Code Marketing Breast-Milk Substitutes WHO 2011

8/22/2019 Code Marketing Breast-Milk Substitutes WHO 2011

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Country implementationof the InternationalCode of Marketing of

Breast-milk Substitutes:Status report 2011


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WHO Library Cataloguing-in-Publication Data

Country implementation o the international code o marketing o breast-milk substitutes:

status report 2011.

1.Breast eeding. 2.Inant ood. 3.Bottle eeding. 4.Inant nutrition disorders prevention

and control. 4.Growth and development. 5.National health programs. I.World Health

Organization.

ISBN 978 92 4 150598 7 (NLM classication : WS 120)

World Health Organization 2013

All rights reserved. Publications o the World Health Organization are available on the WHO web site (www.who.int)or can be purchased rom WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland(tel.: +41 22 791 3264; ax: +41 22 791 4857; e-mail: [email protected]). Requests or permission to reproduceor translate WHO publications whether or sale or or non-commercial distribution should be addressed to WHOPress through the WHO web site (www.who.int/about/licensing/copyright_orm/en/index.html).

The designations employed and the presentation o the material in this publication do not imply the expression o anyopinion whatsoever on the part o the World Health Organization concerning the legal status o any country, territory,city or area or o its authorities, or concerning the delimitation o its rontiers or boundaries. Dotted lines on mapsrepresent approximate border lines or which there may not yet be ull agreement.

The mention o specic companies or o certain manuacturers products does not imply that they are endorsed orrecommended by the World Health Organization in preerence to others o a similar nature that are not mentioned.Errors and omissions excepted, the names o proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to veriy the inormation contained inthis publication. However, the published material is being distributed without warranty o any kind, either expressed orimplied. The responsibility or the interpretation and use o the material lies with the reader. In no event shall the WorldHealth Organization be liable or damages arising rom its use.

Cover design by Alberto MarchPrinted in Switzerland

Suggested citationWHO. Country implementation o the International Code o Marketing o Breast-milk Substitutes: status report 2011.Geneva, World Health Organization, 2013.

Descargado el 02/08/2013, de.http://apps.who.int/iris/bitstream/10665/85621/1/9789241505987_eng.pdf


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Contents

Acknowledgements iv

Abbreviations v

Executive summary vii

1. Introduction 1

2. Data on country implementation of theInternational Code 4

2.1 Legislative status 6 2.2 Key provisions o national legal measures 7

2.3 Specifc issues and concerns 11

3. The Code: key elements for successfulimplementation 13

4. Why is it important to implement/monitor theimplementation 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


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Acknowledgements

The preparation o this report was coordinated by Dr Carmen Casanovas, Department o Nutritionor Health and Development and Mr Marcus Stahlhoer, Department o Maternal, Newborn, Child

and Adolescent Health under the supervision o Dr Francesco Branca, Director, Department o

Nutrition or Health and Development, World Health Organization (WHO), Geneva, Switzerland.

A preliminary drat was written by Mr Alessandro Iellamo and Mr Rene Raya, independent

consultants rom the Philippines. Most o 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 Pea-Rosas rom the Department o Nutrition

or Health and Development, and Dr Bernadette Daelmans and Dr Elizabeth Mason rom the

Department o Maternal, Newborn, Child and Adolescent Health, WHO, and rom Mr David

Clark, Nutrition Specialist (Legal), Programme Division, UNICEF, New York, USA. We would liketo thank internal and external reviewers, particularly Dr Peggy Henderson who edited the drat

version o this report. All individuals involved in the preparation o this publication completed a

WHO Declaration o Interest, and it was considered that none had a perceived or real confict o

interest.

Financial support

WHO thanks the Government o Luxembourg and Micronutrient Initiative or providing nancial

support or this work.


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Abbreviations

BMS Breast-milk substituteCode International Code o Marketing o Breast-milk Substitutes and subsequent

World Health Assembly Resolutions

CRC Convention on the Rights o the Child

DoH Department o Health

International Code International Code o Marketing o Breast-milk Substitutes

IRR Implementing rules and regulations

MoH Ministry o Health

NGO Nongovernmental organization

PAHO Pan American Health Organization

UNICEF United Nations Childrens Fund

WBTi World Breasteeding Trends Initiative

WHA World Health Assembly

WHO World Health Organization


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Globally, breasteeding has the potential to prevent 220 000 deaths among children under veeach year. Early initiation o breasteeding could prevent about one th o neonatal deaths, but

less than hal o inants are put to the breast within one hour o birth. WHO recommends that all

inants should be exclusively breasted or the rst six months o lie, but actual practice is low

(38%). Only about hal o children aged 2023 months are breasted despite the recommendation

that breasteeding continue or up to 2 years or beyond.

The implementation and enorcement o the standards and recommendations contained in the

International Code o Marketing o Breast-milk Substitutes and subsequent relevant Health

Assembly Resolutions (the Code) are critical or ensuring an environment that supports proper

inant and young child eeding and contributing to the attainment o Millennium Development

Goal 4 (reduce child mortality by two thirds).

This report summarizes the progress countries have made in implementing the Code. It is basedon data received rom WHO Member States between 2008 and 2010 and on inormation or

2011 rom UNICEF.

Thirty years ater its endorsement, only 37 out o 199 countries reporting (19%) have passed

laws refecting all o the recommendations o the Code. Sixty-nine countries (35%) ully prohibit

advertising o breast-milk substitutes; 62 (31%) completely prohibit ree samples or low-cost

suppplies; 64 (32%) completely prohibit gits o any kind rom relevant manuacturers to health

workers; and 83 (42%) require a message about the superiority o breasteeding on breast-

milk substitute labels. Only 45 countries (23%) report having a unctioning implementation and

monitoring system.

Key areas where urther eorts are needed which were raised by Member States include: 1) gapsin existing national legislation; 2) clarity on processes necessary or the adaptation o the Code;

3) diculty in gaining regulatory approval o drat measures; 4) weak implementation; 5) poor

monitoring systems; and 5) reported violations by the industry.

To ensure the successul implementation o the Code, the ollowing are considered critical by

government ocials or national authorities: 1) political commitment and advocacy; 2) a critical

mass o advocates; 3) legislation; and 4) knowledge about the Code and its implications.

Actions at both international and national levels are needed to ensure ull implementation o the

Code. Member States need additional support rom international agencies. Human rights treaty

monitoring bodies must step-up reviews o Code implementation as part o States obligations

under relevant human rights instruments. There is also a need to invest in eorts to disseminate

inormation on Code implementation and create capacity or Code monitoring. At the nationallevel, governments should pass legislation, set up unctional monitoring and enorcement

mechanisms, orge partnerships with civil society and set up documentation and reporting

systems or violations.

The Code remains a catalyst or change and a core element in which countries should invest to

curb child mortality through improved inant and young child nutrition.

Executive summary


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1.Introduction


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On 21 May 1981, the World Health Assembly (WHA) adopted the International Code o Marketing

o Breast-milk Substitutes (hereinater reerred to as the International Code) under Resolution

Number 34.22, with 118 votes or, 1 against and 3 abstentions.

The International Code took into account a WHO/UNICEF report on inant and young child

eeding which stressed the importance o an adequate basis on which women can have a trueand objective choice (1). It also emphasized the need or education and inormation about inant

and young child eeding and or the establishment o measures at government level to protectwomen against misinormation.1

The International Code also recognized that inappropriate eeding practices lead to inant

malnutrition, morbidity and mortality in all countries and that improper practice in the marketing

o breast-milk substitutes [BMS] and related products can contribute to this major public

health problem. Subsequent WHA Resolutions have rearmed and stressed the importance

o Member States promoting, protecting and supporting breasteeding through the passage o

meaningul legislation and/or regulations that would put the minimum standards recommended

by the International Code in place.

