNICEF, 2011; WHO, 2010 UNICEF, 2011 UNICEF, 2011; WHO, 2008 & 2010 –

Czech Republic Many provisions into law

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

No.

Country or area

Legislation status

Progress

Source

32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48

Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine

No available information Many provisions into law Many provisions into law No available information Many provisions into law No available information Measures being studied Measures being studied No available information No available information Measures being studied Many provisions into law Many provisions into law Many provisions into law Some provisions voluntary Many provisions into law Few provisions into law

– No available information No available information – No available information – No available information No available information – – No available information No available information No available information No available information No available information No available information No available information

– UNICEF, 2011 UNICEF, 2011; WHO, 2008 & 2011 – UNICEF, 2011 – UNICEF, 2011; WHO, 2010 UNICEF, 2011 – – UNICEF, 2011; WHO, 2008 & 2010 UNICEF, 2011 UNICEF, 2011; WHO, 2008 & 2010 UNICEF, 2011; WHO, 2008 & 2010 UNICEF, 2011 WHO, 2010 WHO, 2008

49 50 51 52

Few provisions into law Few provisions into law No available information

No available information No available information – No available information

UNICEF, 2011 UNICEF, 2011; WHO, 2010 – UNICEF, 2011

United Kingdom Many provisions into law of Great Britain and Northern Ireland Uzbekistan Measures being studied

No available information

UNICEF, 2011; WHO, 2008 & 2010

Table 1.5 Legislative status in countries and areas of WHO South-East Asia Region No. Country or area Legislation status Progress Source

Bangladesh

Many provisions into law

Ordinance on Breast-milk Substitutes (Regulation of Marketing) passed 12 May 1984. Ongoing effort to amend existing regulation. No available information –

UNICEF, 2011; WBTi, 2011; WHO, 2010

2 3

Bhutan Democratic People’s Republic of Korea India

Some provisions voluntary No available information

WBTi, 2011; UNICEF, 2011 –

Full into law

Infant Milk Substitutes, Feeding Bottles and Infant foods (Regulation of production, supply and distribution) Act passed in 1992 (IMS Act). It was amended in 2003. Decree of MoH No. 237 passed in 1997. Ongoing effort to pass new law that will adopt the Code. Regulation on Import, Production and sale of BMS passed in 2008. No available information BMS Act 2049 passed in 1992. Regulation under Directive No. 107 of Consumer Protection Act passed 23 March 2004.

UNICEF, 2011; WBTi, 2011; WHO, 2008 & 2010

Indonesia

Many provisions into law, with voluntary and other national measures Full into law

UNICEF, 2011; WBTi, 2011; WHO, 2008

Maldives

UNICEF, 2011; WBTi, 2011; WHO, 2008 & 2010 UNICEF, 2011; WHO, 2008 UNICEF, 2011; WBTi, 2011; WHO, 2008 & 2010 UNICEF, 2011; WBTi, 2011; WHO, 2008 & 2010

7 8 9

Myanmar Nepal Sri Lanka

Being studied Full into law Full into law

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

10 11

Thailand Timor-Leste

Voluntary measures No available information Voluntary measures. Law drafted, awaiting approval. No available information

UNICEF, 2011; WBTi, 2011; WHO, 2008 & 2010 WHO, 2010

Table 1.6 Legislative status in countries and areas in the WHO Western Pacific Region No. Country or area Legislation status Progress Source

1 2 3 4

Australia Brunei Darussalam Cambodia China

Voluntary measures Voluntary and other national measures Many provisions into law Many provisions into law

No available information No available information Sub-decree passed 17 August 2009 Regulations of Marketing of BMS passed 13 June 1995. Since 2009, MoH reported to be working on amendments of regulations. – Marketing control for foods passed 2 October 2002 –

UNICEF, 2011; WHO, 2008 WHO, 2008 UNICEF, 2011; WHO, 2008 & 2010 UNICEF, 2011; WBTi, 2011; WHO, 2008 & 2010

5 6 7 8 9 10

Cook Islands Fiji French Polynesia Japan Kiribati Lao People’s Democratic Republic

No available information Full into law Same as France

– UNICEF, 2011; WHO, 2008 & 2010 – UNICEF, 2011 WHO, 2010 UNICEF, 2011; WHO, 2008 & 2010

Few provisions into law No available information Voluntary and other national measures Many provisions into law No available information Decision of MoH on Control of Marketing of Infant and Young Child Food Products approved 3 August 2007.

