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. 2023 Oct 23:11:1176478.
doi: 10.3389/fpubh.2023.1176478. eCollection 2023.

Law matters - assessment of country-level code implementation and sales of breastmilk substitutes in South Asia

Constance Ching  1 , Vani Sethi  2 , Tuan Thanh Nguyen  1 , Zivai Murira  2 , Katherine Shats  3 , Dhammica Rowel  4 , Khadheeja Ahmed  5 , Kinley Dorji  6 , Indrani Chakma  6 , Karan Courtney Haag  7 , Phulgendra Prasad Singh  7 , Salma Khatoon  8 , Uzma Khurram Bukhari  9 , Ahmadwali Aminee  10 , Sebanti Ghosh  11 , Thomas Forissier  11 , Kristen Kappos  12 , Paul Zambrano  13 , Golam Mohiuddin Khan  14
Affiliations

Law matters - assessment of country-level code implementation and sales of breastmilk substitutes in South Asia

Constance Ching et al. Front Public Health. .

Abstract

Objectives: This study examines the status of implementation of the International Code of Marketing of Breast-milk Substitutes of eight countries in the South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka), and describes the sales value and volume of commercial milk formula (CMF) marketed as breastmilk substitutes (BMS) and baby food in four countries (Bangladesh, India, Pakistan, and Sri Lanka).

Design: A mix of descriptive methods is used to assess national status of Code implementation, including a desk review of the 2022 WHO/UNICEF/IBFAN Code Status Report, systematic content analysis of national Code measures, and insights generated from the participation of key government and UNICEF/WHO actors in a regional workshop that aimed to identify each country's barriers, gaps, and the status of Code implementation. Data on the sales value and volume of CMF and baby food between 2007 to 2021 and with the prediction to 2026 in Bangladesh, India, Pakistan, and Sri Lanka were obtained from Global Data.

Findings: There are major gaps in Code implementation in countries even with legal measures considered substantially aligned with the Code, such as the inadequate age range of CMF covered in the scope, insufficient safeguards against conflicts of interest in the health system, lack of warning of risks of intrinsic contamination of powdered milk formula, and an absence of effective monitoring and enforcement mechanisms. Data on CMF sales shows health facilities and pharmacies sustain the highest sales. Lower sales volume of infant formula (including special formula), compared to other CMF such as follow-up formula and growing-up milk, has been observed in three of the four countries (Bangladesh, India, and Sri Lanka). Overall, GUM, followed by baby cereals, accounted for a large portion of CMF and baby foods sales in the same three countries.

Recommended actions include: (1) Closing the gaps between national measures and the Code, (2) Ensuring effective monitoring and enforcement mechanisms, (3) Strengthening conflicts of interest safeguards in the health system, (4) Tackling digital marketing, and (5) Galvanizing political support and support from in-country public health and women's rights jurist networks.

Keywords: South Asia; baby foods; baby milks; breastfeeding; breastmilk substitutes; commercial milk formula; inappropriate marketing; legal measures.

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Conflict of interest statement

4.1.8.Conflicts of interest within the health system and government, such as industry sponsorship of health programs and industry’s participation in policymaking and monitoring, can impede the adoption of strong laws and proper enforcement. This study reveals two main problems. Firstly, for some countries, their law specifies that financial or material inducements are not allowed only if they are used for promoting products covered in the law. This creates situations where financial or materials inducements could arguably be allowed so long as they are not explicitly specified with a purpose to promote designated products. Secondly, the definition of conflicts of interest may not be clear, allowing room for companies to establish ambiguous ‘partnerships’ or ‘corporate social responsibility’ campaigns that are fraught with conflicts of interest. The 2016 WHO Guidance reinforces with clearer conflicts of interest safeguards within the health systems.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Summary of SWOT analysis.
Figure 2
Figure 2
Percentage of the contribution of value (A) and volume (B) of the four countries to Asia Pacific region and the world.
Figure 3
Figure 3
Value trends of baby foods and CMF segmentation in Bangladesh (A), India (B), Pakistan (C), and Sri Lanka (D) (actual 2007–2021, projection 2022–2026).
Figure 4
Figure 4
Volume trends of baby foods and CMF segmentation in Bangladesh (A), India (B), Pakistan (C), and Sri Lanka (D) (actual 2007–2021, projection 2022–2026).
Figure 5
Figure 5
Trends of per capita expenditure and consumption of CMF in India (2007–2026).
Figure 6
Figure 6
Key distribution channels of baby foods (A) and CMF (B) by country (2021).
See this image and copyright information in PMC

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