Ater 20 years o International Code implementation, the WHO/UNICEF Global strategy or

inant and young child eeding (2) clearly indicated that:

Breasteeding is an unequalled way o providing ideal ood or the healthy growth and development o

inants; it is also an integral part o the reproductive process with important implications or the health o

mothers. As a global public health recommendation, inants should be exclusively breasted or the frst

six months o lie to achieve optimal growth, development and health. Thereater, to meet their evolving

nutritional requirements, inants should receive nutritionally adequate and sae complementary oods

while breasteeding continues or up to two years o age or beyond.

Eective implementation and monitoring o the International Code is also supported by the United

Nations Convention on the Rights o the Child (CRC), and its monitoring body, the Committee

on the Rights o the Child, thus providing an additional normative and legal oundation. Article 24

o the CRC the childs right to health and health care requires countries to take appropriate

measures to combat disease and malnutrition through, inter alia, the provision o adequate

nutritious oods, and to ensure that all segments o society, in particular parents and children,are inormed () and supported in the use o basic knowledge o child health and nutrition,the advantages o breasteeding (). In addition, in its review o national implementation othe CRC and subsequent dialogue with governments, the Committee on the Rights o the Child

consistently calls upon countries to ensure ull protection, promotion and support to breasteeding,

and to give eect to the International Code and subsequent relevant WHA resolutions. This has

been reiterated in General Comment No. 15, The right o the child to the enjoyment o the highest

attainable standard o health (Article 24) (3).2

Globally, breasteeding has the potential to prevent 220 000 under-ve deaths per year (4). Over30 studies rom around the world, in developing and developed countries alike, have shown that

breasteeding dramatically reduces the risk o dying (5). A WHO pooled analysis (6) indicates

that breasteeding could prevent over three ourths o deaths in early inancy, and 37% o deathsduring the second year o lie. A cohort study in Brazil revealed that non-breasted children,

compared to those exclusively breasted, have 14 times the risk o dying rom diarrhoea, 3.6

times the risk o dying rom pneumonia, and 2.5 times the risk o dying rom other inections

(7). A pooled analysis o studies in Ghana, India and Peru showed that non-breasted inants

are 10 times more susceptible to dying, compared to predominantly or exclusively breasted

inants. The risk o death was 2.5 times higher comparing partially breasted inants with those

predominantly or exclusively breasted (8). A study in Ghana revealed that inants who were

1 International Code o Marketing o Breast-milk Substitutes. Geneva, World Health Organization, 1981 (http://w ww.who.int/nutrition/publications/inanteeding/9241541601/en/index.html, accessed 26 July 2013)

2 States are required to introduce into national law, implement and enorce internationally agreed standards concerningchildrens right to health, including the International Code o Marketing o Breast-milk Substitutes (Paragraph 44,page 11).


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exclusively breasted during the rst hour o lie were 9 times less likely to die than those who

were initiated to mixed ormula and breast milk within 72 hours o birth ( 9). Even in the United

States o America, where death rom inection is relatively uncommon, there were 21% to 24%

ewer deaths among children who were breasted (10).

Cognitive development is enhanced and the risk o some chronic diseases reduced by

breasteeding. Numerous studies, including a randomized trial (7), show that being breasted

enhances intelligence quotient; the randomized trial showed breasteeding promotion raisedintelligence quotient by about 6 points. There are also long-term benets o breasteeding in the

orm o lower blood pressure and total cholesterol, and lower prevalence o overweight/obesity

and type-2 diabetes (6).

With regard to mothers, high quality studies show that breasteeding reduces ovarian cancer by

27% to 40% (1113) and breast cancer by 40% to 80% (1417). Exclusive breasteeding has

an eect on birth spacing that is as e ective as contraceptives or the rst 6 months a ter delivery

(18). Breasteeding, which releases oxytocin ater delivery, also reduces uterine bleeding.

Despite the overwhelming short- and long-term benets o breasteeding or both the child and

mother, a large gap still separates current practices rom accepted recommendations (19).

Although early initiation could prevent about one th o neonatal deaths, less than hal o inants

are put to the breast within one hour o birth. Although WHO recommends 6 months o exclusivebreasteeding, current prevalence o this practice is low (36%). Only about 50% o children

2023 months old are breasted despite the recommendation that all children be breasted or

up to 2 years or beyond.

The implementation and enorcement o the standards and recommendations contained in the

International Code and subsequent WHA Resolutions (hereinater reerred to as the Code) by

Member States are critical in ensuring proper inant and young child eeding practices are in

place and contribute to the attainment o Millennium Development Goals 4 and 5.

WHO reports to the WHA on the status o Code implementation every other year. This report

is based on inormation provided by Member States, usually in a paragraph summarizing the

situation in the six WHO regions. WHA Resolution 65.6 rom May 20121 requested WHO to

support Member States in the monitoring and evaluation o policies and programmes, including

those o the Global strategy or inant and young child eeding , with the latest evidence onnutrition and to report, through the Executive Board, to the Sixty-seventh World Health Assembly

on progress in the implementation o the comprehensive implementation plan, together with the

report on implementation o the International Code o Marketing o Breast-milk Substitutes and

related Health Assembly resolutions.

This is the rst WHO publication documenting actions taken by countries; it is intended to support

Member States to develop or strengthen legislative, regulatory and/or other eective measures to

control the marketing o breast-milk substitutes, as requested by the WHA in May 2012.

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


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2.Data on countryimplementation of theInternational Code


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The adoption o the International Code by the WHA in May 1981 through resolution WHA34.22

marked an historical step in eorts to protect breasteeding and contribute to the establishment

and support o appropriate inant and young child eeding 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 o the International Code, and under Article 11.1 are requested to

take action to give eect to the principles and aim o this Code, as appropriate to their social andlegislative ramework, including the adoption o national legislation, regulation or other suitable

measures In addition, as previously mentioned, implementation and monitoring o the Code isurther supported by legal obligations under the CRC.1

Ater 30 years since its passage, Member States and other countries and areas rom all the

WHO regions have been working at dierent levels to translate the global recommendations into

eective local measures, to be able to put the comprehensive set o standards and policies into

practice. In line with Article 62 o the WHO Constitution, Member States are requested to update

WHO on the status o implementation o the Code regularly and at the same time, in compliance

with Article 11.7 o the International Code, WHO reports the status o implementation o the

Code to the World Health Assembly.

This report presents a summary o the progress made by countries in the implementation othe Code, limited to the ollowing set o inormation: a) legislative status; b) specic provisions:

advertising o BMS to the general public, sale or promotions to the general public, ree or low-

cost supplies o BMS, materials or gits to health workers and health acilities, labelling and

monitoring; and c) issues o concern.

Several sources were used to review the status o Code implementation:

WHO. Summary code survey or the report to the World Health Assembly on the

implementation o the International Code o Marketing o Breast-milk Substitutes. Geneva,

WHO, 2008.

WHO. Survey or the global nutrition policy review: module 3 on the International Code o

Marketing o Breast-milk Substitutes. Geneva, WHO, 2010.

UNICEF. National implementation o the International Code o Marketing o Breast-milk

Substitutes. New York, UNICEF, 2011.

Pan American Health Organization [PAHO]. 30 Aos del Cdigo en Amrica Latina [30

years o the Code in Latin America]. Washington DC, PAHO, 2011.

World Breasteeding Trends Initiative [WBTi]. Toolkit (2011) and website (or reports

where a ministry o health is indicated as a part o the monitoring process), http://www.

worldbreasteedingtrends.org/, accessed 12 May 2012.

European Union Project on Promotion o Breasteeding in Europe. Protection, promotion andsupport o breasteeding in Europe: a blueprint or action (revised) . Luxembourg, European

Commission, Directorate Public Health and Risk Assessment, 2008.

These reerences were used to generate the tables in this report, including those in Annex I and

Annex II, based on data or the period up to April 2011. Several issues and concerns were noted

during the review and processing o the data. The survey conducted by WHO clearly shows that

there is a need to clariy some o the language used in the Code, and develop a denition o terms

and/or a glossary to serve as a guide in lling out the questionnaire. In some cases, contradictions

between reerences were observed, mainly in relation to the actual legislative status o existing

measures in several countries and areas, as highlighted in Annex I.