11 12 13

Malaysia

Voluntary and other national measures No available information –

UNICEF, 2011; WHO, 2008 & 2010 WHO, 2008 –

Marshall Islands Voluntary and other national measures Micronesia (Federated States of) Mongolia No available information

Few provisions into law National law approved by Parliament in July 2005. In 2008, MoH approved regulations necessary for implementation of law No available information Voluntary and other national measures No action Full into law Many provisions into law – No available information – No available information No available information

UNICEF, 2011; WBTi, 2011; WHO, 2008 & 2010

15 16 17 18 19

Nauru New Zealand Niue Palau Papua New Guinea

– UNICEF, 2011; WHO, 2008 UNICEF, 2011 UNICEF, 2011 UNICEF 2011; WHO, 2008

No.

Country or area

Legislation status

Progress

Source

Philippines

Full into law

Executive Order 51 passed UNICEF, 2011; WBTi, in 1986. First set of 2011; WHO, 2008 & implementing IRR issued 2010 by Department of Health (DoH) in 1987. In 2004, DoH and partners agreed to review and revise IRR. New set of IRR issued in May 2006. Industry challenged the new IRR at Supreme Court. Case lasted more than 1 year, until the Supreme Court issued a final resolution on 7 October 2007, validating 56 of 59 of the provisions of the IRR. WBTi, 2011; WHO, 2008 & 2010

Republic of Korea

Few provisions into law Food Sanitation Act, Livestock Processing Act and Mother and Child Health Act passed 7 January 2009 Voluntary and other national measures Some provisions voluntary No available information Sale of Infant Foods Ethics Committee Singapore Code of Ethics (SIFECS) initially developed on 1 January 1979, now on third edition. – – Food Safety Act of 2006 covers BMS. Ongoing effort to develop comprehensive breastfeeding policy. –

22 23

Samoa Singapore

WHO, 2008 UNICEF, 2011; WHO, 2008 & 2010

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

24 25 26

Solomon Islands Tonga Tuvalu

No available information No available information Voluntary and other national measures

– – WHO, 2010

27 28

Vanuatu Viet Nam

No available information Many provisions into law

–

Government Decree UNICEF, 2011; WBTi, No. 21/2006/ND-CP 2011; WHO, 2010 on Trading In and Use of Nutritious Products for Infants passed 27 February 2006. Circular No. 45 of MoH on administrative sanctions also passed. Ongoing effort to review and eventually revise Decree No. 21 and Cicrular No. 45.

ANNEX II LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling

Key provisions in the legal measures by country1

Table 2.1 Key provisions of legislation/regulations in countries and areas in the WHO African Region

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Sales promotions prohibited Free or low-cost supplies of BMS

Materials or gifts to health workers and/or health facilities

Recommended age for designated product

Message on superiority of breastfeeding

Functioning implementation and monitoring mechanism

Source

Algeria – Full Full – – Full Full – – – – – – – – – – – – – – – – – – – – – Full Full Full Full – – – – – – Yes Yes – – – – – – – Full Full Yes Full Full Yes – – – –

–

– – Yes Yes – – Yes Yes – – – – – – –

– – Full Full – – Full Full – – – – – – –

– – WHO, 2008 WHO, 2008 – – WHO, 2008 WHO, 2008 – – WHO, 2008 – – – –

Angola

–

Benin – –

0–12

Full

Botswana

0–36

Full

Burkina Faso

–

Burundi

–

Cameroon

0–30

Full

Cape Verde – – – – – – –

0–24

Full

Central African Republic

–

Chad

–

Comoros

–

Congo

–

Cote d’Ivoire

–

Democratic Republic of the Congo

–

Equatorial Guinea

–

Sources for Annex II are shown in Section 2 .

