Marketing of breast-milk substitutes: national implementation of the international code, status report 2022: Middle East and North African region

Predatory marketing of breast-milk substitutes continues to be highly prevalent worldwide. As documented in a recent multi-country study on the reach and influence of marketing on infant feeding conducted by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), marketing of breast-milk substitutes diminishes the perceived value of breastfeeding and undermines women’s confidence in their ability to breastfeed. Marketing plays on expectations and anxieties around feeding and positions formula milk as a better alternative to breast milk. This brief summarizes data for the Middle East and North Africa region* based on the global Code status report 2022.** The report presents the national legal status of the International Code of Marketing of Breast- milk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions (“the Code”), including the extent to which its provisions have been incorporated in national legal measures. Methodology WHO, UNICEF and International Baby Foods Action Network (IBFAN) routinely collect information on legal measures adopted by countries to implement the Code. The legal measures are analysed on scope and content by using a standardized checklist of Code provisions. A scoring algorithm is then applied to classify countries’ legislation into categories. The algorithm assigns points values for each Code provision, with a maximum total of 100 points for measures that reflect all provisions in the Code. Countries with legal measures that scored 75 or greater are considered to be “substantially aligned with the Code”, those with scores of 50 - < 75 are considered to be “moderately aligned with the Code”, and those with scores < 50 are considered to have “some provisions of the Code included”. This algorithm facilitates a systematic and objective classification of countries and their legal measures. * For this report, the Middle East and North Africa region includes all countries that are part of the WHO Eastern Mediterranean Region or the UNICEF Middle East and North Africa region. ** Marketing of breast-milk substitutes: national implementation of the International Code | Status report 2022. Geneva: World Health Organization; 2022. https://www.who.int/publications/i/item/9789240048799. Marketing of breast‑milk substitutes National implementation of the International Code, status report 2022 – Middle East and North African Region Substantially aligned with the Code Some provisions of the Code included Moderately aligned with the Code No legal measures 32 41 71 50 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Middle East and North Africa Global 6 7 5 5 Figure 1. Legal status of the Code as enacted in countries, Middle East and North Africa region (N=23) and Global (N=194) Figure 2. Map showing national legal status of the Code in Middle East and North Africa region, 2022. The health system has been a traditional conduit for promoting products falling under the scope of the Code, and promotion in health facilities persists in many countries. In spite of this, too few countries have robust measures in place to reduce these promotional practices. While many countries (15)7 prohibit the use of facilities for promotion, a surprisingly low number of countries (5)8 prohibit gifts or incentives to health workers and only some (11)9 have provisions in place that prohibit the distribution of free or low-cost supplies in the health care system. In addition, only 4 countries10 have legal restrictions on industry sponsorship of meetings of health professionals or scientific groups. Only a few countries (3)11 prohibit the inclusion of nutrition and health claims on labels, but more (13)12 prohibit the use of pictures on labels that may idealize the use of infant formula. For national Code legislation or regulations to be effective, responsible government agencies must be empowered to monitor compliance with national legal measures, identify Code violations, and take corrective action when violations are identified, through administrative, legal or other sanctions. Therefore, legal measures must include clear provisions which enable and empower authorized agencies to take the corrective action needed. However, only 10 Middle East and North Africa countries13 have measures Findings: legal status of the Code Over the past two years, protections against inappropriate marketing of breast-milk substitutes were strengthened in Oman. Of the 23 countries in the Middle East and North Africa region, 18 countries have adopted legal measures to implement at least some of the provisions in the Code. Of these, 6 countries1 have measures in place that are substantially aligned with the Code. Unfortunately, 5 countries2 have yet to enact legal measures on the Code. Findings: characteristics of legal measures Of the 18 countries with Code laws, only 53 have measures clearly covering the full breadth of breast-milk substitutes, which includes milk products targeted for use up to at least 36 months (see Figure 3). While only some Middle East and North Africa countries (5)4 prohibit the distribution of informational or educational materials from manufacturers or distributors, many more have prohibitions on advertising (16)5 and the use of promotional devices at points of sale (14)6. Marketing of breast-milk substitutes: national implementation of the International Code, status report 2022 – Middle East and North African Region 2 that clearly spell out who in government is responsible for monitoring compliance, and only 1314 define sanctions for violations. Conclusions While promotion of breast-milk substitutes using unethical marketing practices continues throughout the world, many countries are fighting back. A majority of Middle East and North Africa countries have legislation prohibiting at least some forms of promotion. But significant gaps in national legislation remain. Provisions to prevent conflicts of interest are notably lacking and even the most obvious form of promotion, public advertisements, is not adequately covered. High-level political will, constraints on industry lobbying, accountability measures, monitoring and enforcement mechanisms, education on the Code, and investment in human and financial resources are desperately needed across Middle East and North Africa to accelerate progress in protecting the health of mothers and babies through breastfeeding. Recommendations 1. Countries that have not revised their laws or regulations on the marketing of breast-milk substitutes in the past few years should use this report to identify gaps in coverage of all Code provisions and take action to update their legal measures. The WHO/EURO model law is a tool to help to strengthen national regulatory frameworks to protect infants and young children from the harmful effects of food marketing. 