1 The CRC has been ratied by all but two United Nations Member States Somalia and the United States andthus enjoys near-universal ratication and recognition as the principal legally binding treaty on the protection andpromotion o all aspects related to the overall well-being o children.


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2.1 Legislative status

As mentioned above, Article 11.1 o the International Code states that Governments should takeaction to give eect to the principles and aim o this Code, as appropriate to their social and

legislative ramework, including the adoption o national legislation, regulation or other suitablemeasures Table 1 shows actual progress as reported by countries and areas in their eorts

to apply the Code.

Table 1 Legislative status by WHO Region

WHO Region Fullintolaw

Manyintolaw

Fewintolaw

Voluntary

Fewvoluntary

Drafted

Stillstudying

Actiontoendfree

suppliesonly

Noaction

Noinformation

Total

Arican 13 6 5 9 1 6 3 0 2 2 47

Americas 8 54

(1)9 2 1 0 0

5

(2)1 35 (3)

Eastern

Mediterranean7 5 2 2 0 1 1 2 1 (1) 21 (1)

European 2 23 6 0 1 2 7 0 1 11 53

South-East Asia 4 2 0 3 1 0 0 0 0 1 11

Western Pacic 35

(1)3 8 1 0 0 0 1 6 27 (1)

Total 37 46 (1) 20 (1) 31 6 10 11 2 10 (2) 21 (1) 194 (5)

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

UNICEF categorizes the legislative status o the implementation o the Code into 10 levels (20),

which are used in this report:

1. ull into law, which means they have enacted legislation or other legal measures on all

provisions o the Code;

2. many into law, which means they have enacted legislation or other legal measures on

many provisions o the Code;

3. ew into law, which means they have enacted legislation or other legal measures on a ew

provisions o the Code;

4. voluntary, which means they have adopted all or most o the provisions o the Code

through non-binding measures;

5. ew voluntary, which means they have adopted some but not all provisions o the Codethrough non-binding measures;

6. drated, which means that there is a nal drat o a law or other measures, but it is still

awaiting approval;

7. still studying, which means they are still studying how to implement the Code;

8. action to end ree supplies only, which means they have taken some action to end ree andlow-cost supplies o BMS, but they have not implemented other provisions o the Code;

9. no action, which means they have not taken any steps towards the implementation o the

Code; and

10. no available inormation, which means there is no inormation to determine the legislativestatus o the Code in the country.


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As o April 2011, out o 199 countries reporting, 165 countries (83%) had translated the Code

into a national measure, a major milestone in the eorts towards the protection o breasteeding.

O these 165 countries, 105 (64%) have translated the Code into national legislation, but only

37 (22%) have been able to adapt in ull the various recommendations o 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 o national legal measures

As stated earlier, Article 62 o the WHO Constitution requests Member States to update WHO

on the status o implementation o the Code regularly. At the same time, in compliance with

Article 11.7 o the International Code, WHO reports the status o implementation o the Code

to the World Health Assembly. WHO has disseminated to all Member States the Nutritionpolicy review survey, in which Module 3 is dedicated to key inormation and data on the status

o implementation o the Code as well as the key provisions o the legal measures in place in

each country. The data collected rom surveys carried out in 2007 (published in 2008) and 2010

helped generate the tables that present the key provisions o national legal measures.

The scope o the International Code, as set out in Article 2,

applies to the marketing, and practices related thereto, o the ollowing products: breast-milk substitutes ,including inant ormula; other milk products, oods and beverages, including bottle-ed complementary

oods, when marketed or otherwise represented to be suitable, with or without modifcation, or use as

a partial or total replacement o breast milk; eeding bottles and teats.

It also applies to their quality and availability, and to inormation concerning their use. Table 2

shows the age o inants to which the scope o national legal measures applies.

Table 2 Scope o the Code age range o inants (months) by WHO Region

WHO region

Age (months)

Noage

limit

Noanswer/

Noinformation

Total

04

06

012

024

030

036

060

Arican 0 2 2 4 1 4 2 1 31 47

Americas 0 0 2 6 0 1 0 0 26 (3) 35 (3)

Eastern

Mediterranean1 0 3 3 0 0 0 0 14 (1) 21 (1)

European 1 6 12 1 0 7 0 0 26 53

South-East Asia 0 1 2 3 0 0 0 0 5 11

Western Pacic 1 1 2 (1) 2 0 2 0 0 19 27 (1)

Total 3 10 23 (1) 19 1 14 2 1 121 (4) 194 (5)


O 199 countries, 125 (63%) did not answer or did not clearly state the scope o the legal

measure in terms o the age to which it applies. A total o 74 countries reported some age

limit in the scope o their measures. O these, 24 (32%) reported an age limit o 012 months,

19 (26%) reported an age limit o 024 months and 15 (20%) had an age limit o 036 months.

The data show that country-level adaptation o the Code and subsequent development o local

measures vary based on the interpretation and understanding o the recommendations o the

Code.


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2.2.1 Prohibition of advertising and sales promotions of BMS

Article 5.1 o the International Code states that there should be no advertising or other orm o

promotion to the general public o products within the scope o the Code.1 Article 5.3 urther

states that there should be no point-o-sale advertising, giving o 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.

O 199 countries responding, only 80 (40%) provided inormation on advertising products withinthe scope o the Code (Table 3). In all, 69 countries (35%) ully prohibited advertising. A total

o 119 countries (60%) did not answer or did not clearly state whether there was a prohibition.

Table 3 Prohibition o advertising o BMS by WHO Region (21)

WHO Region Full Partial NoNo answer/

No informationTotal

Arican 16 0 0 31 47

Americas 12 0 1 22 (3) 35 (3)

Eastern

Mediterranean5 0 1 15 (1) 21 (1)

European 22 4 4 23 53

South-East Asia 6 0 0 5 11

Western Pacic 7 (1) 1 0 19 27 (1)

Total 68 (1) 5 6 115 (4) 194 (5)


Table 4 shows that 199 countries also provided inormation on the prohibition o sales promotions,

o which 68 (34%) ully prohibited them. However, 119 (60%) did not answer or did not clearly

state their stand on their prohibition.

Table 4 Prohibition o sale promotions by WHO Region (21)

WHO Region Full Partial NoNo answer/

No informationTotal

Arican 16 0 0 31 47

Americas 12 0 1 22 (3) 35 (3)

Eastern


European 22 4 4 23 53


Western Pacic 7 (1) 1 0 19 27 (1)

Total 67 (1) 5 7 115 (4) 194 (5)


1 The scope o the International Code as set out by Article 2 states that the Code applies to the marketing, andpract ices related thereto, o the ollowing products: breast-milk substi tutes, including inant ormula; other milk

products, oods and beverages, including bottle ed complementary oods , when marketed or otherwise representedto be suitable, with or without modifcation, or use as a partial or total replacement o breast milk; eeding bottlesand teats. It also applies to their quality and availability, and to inormation concerning their use.


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2.2.2 Prohibition of free or low-cost supplies of BMS and materials/gifts to healthworkers and health facilities

Article 6.6 o the International Code states that ree or low-cost supplies o BMS to health

care acilities should be prohibited. This article applies to both use o such products within a

acility and to the distribution o such products or use outside o a acility. This article is urther

supported by WHA Resolution 47.5. Free or low-cost supplies may only be given or distribution

to those inants who must be ed with BMS, and may only be distributed by the institution itsel.

Such donations or low-price sales should not be used by manuacturers or distributors as a sales

inducement.

Table 5 illustrates that out o 199 countries, 119 (60%) did not answer or did not clearly state

their stand on the prohibition o ree or low-cost supplies o BMS. O the 79 that provided this

inormation, 62 completely prohibited ree samples or low-cost supplies. Only 10 countries (5%)

reported that they did not prohibit ree or low-cost supplies o BMS.