40 LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling Sales promotions prohibited Free or low-cost supplies of BMS Materials or gifts to health workers and/or health facilities Message on superiority of breastfeeding Recommended age for designated product Functioning implementation and monitoring mechanism Source

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Eritrea – – – Full – Full Full – – Full – – – – Full – Full Full – Full – – – – – – – – Full – Full Full – – Full Full – Full – – – – Partial Full – – – – – – – – – – – – Yes – Yes Yes – Yes – – – – Full Full Yes – – – – – – Full Full Yes – – Yes – – – – Yes – Yes – – Yes – – – – Full Full Yes Yes Yes – – – – Full Full Yes Yes – – – – – – – – – – – – – Full – No No – – Partial – – – – No – Full Full – No – – – – – – – – – –

–

– WHO, 2010 – WHO, 2008 WHO, 2010 WHO, 2008 WHO, 2010 WHO, 2010 – WHO, 2008 WHO, 2008 – – WHO, 2010 WHO, 2010 WHO, 2010 – WHO, 2010 WHO, 2010 – WHO, 2008 – WHO, 2008 WHO, 2008 –

Ethiopia

–

Gabon

–

Gambia

–

Ghana

No age limit

Full

Guinea

–

Guinea-Bissau – – – – – – –

0–36

Full

Kenya

0–24

Full

Lesotho

–

Liberia

–

Madagascar

0–6

Full

Malawi

–

Mali

–

Mauritania

–

Mauritius

–

Mozambique

0–36

Full

Namibia

–

Niger –

0–60

Full

Nigeria

0–36

Full

Rwanda

–

Sao Tome and Principe – – – –

0–24

Full

Senegal

–

Seychelles

–

Sierra Leone

–

South Africa

–

LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Sales promotions prohibited Free or low-cost supplies of BMS

Materials or gifts to health workers and/or health facilities Message on superiority of breastfeeding

Recommended age for designated product

Functioning implementation and monitoring mechanism

Source

Swaziland Full – Full Full Full Full Full Yes Full Full Yes Full Full Yes Yes Yes Yes – – – – Full Full Yes Yes

–

– – – Full Full Full

– WHO, 2010 – WHO, 2008 WHO, 2008 WHO, 2008

Togo

0–6

Full

Uganda

–

United Republic of Tanzania

0–12

Full

Zambia

0–24

Full

Zimbabwe

0–60

Full

42 LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling Sales promotions prohibited Free or low-cost supplies of BMS Materials or gifts to health workers and/or health facilities Message on superiority of breastfeeding Recommended age for designated product Functioning implementation and monitoring mechanism Source

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Table 2.2 Key provisions of legislation/regulations in countries and areas in the WHO Region of the Americas

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Antigua and Barbuda – Full – – – Full Full – – – – Full – Full Full – – – Full – – – Full Full Full – – Full Full – – – Full Full Full – – – – – – – – – Yes – Yes/Noa Yes – – – Yes – – – Full Full Yes Full Full Yes – – – – Yes Yes – – – – Yes – Yes Yes – – – Yes – – – – – – – – Full Full Yes Yes – – – – – – – – – – – –

–

WHO, 2010 No WHO, 2010 – WHO, 2010 – No Full – – – – No – No Full – – – Full WHO, 2010 WHO, 2010 WHO, 2010 – WHO, 2010 – WHO, 2008 & 2010 – WHO, 2010 WHO, 2008 WHO, 2010 WHO, 2010 WHO, 2010 WHO, 2010

Argentina

–

Full

Bahamas

–

Barbados

–

Belize

–

Bolivia (Plurinational State of)

0–24

Full

Brazil – – – –

0–36

Full

British Virgin Islands

–

Canada

–

Chile

–

Colombia

–

Costa Rica –

0–24

Full

Cuba

–

Dominica

–

Full

Dominican Republic – – –

0–24

Full

Ecuador

–

El Salvador

–

Grenada

–

Guatemala

–

Full

Recommended age indicated for some products, but not all.

LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Sales promotions prohibited Free or low-cost supplies of BMS

Materials or gifts to health workers and/or health facilities Message on superiority of breastfeeding

Recommended age for designated product

Functioning implementation and monitoring mechanism

Source

Guyana – Full – No – – Full Full Full – – – – – – – Full – – Full – – – – – – – – Full – – – – – – – Full Full Yes – – – – – – – Yes – Full Full Yes Full Full Yes – – – – – – – – Yes Yes Yes – – – – – – – Yes – No No Yes No – – – – Full Full Yes Yes – – – – – – No – Full – – No No Full – – – – – –– – Full –

–

– – WHO, 2008 & 2010 WHO, 2008 WHO, 2008 & 2010 WHO, 2010 – WHO, 2008 WHO, 2008 WHO, 2010 – WHO, 2008 WHO, 2010 WHO, 2010 WHO, 2008 WHO, 2008 WHO, 2010 WHO, 2010 WHO, 2008

Haiti

–

Honduras –

0–24

Full

Jamaica

–

Mexico – –

0–12

Montserrat

–

Nicaragua

–

Panama

0–12

Full

Paraguay – – – – – – –

0–24

Full

Peru

0–24

Full

Puerto Rico

–

Saint Kitts and Nevis

–

Saint Lucia

–

Saint Vincent and the Grenadines

–

Suriname

–

Trinidad and Tobago

–

United States of America

–

Uruguay –

–

Full

Venezuela (Bolivarian Republic of)

–

44 LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling Sales promotions prohibited Free or low-cost supplies of BMS Materials or gifts to health workers and/or health facilities Message on superiority of breastfeeding Recommended age for designated product Functioning implementation and monitoring mechanism Source

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Table 2.3 Key provisions of legislation/regulations in countries and areas in the WHO Eastern Mediterranean Region

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Afghanistan Full – Full Full – Full – – – – No – – – – – – – – – – – – – – – Full – – Full – – – – – – – – – – – Partial Full – – – No – – Yes – Yes – – – – – – – – – – – – – – Full Full Yes – – – – Yes – – – – Yes – – Yes – Yes – – – – – Full Full Yes Yes Full Full Yes Yes – – – – Full Full Yes Yes – –

0–24

Yes

No Full Full Full – – – – – – No – – Full – Full – – – – –

WHO, 2008 WHO, 2010 – WHO, 2008 WHO, 2008 WHO, 2008 WHO, 2008 – – – – WHO, 2010 – – WHO, 2008 – WHO, 2008 – – – – –

Bahrain

0–12

Full

Dijbouti

–

Egypt

0–24

Full

Iran (Islamic Republic of) – – – – – – – – – – – – – – –

0–24

Full

Iraq

0–12

Jordan

–

Full

Kuwait

–

Lebanon

–

Libya

–

Morocco

–

Oman

0–4

Full

Pakistan

–

Qatar

–

Saudi Arabia

0–12

Somalia

–

Sudan

–

Syrian Arab Republic

–

Tunisia

–

United Arab Emirates

–

West Bank and Gaza Strip

–

Yemen

–

Table 2.4 Key provisions of legislation/regulations in countries and areas in the WHO European Region LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Sales promotions prohibited Free or low-cost supplies of BMS

Materials or gifts to health workers and/or health facilities Message on superiority of breastfeeding

Recommended age for designated product

Functioning implementation and monitoring mechanism

Source

Albania – No Partial Full Full Full – Partial Partial – – – Full Full – No Full Full Full Full No Partial No No Full – Partial No No Full – Full Partial No No Partial – – – – – – Partial No Yes – – – Yes Yes – Yes Yes Yes Yes Yes Partial No Yes – – – Partial No Yes No No Yes Full Full Yes Yes Yes Yes – Yes Yes – – – Yes Yes – Yes Yes Yes Yes Yes Partial Full Yes Yes No No No Yes – – – –

