Sri Sukotjo*, Irma Hidayana**, Harriet Torlesse*** VIOLATIONS OF THE INTERNATIONAL CODE OF MARKETING OF BREAST-MILK SUBSTITUTES IN INDONESIA Sri Sukotjo*, Irma Hidayana**, Harriet Torlesse*** *UNICEF Indonesia, **Independent Consultant, ***UNICEF ROSA

Indonesia Middle Income Country 4th Populous Country in the world (253 million Pop) Decentralized government: 34 provinces and >500 districts across >17,000 islands

Focus only on Exclusive Breastfeeding! Ministerial Decrees Prior to 2009 Government Regulation EBF (2012) Labor Law 2003 Health Law 2009 Ministerial Decrees Local Regulations (Sub National) Indicators in RPJMN, RENSTRA, RAN HAM 2012 - onwards Focus only on Exclusive Breastfeeding! Indonesia has passed several laws and government regulations aimed at protecting breastfeeding The 2009 Health Law and Government Regulation 33/2012 obligates government to protect exclusive breastfeeding for infants under six months. The Government Regulation specifies the role of health facilities and health workers in promoting, protecting and supporting exclusive breastfeeding. Health facilities and health workers are not permitted to sell, give or promote infant formula in any way to infants aged less than six months, and formula companies were prohibited from marketing their products in health facilities.   Several regulations control labelling, advertising and the quality of formula products, but it only covers the labelling of foods for infants aged less than 12 months The major gap in the law and regulation is that the focus is only on exclusive breastfeeding and they do not protect continued breastfeeding from 6 months to at least two years. This permits the promotion of follow-on formulas and growing up milks. Given the similarity in labelling and branding among the various formulas and milks, this results in cross promotion which also undermines exclusive breastfeeding too. *Source: 2003, 2007, 2012 – IDHS 2015 – PSG (MoH Nutrition Survey)

Optimal breastfeeding improves human capital development and reduces health expenditures for government and families* 5,376 children’s lives could be saved annually Nearly USD 270 million in health care costs saved annually More than USD 1.3 billion in wages losses prevented annually 13.7 percent of monthly earnings saved on formula costs Recent global analysis of scientific evidence has confirmed the immense importance of breastmilk and breastfeeding., Breast milk is the ideal food for infants. It is safe, clean and contains antibodies which help protect against many common childhood illnesses. Breastfed children perform better on intelligence tests, are less likely to be overweight or obese and less prone to diabetes later in life. Women who breastfeed also have a reduced risk of breast and ovarian cancers. New analysis conducted by the University of Padjajaran revealed that improved breastfeeding in Indonesia could save 5377 child lives and IDR 3 trillion in health costs every year by preventing childhood illnesses such as pneumonia and diarrhoea. In addition, boosting breastfeeding could save IDR 17 trillion in wages each year due to improvements in cognitive ability and increased earnings in later life. *Walters, D., S. Horton, A.Y.M. Siregar, P. Pitriyan, N. Hajeebhoy, R. Mathisen, P.T.H. Linh, C. Rudert. The Cost of Not Breastfeeding in Southeast Asia. Health Policy and Planning Advance: 2016.

BMS Marketing is a critical issue in Indonesia… Two studies in 2012 and 2015, using IGBM protocol conducted to monitor compliance with the provisions of the Code and subsequent WHA resolutions Description 2012 2015 Areas (Province) 6 1 Number of health care facilities 18 37 Number of women interviewed (pregnant & 0-6mo) 874 856 Number of health care professional interviewed 77 127 Number of retail outlets visited 111 Number of product assessed 44 172 An independent study on violations of the International Code was conducted in 2012 and in 2015 in Indonesia. This study, using IGBM protocol, examined violations in the mass media, and in health facilities and retail outlets. Pregnant women and mothers were selected using systematic random sampling with interval

Common Advices Received 2012 2015 “Replace breastmilk with formula” “Give SGM so baby won’t get diatrrhea” “In addition to breastmilk, also give S26 so the baby is full and sleep well “Formula as temporary food due to indications” “Continue with exclusive breastfeeding” Health Professional 11.3 % 5.5% Violation of Article 5-5 and 6.2 Article 5.5. Marketing personnel in their business capacity should not seek direct or indirectly to pregnant mother, mothers and other family members, samples or products within the scope of the code; Article 6.2 No facility of a health care system should be used for the purpose of promoting infant formula or other products within the scope of the code In 2012- 11.3% percent mothers reported that they received advices from health professional compared to 5.5% in 2015 In 2012- 1.9% percent mothers reported that they received advice from company representatives compared to 2.9% in 2015 Information/recommendation/advice given to these women includes issues related to the use of formula milk to supplement breastmilk – especially when the breastmilk has not come out yet – advantages of formula milk, food/drinks besides breastmilk which is suited based on infant’s age, use of teat that fits in the infant’s mouth. Within some of the advice, they mentioned brands. Company Representative “Formula as a complement when breastmilk is not sufficient or to increase baby’s weight” “Formula provides nutrition needed by babies and is affordable” “Morinaga contains nutrition required for the growth and baby’s brain” “Let’s join Bebelac club” 1.9 % 2.9%