Table 5 Prohibition o ree/low-cost supplies o BMS by WHO Region (21)

WHO Region Full/Yes Partial NoNo answer/

No informationTotal

Arican 15 1 0 31 47

Americas 12 0 1 22 (3) 35 (3)

Eastern


European 15 6 8 24 53


Western Pacic 8 (1) 0 0 19 27 (1)

Total 61 (1) 8 10 115 (4) 194 (5)


According to Article 7.3 o the International Code, neither nancial nor material inducements topromote products within the scope o the Code should be oered by manuacturers or distributors

to health workers or members o their amilies, nor should they be accepted by health workers or

members o their amilies.

Table 6 shows that 64 countries (32%) reported completely prohibiting gits to health workers,

in ull compliance with the Code, but 12 countries (6%) said they did not. Out o 199 countries,

120 did not answer or did not clearly state whether they prohibited materials or gits to health

workers and health acilities.

Table 6 Prohibition o materials/gits to health workers and health acilities by

WHO Region (21)

WHO Region Full/yes No PartialNo answer/

No informationTotal

Arican 16 0 0 31 47

Americas 12 1 0 22 (3) 35 (3)

Eastern


European 15 10 3 25 53


Western Pacic 8 (1) 0 0 19 27 (1)

Total 63 (1) 12 3 116 (4) 194 (5)



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2.2.3 Labelling

According to Article 9.2(b) manuacturers and distributors o inant ormula 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 o the superiority o breasteeding.

Table 7 shows that 83 countries (42%) reported requiring a message on the superiority o

breasteeding on BMS labels, while one country (1%) reported that there is no requirement. Othe total o 199 countries, 115 did not answer or did not clearly state whether having a message

on the superiority o breasteeding on the label was required.

Table 7 Labelling: message on superiority o breasteeding by WHO Region (21)

WHO Region Yes NoNo answer/

No informationTotal

Arican 15 0 32 47

Americas 12 1 22 (3) 35 (3)

Eastern Mediterranean 8 0 13 (1) 21 (1)

European 31 0 22 53

South-East Asian 6 0 5 11

Western Pacic 10 (1) 0 17 27 (1)

Total 82 (1) 1 111 (4) 194 (5)


As shown in Table 8, 79 countries (40%) reported that there should be a recommended age or

the designated product on the label, in ull compliance with the recommendations o the Code,

while 4 countries (2%) reported none. Out o 199 countries, 116 did not answer or did not clearly

state whether or not they require a recommended age on the label o BMS.

Table 8 Labelling: recommended age or designated product by WHO Region (21)

WHO Region Yes NoNo answer/

No informationTotal

Arican 16 0 31 47

Americas 12 0 23 (3) 35 (3)

Eastern Mediterranean 7 1 13 (1) 21 (1)

European 30 1 22 53

South-East Asian 5 1 5 11

Western Pacic 8 (1) 1 18 27 (1)

Total 78 (1) 4 112 (4) 194 (5)


2.2.4 Functioning implementation and monitoring system

Article 11 o the International Code includes a requirement or governments to take necessary

measures to give eect to the provisions o the Code within their legal and social inrastructure,

including the adoption o national legislation, regulations or other appropriate measures. The

responsibility or monitoring the implementation o the Code rests with governments, both

individually and in collaboration with other parties (e.g. WHO, nongovernmental organizations

[NGOs], proessional groups). Criteria or monitoring mechanisms to ensure ecacy include:

independence and transparency

reedom rom commercial infuence

empowerment to investigate code violations

empowerment to impose legal sanctions.


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Responses related to implementation and monitoring mechanisms are summarized in Table 9.

Table 9 Functioning implementation and monitoring system by WHO Region (21)

WHO Region Full/Yes Partial NoNo answer/No

informationTotal

Arican 10 1 4 32 47

Americas 6 0 7 22 (3) 35 (3)

Eastern


European 13 9 8 23 53

South-East Asian 3 0 3 5 11

Western Pacic 7 0 3 17 27 (1)

Total 44 (1) 10 27 113 (4) 194 (5)


Only 45 countries (23%) reported having a unctioning implementation and monitoring system.

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

monitoring system.

2.3 Specifc issues and concerns

Table 10 presents the specic issues and concerns raised by countries in relation to the

implementation o the Code. The issues clustered into the sub-groups shown in the table.

Table 10 Specifc issues and concerns by WHO Region (21,22,23)

WHO Region Totalwith

report

Lawsand

regulation

s

andinfo

dissemina

tion

Problems

with

provisions

Training

Code

monitors

Industry

Regulatory

mechanisms

Arican 13 10 3 6 5 3 1

Americas 14 12 1 9

Eastern

Mediterranean5 5 1 1

European 3 3

South-East Asian 9 9 3 3 1

Western Pacic 9 9 2 4 1

TOTAL 53 48 3 12 14 14 1

2.3 .1 Laws, regulations and information dissemination

O the 53 countries reporting issues and concerns, 48 mentioned the law, regulations and

their dissemination. Key concerns are related to the identication o gaps in existing national

legislation, which does not contain all the recommendations o the Code. Issues raised are also

related to the processes and procedures necessary or the adaptation o the Code into national

measures. Countries expressed diculty in having their drat measures passed and approved or

implementation.

The need to review the actual implementation o the Code and identiy areas that should be

strengthened and updated were also identied.

Generally, all countries reported poor inormation dissemination among health care providers as

well as district ocials, and a ew countries added that inormation dissemination is insucient


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even at the level o proessional groups, policy planners, law enorcers and other stakeholders.

There was a call or the development o clear guidelines or service providers, as well as the

design o a more eective 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 mechanismsCountries reported weak implementation or implementation gaps related to low technical

capacity, as well as the diculties that ministries o health (MoHs) may have in the enorcement

o measures.

At the same time, countries reported delays and diculties in the setting up o national oversight

committees or monitoring bodies that would support MoHs. They also noted that there is a need

to obtain the support o all line ministries.

Countries reported limitations in the reach/coverage o measures. Poor or weak enorcement was

mentioned by several countries, and there is a clear call to identiy ways to enorce or strengthen

enorcement.

2.3.3 Training

Countries called or the setting-up o common procedures or 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 identied by

countries as key issues that need to be addressed. Countries identied inadequate mechanisms

or reporting violations at national, state and district levels. The causes were linked to lack o

appropriate unding as well as the capacity o assigned sta to conduct monitoring activities.

The majority o 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

o countries. Very aggressive direct marketing or indirect advertisements to mothers exist. In

some instances countries reported that the industry resisted all provisions o regulations, and

this resistance is sometimes expressed as pressure on government to limit implementation or

upgrading/updating o the law.


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3.The Code: key elements forsuccessful implementation


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As stated earlier, Member States and other countries and areas have made major progress in

their eorts 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 successul implementation, the Code

needs international and national support and commitment.

During the review o the data collected through various sources (see Section 2), key elements

were identied, both at the international and national levels, to ensure successul implementation

o the Code:

International level

At the international level, monitoring and tracking eorts need to be systematized. The data

collected by WHO in 2008 and 2010 have provided great insights on the actual status o

implementation o the Code, but at the same time have shown countries limitations and diculties

in identiying, collecting and reporting key inormation.

In line with the Global strategy or inant and young child eeding (2), international organizations

need to ensure that:

inant and young child eeding is placed at the top o the global public health agenda;

consistent technical support is given to Member States on the implementation o the Code;

the Code is given ull consideration in trade policies and negotiations;

updated research is carried out on marketing practices and the status o implementation o

the Code.

National level

For many countries, there are important gaps in knowledge with regard to various aspects o Code

implementation. A country analysis on the status o implementation o the Code is recommended,

to help guide a constructive process towards the ollowing:

Political commitment and advocacy are key elements where there is no law or rules and

regulations to push or enactment and implementation, enorcement and monitoring, and

where the law, rules and regulations or implementation is too weak to push or amendment

and/or improved implementation, enorcement, monitoring and oversight;

Creating a critical mass o Code advocates and supporters is crucial or ensuring an

enabling and supportive environment or Code implementation, enorcement and monitoring.

Awareness and sensitization eorts on the importance o the Code as a tool and mechanism

or the protection, promotion and support to breasteeding must be aimed at a wide audience,

and be tailored to the specic responsibilities and mandates o relevant stakeholders.