0–36

Full

Yes

Full – Full Partial Full Partial No – Partial Partial – – – Partial Full – Partial Full Full No Full

WHO, 2010 – WHO, 2010 WHO, 2008 WHO, 2008 WHO, 2008 WHO, 2010 WHO, 2010 WHO, 2008 WHO, 2010 – – – WHO, 2008 WHO, 2008 & 2010 – WHO, 2008 WHO, 2008 WHO, 2010 WHO, 2010 WHO, 2010

Andorra

–

Armenia

0–6

Full

Austria

0–36

Partial

Azerbaijan

0–36

Full

Belarus

0–12

Full

Belgium

–

Bosnia and Herzegovina

–

Bulgaria

0–12

Partial

Croatia

–

Cyprus

–

Czech Republic

–

Denmark

–

Estonia

0–36

Full

Finland (EU Directive 2008)

0–12

Full

France

–

Georgia

0–12

Full

Germany

0–4

Full

Greece

0–6

Partial

Hungary (EU Directive 2008)

0–12

Full

Iceland (EU Directive 2008)

0–12

Partial

EU Directive 2008 means that the country responded according to the guidelines for this Directive.

46 LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling Sales promotions prohibited Free or low-cost supplies of BMS Materials or gifts to health workers and/or health facilities Message on superiority of breastfeeding Recommended age for designated product Functioning implementation and monitoring mechanism Source

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Ireland – Full Partial – Full Full – Full – – – Full No – Full – – – Full Full – – Full Full – – – Full Full – – – – Full – – – Full Full No No – – – Yes Yes – Yes Yes – – Yes Yes – – – – – – – Full Full Yes – – – – Yes – – – Yes Yes – Yes Yes – – Yes Yes – Full Full Yes Yes Full Partial Yes Yes – – – – Full Full Yes Yes Full Full Yes Yes No Partial – Partial No – No – – – Full Full – No No – – – Full – – – – – –

–

– – WHO, 2008 WHO, 2008 – WHO, 2010 WHO, 2010 – WHO, 2010 – – – WHO, 2010 WHO, 2008 & 2010 – WHO, 2008 WHO, 2010 – – WHO, 2008 WHO, 2010 –

Israel

–

Italy

0–12

Full

Kazakhstan

0–12

Full

Kyrgyzstan

–

Latvia

–

Full

Lithuania

–

Full

Luxembourg

–

Malta (EU Directive 2008)

0–6

Full

Monaco

–

Montenegro

–

Netherlands

–

Norway

0–12

Full

Poland

0–36

Portugal

–

Republic of Moldova

0–24

Full

Romania

0–12

–

Russian Federation

–

San Marino

–

Serbia

–

Full

Slovakia (EU Directive 2008)

0–6

Full

Slovenia

–

LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Sales promotions prohibited Free or low-cost supplies of BMS

Materials or gifts to health workers and/or health facilities Message on superiority of breastfeeding

Recommended age for designated product

Functioning implementation and monitoring mechanism

Source

Spain Full Full Full – No Full – Full – – – Full Full – – – Yes – Full Full Yes Full Full Yes – – – – Yes Yes – Yes – No No Yes Yes Full Full Yes Yes Full Full Yes Yes

0–12

Full

Yes

Partial Partial Full Full – No Full – Full –

WHO, 2008 WHO, 2010 WHO, 2008 WHO, 2010 – WHO, 2010 WHO, 2008 – WHO, 2010 –

0–36

Full

Sweden

0–36

Full

0–6

Full

Switzerland

–

Tajikistan

0–6

The former Yugoslav Republic of Macedonia

0–12

Full

Turkey

–

Turkmenistan

0–36

Full

Ukraine

–

United Kingdom of Great Britain and Northern Ireland (EU Directive 2008) – – – – – –

–

Uzbekistan

–

WHO, 2010

48 LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling Sales promotions prohibited Free or low-cost supplies of BMS Materials or gifts to health workers and/or health facilities Message on superiority of breastfeeding Recommended age for designated product Functioning implementation and monitoring mechanism Source