2. Countries that have not yet enacted legal measures on the Code should recognize their obligations, both under international human rights law and international agreements, to eliminate inappropriate marketing practices through regulatory action. 3. Countries should examine the new promotional techniques being used in digital media and explore how legal channels can be better utilized to stop this type of promotion. While many digital strategies are already covered in existing legal provisions and simply need stronger monitoring and enforcement, some online and social media promotional approaches will require adaptations to existing regulations. 4. Governments must allocate adequate budgets and human resources to ensure that national Code legislation is monitored and fully enforced, guaranteeing that deterrent sanctions are routinely applied in the case of violations. 5. Health professional bodies and health care workers should carry out their responsibilities under the Code and national legislation to avoid conflicts of interest and fully protect, promote and support optimal infant and young child feeding. Figure 3. Number of countries in the Middle East and North Africa region with key code provisions enumerated in legal measures. 5 5 16 14 15 5 11 4 3 13 10 13 0 5 10 15 20 Scope includes BMS to 36 months PROHIBITIONS Informational/educational materials from industry Advertising Promotional devices at point of sale Use of health care facility for promotion Gifts or incentives to health workers Free or low-cost supplies in any part of the health care system Sponsorship of meetings of health professionals or scientific meetings Nutrition and health claims on label Pictures that may idealize the use of infant formula MONITORING AND ENFORCEMENT Identifies who is responsible for monitoring compliance Defines sanctions for violations MIDDLE EAST AND NORTH AFRICA BRIEF ON THE 2022 STATUS REPORT 3 Endnotes 1 The countries with legal measures substantially aligned with the Code are Afghanistan, Bahrain, Kuwait, Lebanon, Saudi Arabia, and United Arab Emirates. 2 The countries with no legal measures on the Code are Israel, Libya, Morocco, Qatar, Somalia. 3 The countries with measures covering the full breadth of breast-milk substitutes are Bahrain, Kuwait, Lebanon, Oman, and Saudi Arabia. 4 The countries that prohibit the distribution of informational or educational materials from manufacturers or distributors Afghanistan, Bahrain, Egypt, Lebanon, and Pakistan. 5 The countries that have prohibitions on advertising are Afghanistan, Bahrain, Djibouti, Egypt, Iran (Islamic Republic of), Jordan, Kuwait, Lebanon, Oman, Pakistan, Saudi Arabia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen. 6 The countries that prohibit promotional devices at points of sale are Afghanistan, Bahrain, Djibouti, Jordan, Kuwait, Lebanon, Oman, Pakistan, Saudi Arabia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen. 7 The countries that prohibit the use of health care facilities for promotion are Afghanistan, Bahrain, Djibouti, Iraq, Jordan, Kuwait, Lebanon, Oman, Pakistan, Saudi Arabia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen. 8 The countries that prohibit gifts or incentives to health workers or health systems are Afghanistan, Kuwait, Lebanon, Pakistan, and United Arab Emirates. 9 The countries that prohibit the distribution of free or low-cost supplies in the health care system are Afghanistan, Bahrain, Djibouti, Iraq, Kuwait, Lebanon, Oman, Pakistan, Syrian Arab Republic, Tunisia, and United Arab Emirates. 10 The countries that have legal restrictions on industry sponsorship of meetings of health professionals or scientific groups are Afghanistan, Kuwait, Lebanon, United Arab Emirates. 11 The countries that prohibit the inclusion of nutrition and health claims on labels are Afghanistan, Oman, and United Arab Emirates. 12 The countries prohibiting idealizing imagery on labels are Afghanistan, Algeria, Bahrain, Iraq, Kuwait, Lebanon, Oman, Pakistan, Saudi Arabia, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen. 13 The countries that clearly spell out who in government is responsible for monitoring compliance are Afghanistan, Bahrain, Iran (Islamic Republic of), Jordan, Kuwait, Lebanon, Saudi Arabia, Syrian Arab Republic, Tunisia, and United Arab Emirates. 14 The countries that define sanctions for violations are Afghanistan, Bahrain, Djibouti, Iran (Islamic Republic of), Kuwait, Lebanon, Pakistan, Saudi Arabia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen. Marketing of breast-milk substitutes: national implementation of the International Code, status report 2022 – Middle East and North African Region ISBN 978-92-4-005118-8 (electronic version) ISBN 978-92-4-005119-5 (print version) © World Health Organization 2022. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. For more information, please contact: Department of Nutrition and Food Safety World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: nutrition@who.int www.who.int/nutrition Marketing of breast-milk substitutes: national implementation of the International Code, status report 2022 – Middle East and North African Region