Eorts should be made to systematically apply existing tools or capacity building in Code

implementation and monitoring processes. Such tools include training on ormulation o

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 o operations, including what and how to monitor, and sanctions in terms o processes

and application.

Knowledge and understanding o the legal measures and the Code by health care

providers (including private practitioners), relevant ocials, enorcers, Code monitors and

planners, including at district and other local levels, is key or the implementation, enorcement

and monitoring o 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 itsimplementation is weak. The public, particularly women, mothers, and private practitioners,

should appreciate the law and ollow it, as well as promote breasteeding.


25/6215

Functional monitoring and enorcement mechanisms strengthen implementation,

enorcement, monitoring and sanctions because weak laws and implementation and lack o

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 or the enactment, implementation, enorcement and monitoring o the Code, as

well as providing practical breasteeding support at the community level. Documentation and reporting o Code violations or eective tracking, compilation and

systematization o inormation and evidence is needed or uture action and advocacy.


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4.Why is it importantto implement/monitorthe implementationof the Code?


27/6217

Evidence shows that advertising directly to the consumer and other marketing techniques

infuence mothers and amilies in their decisions on how to eed their inants and young children.

For example, distribution o educational materials on breasteeding produced by manuacturers

o inant ormula had a negative impact on exclusive breasteeding (25,26). These educational

materials were most likely to infuence those at higher risk o stopping breasteeding, including

the mothers o rst-born children and those with less ormal education. The distribution o samples

also had an adverse impact on breasteeding (27).

Evidence shows that nearly all mothers are able to breasteed and will do so i they have accurate

inormation and support. However, direct industry infuence through advertisements, inormation

packs and sales representatives, and indirect infuence through the public health system, inundate

mothers with incorrect and biased inormation.

The implementation o the Code is critical towards reducing or eliminating all orm o promotion

o BMS, including direct and indirect promotion to pregnant women and mothers o inants and

young children.

At the same time, the Code can help governments to ensure that the health system is ree rom

commercial infuences, through the elimination o ree sample distribution in health care acilities,

as well as other gits and inducements to health workers.

The Code is instrumental in helping governments reduce risks associated with the use and

distribution o inant ormula in situations where there is need or them, or example or orphans

ater an emergency. At the same time, the implementation o the Code increases awareness by

Member States and communities o the intrinsic and extrinsic risks o contamination o BMS.1

The successul implementation o the Code requires a clear and unctioning monitoring mechanism

or accurate assessment and tracking o the extent o implementation across countries and

regions specically or the ollowing:

determine progress and gains in the implementation o the Code

validate strategies that are eective and appropriate or specic country contexts

identiy common issues, problems and challenges ahead

identiy actors that acilitate or hinder the implementation o the Code.

Monitoring provides a wealth o valuable inormation or benchmarking practices that have been

successully carried out and institutionalized in specic countries and which can be replicated

by others. It acilitates sharing o experiences and lessons and thus supports the eorts o

governments and other stakeholders in the implementation o the Code.

There is a need to inorm all stakeholders, both government and non-government entities, to

keep them updated with important issues related to the implementation o the Code. In this

way, interest and vigilance about the Code can be sustained. Inormation about the progress

and achievements made by dierent countries provides inspiration or others to emulate. It also

encourages and strengthens the commitment o governments to pursue eorts to mainstream theimplementation o 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 ully implement

the spirit and letter o the Code. Monitoring tracks the actions and strategies o companies and

advertisers in countries and provides lessons on how to best handle dierent situations. The

results o monitoring also provide important inputs or urther developing and rening a global

strategy or more eective implementation o the Code.

1 Contamination can occur intrinsically or rom extrinsic sources. Intrinsic contamination occurs at some stage duringmanuacture (e.g. rom the manuacturing environment, or rom raw ingredients). Extrinsic contamination is possiblerom the person preparing the ormula and the environment the ormula is prepared in.


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Monitoring inorms policy and acilitates the ollowing:

determining policy gaps and weaknesses in communication strategy

identiying needs o Members States or inormation and capacity building

estimating resource requirements or the ull implementation o the Code.


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5.How to strengthenimplementationof the Code


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Thirty years ater its endorsement by the WHA as Resolution 34.22, the International Code and

subsequent WHA resolutions remain key instruments or the protection o breasteeding 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 o the Code globally, but more needs

to be done, both at the international and national levels.

The ollowing are key practical suggestions aimed at providing a concrete direction to the globaleort to protect breasteeding, and improve inant 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 or Member States in their eorts to

translate the Code into national legal measures.

to develop a database on national legal measures, based on an agreed standard classi-

cation or levels o compliance with all the articles o the Code.

to build the capacity o their sta to support countries in the implementation and monitor-

ing o the Code, and provide support or capacity-building activities at the country level.

to provide support to the United Nations human rights mechanisms in reviewing

governments eorts towards eective Code implementation and monitoring.

2. United Nations human rights mechanisms:

Relevant United Nations treaty monitoring bodies (i.e. the Committee on the Rights o 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 eorts towards Codeimplementation and monitoring through its Universal Periodic Review process.

3. International accreditation bodies:

to incorporate key provisions o the Code as requirements or international accreditation o their

health acilities and health care systems (e.g. International Standards Organization certication).

4. Donors:

to support Civil Society organizations in the independent monitoring, reporting, and dissemination

o inormation and reports on the status o compliance to the Code, and on national measures

and actions taken by manuacturers and distributors, health proessionals and other concerned

groups.

to support the translation wherever possible into relevant local languages o 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 oces to contribute to ensuring thorough and substantive reports

on Code implementation, especially in areas where inormation is lacking. develop a critical mass o Code advocates to promote and disseminate inormation on

the importance and key provisions o the Code.


31/6221

strengthen and strictly monitor violations and impose the corresponding sanctions to

such violations;

actively disseminate inormation concerning actions taken and sanctions imposed on

Code violators or public awareness building;

acilitate the mobilization o civil society organizations to support the monitoring and

documentation o violations o the Code and assist in eorts or 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 ocials, enorcers, Code

monitors and planners down to local level or implementation and monitoring.

provide direct sustained education and inormation using multimedia channels to the

general public down to community level, including in schools, colleges and universities.

incorporate the essential provisions o the Code into school curricula, particularly at the

tertiary level or health proessions. The quality o education and training on breasteeding

should be reviewed and upgraded, specically on the law and its application andmonitoring. 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 o appropriate technology (such as email, mobile phone messaging and

social networking).

undertake eective tracking and documentation o violations or administrative action,

legislative measures and judicial sanctions. The actions taken by industry players must

be monitored and checked, especially where there are systematic violations o the Code,

such as cases o aggressive resistance to compliance.

link the Code and its implementation to overall public health concerns to ensure

reinorcement and synergy.

Member States and other countries and areas have shown that the Code is still a dynamic and

critical reerence even ater its 30 years o existence. It remains a catalyst or change and a core

element in which countries need to invest in their eorts to curb child and maternal mortality

through improved inant and young child nutrition.

Key gaps and limitations were identied by the countries themselves, as well as uture directions

and eorts. This review should help international agencies, as well as other groups and

organizations, in identiying and prioritizing a key set o strategies and interventions that can

support and contribute to the ongoing work being done at country level.


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References


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1. Joint WHO/UNICEF meeting on inant and young child eeding. Geneva, 912 October

1979: statement, recommendations, list o participants. Geneva, World Health Organization,

1979.

2. WHO/UNICEF. Global strategy or inant and young child eeding. Geneva, World HealthOrganization, 2003.

3. CRC/C/GC/15 General Comment No. 15, United Nations Committee on the Rights o the

Child. 2013.

4. Bhutta ZA et al. Evidence-based interventions or improvement o 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. Len-Cava N et al. Quantiying the benefts o breasteeding: a summary o the evidence.Washington DC, PAHO, 2002.

6. WHO Collaborative Study Team on the role o breasteeding on the prevention o inant

mortality. Eect o breast-eeding on inant and child mortality due to inectious disease in

less developed countries: a pooled analysis. Lancet, 2000, 355:451455.