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Table 2.5 Key provisions of legislation/regulations in countries and areas of the WHO South-East Asia Region

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Bangladesh – – Full Full Full Full – Full Full – – – – – – Full Full Full Full – – Full Full Yes – No Yes – – Full Full Yes Full Full Yes Full Full Yes – – – – Yes Yes Yes Yes – Yes Yes – – – – – –

0–24

Full

Yes

Full

Yes

No – – Full Full Full No – No Yes – –

WHO, 2010 – – WHO, 2010 WHO, 2008 WHO, 2008 WHO, 2010 WHO, 2008 WHO, 2010 WHO, 2010 WHO, 2010 WHO, 2010

Bhutan

–

Democratic People’s Republic of Korea

–

India

0–24

Full

Indonesia

0–24

Full

Maldives

Other

Full

0–6

Full

Myanmar

0–12

–

Nepal

–

Full

Sri Lanka

0–12

Full

Thailand

–

Timor-Leste

–

Table 2.6 Key provisions of legislation/regulations in countries and areas in the WHO Western Pacific Region LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Sales promotions prohibited Free or low-cost supplies of BMS

Materials or gifts to health workers and/or health facilities Message on superiority of breastfeeding

Recommended age for designated product

Functioning implementation and monitoring mechanism

Source

Australia – Full Full Full – Full Full – – Full – – – Full – – – – – – – – – – Full – – – – Full – – – – – – – Full Full – – – Yes – – – Yes – Yes – – – – – – Full Full Yes Full Full Yes – – – Full Full No – Yes Yes – – Yes – – – Yes – Yes – – – Full Full Yes Yes Yes Full Full Yes Yes – – – – –

0–12

–

Yes

Full – – Full No – No Full – – No – – – Full – Full – – –

WHO, 2008 WHO, 2008 WHO, 2008 WHO, 2010 WHO, 2010 – WHO, 2010 WHO, 2010 – WHO, 2010 WHO, 2010 WHO, 2010 WHO, 2008 – WHO, 2010 – WHO, 2008 – – WHO, 2008

Brunei Darussalam

–

Cambodia

0–24

Full

0–24 –

Full

China

0–4

Full

Cook Islands

–

Fiji – –

–

Full

French Polynesia

0–12

Full

Japan

–

Kiribati

–

Lao People’s Democratic Republic – – –

0–24

Full

Malaysia

–

Marshall Islands

–

Micronesia (Federated States) – – – – –

–

Mongolia

–

Full

Nauru

–

New Zealand

0–36

Niue

–

Palau

–

Papua New Guinea

–

50 LEGISLATION AND REGULATIONS Promotion to health workers and health facilities Labelling Sales promotions prohibited Free or low-cost supplies of BMS Materials or gifts to health workers and/or health facilities Message on superiority of breastfeeding Recommended age for designated product Functioning implementation and monitoring mechanism Source

Country implementation of the International Code of Marketing of Breast-milk Substitutes: Status report 2011

Scope of the Code

Promotion to the general public

Country or area

Age limit (months)

Advertising of BMS prohibited

Philippines Full – Full – – – – – – Partial Full Full – – – Yes – – – – – – – – – – – – – – – – – Yes – – – – Full Full – Yes Full Full – Yes Full Full Yes Yes

0–24

Full

Yes

Full Full Full Full – – – – – – Full

WHO, 2008 WHO, 2010 WHO, 2008 WHO, 2010 WHO, 2008 WHO, 2008 & 2010 – – WHO, 2010 – WHO, 2010

0–36

Full

Republic of Korea

–

Full

0–6

Full

Samoa

–

Singapore

–

Solomon Islands

–

Tonga

–

Tuvalu

–

Vanuatu

–

Viet Nam

0–12

Partial

Key facts

Organisation World Health Organization (WHO)

Document type Publications

Adoption date July 30, 2013

Source World Health Organization