Receiving Samples & Gifts: What & Who 2012 2015 Violation of Articles 5-2 and 6-2 2.3% of women have received samples of BMS and other products 15.1% of women have received samples of BMS and other products Milk for Pregnant Mother Infant Formula Growing Up Milk Pacifier, teats Bags etc Milk for Pregnant Mother Infant Formula Growing Up Milk Pacifier, teats Bags etc Article 5.2 Manufacturers and distributors should not provide, directly and indirectly, to pregnant women, mothers or members of their families, samples or products within the scope of the code. Article 6.2 Free samples of BMS were received by 15.1% of women in 2012, and 2.3% in 2015 from health worker or company’s representatives. Among product received are milk for pregnant mother, infant formula, growing up milk, pacifier teats, bags

Health Professional- Visits by Companies Violation of Articles 6-2 of the Code. 15 out of 77 Health Professionals Abbott, Anmum, Friesland, Mead Johnson, Morinaga, Nestle, Nutricia/Danone At least 1 Health Professional in 10 Health Facilities Danone, Friesland Campina, Nestle, Mead Johnson To measure the percentage of health facilities where staff reported having received at least one visit from company personnel in the last 6 months; To identify the companies reported to have made the visits; Studies showed that in 2012 – 15 out of 77 health professional were visited by companies, and at least 1 in 10 health facilities in 2015 2012 2015

Health Facilities- Promotion of Materials 2012 2015 Violation of Articles 6 of the Code. 15 out of 18 Health Facilities Displayed IEC Materials from BMS Manufacturers 12 out of 37 Health Facilities Displayed IEC Materials from BMS Manufacturers In terms of promotion materials displayed in the health facilities- in 2012 15 out of 18 health facilities displayed materials from BMS companies, and 12 out 37 health facilities in 2015

Products Assessed- Compliance to Labelling 2012 2015 Violation of Article 9·1 and 9-2 of the Code 100% Placing pictures or text of baby or other pictures that idealize the use of BMS 46.9% Placing pictures or text of baby or other pictures that idealize the use of BMS Articles 9 (9-2) In terms of products assessed- in 2015, nearly half had labels with text or pictures idealizing BMS for infants The slide showed that an improvement made by local companies in terms of labelling

Promotion at Retail Outlets Violation of Article 5·1 and 5-3 of the Code Promotion starts from Products for Pregnant Mothers to products for Young Children There is no legislation that prohibits the promotion and advertisements of BMS for children aged one and above by BMS manufacturers, distributors or retailers in health facilities, retail outlets, mass media, and elsewhere. As a result is it is common to find promotions and advertisements of BMS for children aged one and above. Increasingly, BMS manufacturers and distributors are using the internet, social media and other electronic means to promote and advertise their products. In addition, several manufacturers market milks for mothers as a means to secure brand loyalty even before an infant is born.

Conclusions Despite recent progress- violations of national legislation and the BMS code persists in Indonesia Parents are exposed to advertising & promotion of BMS products at health facilities, retail outlets and the media Urgent need to bring Indonesia’s legislation fully in line with the Code and the WHA resolutions, and to establish a monitoring and enforcement system Indonesia should amend and strengthen its laws and regulations to enact all provisions of the International Code and its subsequent WHA resolutions. Amendments to existing laws and regulations are required in order that the legislation protects all breastfeeding by prohibiting all promotion of BMS up to the age of three years. These amendments include the following: Include within the scope of legislation all milk products (in either liquid or powdered form) that are specifically marketed for feeding infants and young children up to the age of 3 years, including infant formula, follow-up formula and growing-up milks. All promotion and advertising of all these products should be prohibited. Prohibit all marketing of complementary foods for children less than six months and inappropriate marketing of complementary foods for children 6-35 months. Include all necessary messages in informational and educational materials on infant and young child feeding as specified under the International Code. Explicitly prohibit all advertising and other forms of promotion of designated products to the general public, including contact with pregnant women and mothers, promotion through the internet, social media and other electronic means of communication, as well as within the health system. Prohibit the provision of free or low-cost supplies to health facilities by manufacturers or distributors, and any other financial or material inducements to health workers to promote designated products, taking into consideration relevant resolutions of the WHA to ensure avoidance of conflicts of interest. Include all necessary requirements for labelling of designated products, as in the International Code Establish government mechanisms and funding for robust and sustainable monitoring and enforcement.

THANK YOU Acknowledgement: SEAMEO RECFON, ATNI/Westat, Ministry of Health and all participants in the two studies