7. Victora CG et al. Evidence or protection by breast-eeding against inant deaths rom

inectious diseases in Brazil. Lancet, 1987, 2:319322.

8. Bahl R et al. Inant eeding patterns and risks o death and hospitalization in the rst hal

o inancy: multicentre cohort study. Bulletin o the World Health Organization, 2005,83:418426.

9. Edmond KM et al. Delayed breasteeding initiation increases risk o neonatal mortality.

Pediatrics, 2006, 117:380384.

10. Chen A, Rogan W. Breasteeding and the risk o postneonatal death in the United States.

Pediatrics, 2004, 113(5):e435e439.

11. Ness RB et al. Factors related to infammation o the ovarian epithelium and risk o ovarian

cancer. Epidemiology, 2000, 11:111117.12. Whittemore AS, Harris R, Itnyre J. Characteristics relating to ovarian cancer risk:

collaborative analysis o 12 US case-control studies. American Journal o Epidemiology,1992, 136:11841203.

13. Gwinn ML et al. Pregnancy, breasteeding and oral contraceptives and the risk o epithelial

ovarian cancer. Journal o Clinical Epidemiology, 1990, 43:559568.

14. Zheng T et al. Lactation reduces breast cancer risk in Shandong Province, China. AmericanJournal o Epidemiology, 2000, 152:11291135.

15. Lipworth L, Bailey R, Trichopoulos D. History o breast-eeding in relation to breast cancer

risk: a review o the epidemiologic literature. Journal o the National Cancer Institute, 2000,

92:302312.

16. Romieu I et al. Breast cancer and lactation history in Mexican women. American Journal o

Epidemiology, 1996, 143(6):543552.

17. Yoo K-Y et al. Independent protective eect o lactation against breast cancer: a case-

control study in Japan. American Journal o Epidemiology, 1992, 135(7):726733.

18. Labbok M, Cooney K, Coly S. Guidelines: breasteeding, amily planning, and the Lactational

Amenorrhea Method-LAM. Washington DC, Institute or Reproductive Health, 1994.

19. Lutter CK et al. Undernutrition, poor eeding practices and low coverage o key nutrition

interventions. Pediatrics, 2011, 128: e1e10.

20. UNICEF. National implementation o the International Code o Marketing o Breast-milkSubstitutes. UNICEF, New York, 2011.


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21. Survey or the global nutrition policy review: Module 3 on the International Code o

Marketing o Breast-milk Substitutes. Geneva, World Health Organization, 2010.

22. PAHO. 30 Aos del Cdigo en Amrica Latina [30 years o the Code in Latin America].Washington DC, PAHO, 2011.

23. World Breast-eeding Trends Initiative (WBTi), 2011. WBTi. Toolkit (2011) and website, (orreports where a ministry o health is indicated as a part o the monitoring process), http://

www.worldbreasteedingtrends.org/, accessed 12 May 2012.

24. WHO/UNICEF. Introduction to the International Code o Marketing o Breast-milk

Substitutes. In press.

25. Howard C et al. Oce prenatal ormula advertising and its eect on breasteeding patterns.

Obstetrics and Gynecology, 2000, 95(2):296303.

26. Shealy KR et al. The CDC guide to breasteeding interventions. Atlanta, United States

Department o Health and Human Services, Centers or Disease Control and Prevention,

2005.

27. Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact or mother and

their healthy newborn inants. Cochrane Database o Systematic Reviews 2012. Issue 5.Art No.: CD003519. DOI : 10.1002/14651858.CD003519.pub3.


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Annexes


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ANNEX ILegislative status and historicalevolution by country or area1

Table 1.1 Legislative status in countries and areas o the WHO Arican Region

No. Country or area Legislative status Progress Source

1 AlgeriaFew provisions o theCode into law

No availableinormation

UNICEF, 2011

2 AngolaImplementation othe Code still beingstudied.


UNICEF, 2011

3 Benin Full into lawNo availableinormation

UNICEF, 2011; WHO,2008

4 Botswana Full into lawNo available

inormation

UNICEF, 2011; WHO,

2008

5 Burkina Faso Full into lawNo availableinormation

UNICEF, 2011

6 BurundiMeasures drated stillawaiting nal approval


UNICEF, 2011

7 Cameroon Full into lawNational Code enactedin 2005

UNICEF, 2011; WBTi,2011; WHO, 2008

8 Cape Verde Full into lawNo availableinormation

UNICEF, 2011; WBTi,2011; WHO, 2008

9Central AricanRepublic

No actionNo availableinormation

UNICEF, 2011

10 Chad No actionNo availableinormation UNICEF, 2011

11 ComorosVoluntary and othernational measures


WHO, 2008

12 CongoMeasures drated stillawaiting nal approval


UNICEF, 2011

13 Cte dIvoreMeasures drated stillawaiting nal approval


UNICEF, 2011

14DemocraticRepublic o theCongo

Few provisions into lawNo availableinormation

UNICEF, 2011

15Equatorial

Guinea

No available

inormation

16 EritreaImplementation oCode still beingstudied


UNICEF, 2011

17 EthiopiaFew provision o Codeinto law



18 Gabon Full into lawNo availableinormation

UNICEF, 2011

19 Gambia Full into lawNo availableinormation


20 Ghana Full into lawBreasteedingpromotion regulation

2000

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

1 Sources or Annex 1 are shown in Section 2.


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21 GuineaFew provisions oCode into law



22 Guinea-BissauFew provisions oCode into law

Decree passed in April2005

UNICEF, 2011; WHO,2008 & 2010

23 Kenya Voluntary measures

Country reportedvoluntary measures aso 2007. Since 2008, alaw was being dratedbut is not yet enacted.

UNICEF, 2011; WHO,2008 & 2010

24 LesothoImplementation othe Code still beingstudied


UNICEF, 2011

25 LiberiaSome provisions o theCode translated intovoluntary measures



26 Madagascar Full into lawNo availableinormation


27 Malawi Many provisions o theCode into law

Public Health Act

(34:01), no dateavailable

UNICEF, 2011; WBTi,2011

28 MaliMany provisions o theCode into law


UNICEF, 2011

29 Mauritania

Voluntary and othernational measures.Implementation othe Code still beingstudied



30 Mauritius

Voluntary and othernational measures.Implementation o

the Code still beingstudied


UNICEF, 2011; WHO,2008 & 2010

31 Mozambique Full into law

Law was passed18 November 2005(Diploma MinisterialNo. 129/2007 de 3 deOutubro, Cdigo deComercializao dosSubstitutos do LeiteMaterno)

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

32 NamibiaMeasures drated stillawaiting nal approval


UNICEF, 2011

33 Niger Many provisions intolaw

Law was passed

27 July 1998 (ArreteNo. 00215/msp/portant reglementation)

UNICEF, 2011; WHO,2008 & 2010

34 NigeriaMany provisions intolaw

Country passed theMarketing o BMSAct 41 o 1990, thenamended by Act 22o 1999. Act wasreplaced by NAFDAC-Marketing o Inantand Young ChildrenFood and OtherDesignated Products

(Registration, Sales,etc.) Regulations 2005



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35 RwandaMeasures drated stillawaiting nal approval


UNICEF, 2011

36Sao Tome andPrincipe

Voluntary and othernational measures


WHO, 2008

37 SenegalMany provisions oCode translated intolaw

No available

inormationUNICEF, 2011

38 SeychellesVoluntary and othernational measures


WHO, 2008

39 Sierra Leone

Voluntary and othernational measures.Drated measures stillawaiting approval



40 South Arica Voluntary measuresNo availableinormation

UNICEF, 2011

41 Swaziland Voluntary measuresNo availableinormation

UNICEF, 2011; WBTi,2011

42 Togo Not clear rom surveyresponse. Dratedmeasures or approval

Government adoptedthe Code in 2003.


43 Uganda Full into law

Adopted the Code inthe Food and DrugsAct o 1997 (Marketingo Inant and YoungChild Foods) and adrat amendment inthe Food Saety Acto 2005, but not yetenacted

WBTi, 2011

41United Republic

o Tanzania

Full into lawNo available

inormation

UNICEF, 2011; WHO,

2008

45 ZambiaMany provisions intolaw

Adopted a voluntarymeasure in 1982which was revisedin 1994. In 2006the country passedthe Food & Drugs,Marketing o BreastMilk Substitutes,Regulations

UNICEF, 2011; WBTi,2011; WHO, 2008

46 Zimbabwe Full into lawNo availableinormation



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Table 1.2 Legislative status in countries and areas o the WHO Region o

the Americas


1 Antigua andBarbuda

No action No available inormation WHO, 2010

2 Argentina Many provisions

into law

Has been active in regulating

the production o BMSsince 1969. In 1997, MoHsigned Resolution No. 54/97approving implementation othe Code. This new resolutionneeded joint support o otherministries, which was providedwith Resolutions No. 97 and301 o 2007.

PAHO, 2011; UNICEF,

2011; WHO, 2008

3 Bahamas No availableinormation

UNICEF, 2011

4 Barbados No action No available inormation WHO, 2010

5 Belize Voluntary and

other nationalmeasures

No available inormation WHO, 2008

6 Bolivia (Pluri-national Stateo)

Many provisionsinto law

Law passed 15 August 2006.Working on a regulation toimpose sanctions that or noware not yet part o the law.

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

7 Brazil Full into law Regulation or the Marketing oInant Food (NCAL) approved in1988. This was later amendedinto the Brazilian Regulation orMarketing o oods or inants(NBCAL) in October 1992.Due to the increased numbero reports o alleged violationso the regulation, in 2000, theMoH established a technicalworking group to strengthenit. In 2001, a Ministerial Orderwas issued. On 4 January2006 a law (Ley 11.265) waspassed that aims at regulatingthe marketing o products orinants and young children.


8 British VirginIslands

No action taken No available inormation WHO, 2010

9 Canada Few provisionsinto law No available inormation UNICEF, 2011

10 Chile Mainly voluntarymeasures. Fewprovisions intolaw.

Not all provisions o Code arelaw. Recently, the Presidentvetoed a provision in a newnutrition law that aimed atprohibiting promotion o BMS.

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

11 Colombia Many provisionsinto law

Beore the WHA in 1980, aproposal to regulate marketingo BMS was made, withMinisterial Decree 1220, butit was not approved. In 1992,the proposed decree was

amended into Decree 1397 andeventually approved.

PAHO, 2011; UNICEF,2011; WBTi, 2011


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12 Costa Rica Full into law A technical working group wascreated in 1985 to work onimplementation o the Code. Itsproposal was rejected by theLegislative Assembly. Law 7430o 1992, to oster and support

breasteeding, and RegulationN 24576-S, 1995, were notapproved immediately. It tookthe intervention o the First Ladyto convince the legislative bodyto support and endorse theproposed law. It was eventuallypassed in September 1994 andgazetted in October 1994, aslaw No. 7430. Its regulationswere published in September1995.

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

13 Cuba Few provisionsinto law

No available inormation PAHO, 2011; UNICEF,2011

14 Dominica Few provisionsinto law. Voluntarymeasures

Breasteeding policy adopted in1993 and revised in 1999.

WHO, 2008 & 2010

15 DominicanRepublic

Full into law Law 8-95 passed 19September 1995, and itsregulations 20 January 1996.


16 Ecuador Mainly voluntarymeasures (Codeo conduct).Existing lawor support obreasteeding

does not containany article o theCode.

First regulation o marketingo BMS, limited to inants,approved in 1983. In 1993,manuacturers signed Code oConduct, voluntary measureto sel-regulate their own

marketing activities. Law 101o 1995, or the promotion,support and protection obreasteeding, does not containany article o the Code.


17 El Salvador Measure drated Since 2002, a drated law hasbeen supported by civil societyand international organizations,but still not approved.

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

18 Grenada No actiontaken. Voluntarymeasures limitedto guidelines.


19 Guatemala Full into law, withother voluntarymeasures

Law No. 66-83 o 7 June 1983 UNICEF, 2011; WBTi,2011; WHO, 2008 &2010

20 Guyana Some provisionsvoluntary

No available inormation UNICEF, 2011

21 Haiti Drated measuresawaiting nalapproval



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22 Honduras Norm, regulation,voluntarymeasures

Norm (Agreement 4780) orpromotion and protectiono breasteeding passed 8November 2005. Instrument(it is not a law) does notcontain any sanctions or legal

procedure or prosecutingalleged violations.

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

23 Jamaica Some provisionsvoluntary

No available inormation UNICEF, 2011; WHO,2008

24 Mexico Many provisionsinto laws andregulations

In 1992, manuacturers oBMS and MoH enteredinto agreement to regulatepromotion and distributiono BMS to health workers.Agreement was ratied in1995 and 2000. Law on Health(amended 31 May 2009) clearlyadopts some standards o the

Code in relation to promotion tothe general public.

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

25 Montserrat No action No available inormation WHO, 2010

26 Nicaragua Many provisionsinto law

On 12 December 1981, rstto pass Decree on promotion,support and protection obreasteeding ater WHAendorsement o the Code.Law No. 295 passed in 1999.MoH studying possibility ostrengthening law.

PAHO, 2011; UNICEF,2011; WBTi, 2010

27 Panama Full into law Law No. 50 was passed23 November 1995.

PAHO, 2011; UNICEF,2011; WHO, 2008

28 Paraguay Few provisionsinto law

Law 1478 on marketing o BMSpassed 8 October 1999.

PAHO, 2011; UNICEF,2011; WHO, 2008

29 Peru Full into law Decree No. 020-82-SAapproved in 1982, making ita leading country in adoptingthe Code. Ater several yearsand some reviews, proposalsor its amendment were made,and a new Decree No. 007-2005-SA was created. Despitebeing approved, industryexerted major eorts callingor government to negotiatethe decree and amend it again.Finally, decree 009-2006 SAwas approved.

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

30 Puerto Rico Few provisionsinto law. No law orregulations dealwith marketing oBMS.

Law 79 passed in 2004. PAHO, 2011

31 Saint Kit ts andNevis

Voluntary andother nationalmeasures


32 Saint Lucia No action No available inormation WHO, 2010


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33 Saint Vincentand theGrenadines

Voluntarymeasures(guidelines)


34 Suriname Voluntary andother nationalmeasures


35 Trinidad andTobago

Voluntary andother nationalmeasures


36 United States oAmerica

No action No available inormation UNICEF, 2011; WHO,2010

37 Uruguay Full into law Decree 315 passed in 1994. In2009, MoH issued MinisterialOrdinance containing oneprovision regarding role oMoH in relation to monitoringpractices o manuacturers.


38 Venezuela

(BolivarianRepublic o)

Full into law Resolution No. 405 issued

on 17 August 2004 requiringmandatory labelling or BMS. Insame year, Resolution No. 444,calling or promotion, supportand protection o breasteedingwas signed. Law or promotion,support and protection obreasteeding passed in 2007.

PAHO, 2011; UNICEF,

2011


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Table 1.3 Legislative status in countries and areas o the WHO Eastern

Mediterranean Region

No. Country or area Legislation status Progress Source

1 Aghanistan Full into law No available inormation UNICEF, 2011;WBTi, 2011; WHO,2008

2 Bahrain Full into law No available inormation UNICEF, 20113 Djibouti Many provisions into law No available inormation UNICEF, 2011

4 Egypt Many provisions intodierent laws anddecrees

No inormation available UNICEF, 2011;WBTi, 2011; WHO,2008

5 Iran (IslamicRepublic o)

Full into law withvoluntary and othernational measures

No inormation available UNICEF, 2011;WHO, 2008

6 Iraq Voluntary and othernational measures.Measures drated stillawaiting approval.

No available inormation UNICEF, 2011;WHO, 2008

7 Jordan Many provisions into law No available inormation UNICEF, 2011;WHO, 2008

8 Kuwait Voluntary measures Set o standards onlyimplemented in MoHacilities. Ongoing initiativeto integrate the Code intoKuwait child rights law.

UNICEF, 2011;WBTi, 2011

9 Lebanon Full into law Law enacted 11 December2008


10 Libya Action limited to endree supplies


11 Morocco Drated measures

awaiting approval


12 Oman Many provisions intolaw. Voluntary and othernational measures.

Code o Marketing o BMSpassed 16 March 1998.

UNICEF, 2011;WHO, 2008 & 2010

13 Pakistan Full into law Breasteeding ordinancepassed in 2002, but itsrules and regulations onlyin 2009.


14 Qatar Few provisions into law No available inormation UNICEF, 2011

15 Saudi Arabia Full into law No available inormation UNICEF, 2011

16 Somalia No action No available inormation UNICEF, 2011

17 Sudan Only actions limitedto end ree supplies.Voluntary and othernational measures.

No available inormation UNICEF, 2011;WHO, 2008

18 Syrian ArabRepublic

Measures being studied No available inormation UNICEF, 2011

19 Tunisia Many provisions into law No available inormation UNICEF, 2011

20 United ArabEmirates

Few provisions into law No available inormation UNICEF, 2011

21 West Bank andGaza Strip

No available inormation

22 Yemen Full into law No available inormation UNICEF, 2011


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Table 1.4 Legislative status in countries and areas o the WHO European Region


1 Albania Full into law No available inormation UNICEF, 2011; WHO,2008 & 2010

2 Andorra No available inormation UNICEF, 2011

3 Armenia Few provisions into law No available inormation UNICEF, 2011; WHO,

20104 Austria Many provisions into law No available inormation UNICEF, 2011; WHO,

2008 & 2010

5 Azerbaijan Many provisions into law No available inormation UNICEF, 2011; WHO,2008

6 Belarus Measures being studied No available inormation UNICEF, 2011; WHO,2008

7 Belgium Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2010

8 Bosnia andHerzegovina

Drated measuresawaiting approval

No available inormation UNICEF, 2011; WHO,2008 & 2010

9 Bulgaria No available inormation WHO, 2008

10 Croatia Measures being studied No available inormation UNICEF, 2011; WHO,2008 & 2010

11 Cyprus No available inormation No available inormation

12 Czech Republic Many provisions into law No available inormation UNICEF, 2011

13 Denmark Many provisions into law No available inormation UNICEF, 2011

14 Estonia Few provisions into law No available inormation UNICEF, 2011; WHO,2008

15 Finland Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2010

16 France Many provisions into law No available inormation UNICEF, 2011

17 Georgia Full into law No available inormation UNICEF, 2011; WHO,2008

18 Germany Many provisions into law No available inormation UNICEF, 2011; WHO,2008

19 Greece Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2010

20 Hungary Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2010

21 Iceland No available inormation WHO, 2008

22 Ireland Many provisions into law No available inormation UNICEF, 2011; WHO,2010

23 Israel Few provisions into law No available inormation UNICEF, 2011

24 Italy Many provisions into law No available inormation UNICEF, 2011; WHO,2008

25 Kazakhstan No action No available inormation UNICEF, 2011; WHO,2008

26 Kyrgyzstan Many provisions into law No available inormation UNICEF, 2011

27 Latvia Many provisions into law No available inormation UNICEF, 2011; WHO,2010

28 Lithuania Measures being studied No available inormation UNICEF, 2011; WHO,2010

29 Luxembourg Many provisions into law No available inormation UNICEF, 2011

30 Malta Drated measures

awaiting approval

No available inormation UNICEF, 2011; WHO,

2008 & 2010

31 Monaco No available inormation


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32 Montenegro No available inormation

33 Netherlands Many provisions into law No available inormation UNICEF, 2011

34 Norway Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2011

35 Poland No available inormation

36 Portugal Many provisions into law No available inormation UNICEF, 201137 Republic o

MoldovaNo available inormation

38 Romania Measures being studied No available inormation UNICEF, 2011; WHO,2010

39 RussianFederation

Measures being studied No available inormation UNICEF, 2011

40 San Marino No available inormation

41 Serbia No available inormation

42 Slovakia Measures being studied No available inormation UNICEF, 2011; WHO,2008 & 2010

43 Slovenia Many provisions into law No available inormation UNICEF, 201144 Spain Many provisions into law No available inormation UNICEF, 2011; WHO,

2008 & 2010

45 Sweden Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2010

46 Switzerland Some provisionsvoluntary


47 Tajikistan Many provisions into law No available inormation WHO, 2010

48 The ormerYugoslavRepublic oMacedonia

Few provisions into law No available inormation WHO, 2008

49 Turkey Few provisions into law No available inormation UNICEF, 2011

50 Turkmenistan Few provisions into law No available inormation UNICEF, 2011; WHO,2010

51 Ukraine No available inormation

52 United Kingdomo Great Britainand NorthernIreland

Many provisions into law No available inormation UNICEF, 2011

53 Uzbekistan Measures being studied No available inormation UNICEF, 2011; WHO,2008 & 2010


46/626

Table 1.5 Legislative status in countries and areas o WHO South-East Asia Region


1 Bangladesh Many provisionsinto law

Ordinance on Breast-milkSubstitutes (Regulation oMarketing) passed 12 May1984. Ongoing eort toamend existing regulation.

UNICEF, 2011; WBTi,2011; WHO, 2010

2 Bhutan Some provisionsvoluntary

No available inormation WBTi, 2011; UNICEF,2011

3 DemocraticPeoplesRepublic oKorea


4 India Full into law Inant Milk Substitutes,Feeding Bottles andInant oods (Regulationo production, supply anddistribution) Act passedin 1992 (IMS Act). It was

amended in 2003.

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

5 Indonesia Many provisionsinto law, withvoluntary and othernational measures

Decree o MoH No. 237passed in 1997. Ongoingeort to pass new law thatwill adopt the Code.

UNICEF, 2011; WBTi,2011; WHO, 2008

6 Maldives Full into law Regulation on Import,Production and sale oBMS passed in 2008.

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

7 Myanmar Being studied No available inormation UNICEF, 2011; WHO,2008

8 Nepal Full into law BMS Act 2049 passed in1992.

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

9 Sri Lanka Full into law Regulation under DirectiveNo. 107 o ConsumerProtection Act passed 23March 2004.

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

10 Thailand Voluntary measures No available inormation UNICEF, 2011; WBTi,2011; WHO, 2008 & 2010

11 Timor-Leste Voluntarymeasures. Lawdrated, awaitingapproval.



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Table 1.6 Legislative status in countries and areas in the WHO Western Pacifc

Region


1 Australia Voluntary measures No available inormation UNICEF, 2011; WHO,2008

2 Brunei

Darussalam

Voluntary and other

national measures


3 Cambodia Many provisions intolaw

Sub-decree passed 17August 2009

UNICEF, 2011; WHO,2008 & 2010

4 China Many provisions intolaw

Regulations o Marketingo BMS passed 13 June1995. Since 2009, MoHreported to be workingon amendments oregulations.

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

5 Cook Islands No availableinormation

6 Fiji Full into law Marketing control or oods

passed 2 October 2002

UNICEF, 2011; WHO,

2008 & 20107 French

PolynesiaSame as France

8 Japan Few provisions into law No available inormation UNICEF, 2011

9 Kiribati Voluntary and othernational measures


10 Lao PeoplesDemocraticRepublic

Many provisions intolaw

Decision o MoH onControl o Marketing oInant and Young ChildFood Products approved 3August 2007.

UNICEF, 2011; WHO,2008 & 2010

11 Malaysia Voluntary and other

national measures

UNICEF, 2011; WHO,

2008 & 201012 Marshall Islands Voluntary and other

national measuresNo available inormation WHO, 2008

13 Micronesia(FederatedStates o)


14 Mongolia Few provisions into law National law approved byParliament in July 2005.In 2008, MoH approvedregulations necessary orimplementation o law

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

15 Nauru No available

inormation

16 New Zealand Voluntary and othernational measures


17 Niue No action UNICEF, 2011

18 Palau Full into law No available

Code Marketing Breast-Milk Substitutes WHO 2011

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