Track 1 -Policy Facilitators: Ashraf Coovadia, Siobhan Crowley Rapporteur: Nonhlanhla Dlamini Notes: Sue Jones 1

General comments 2 Some BF issues are projected as HIV issues, but in fact they are about all mother and baby pairs, e.g. teenage mums in schools BF is accepted- the challenge is achieving sustained “exclusive’ breastfeeding

Critical policy issues that need to be tackled if we are to support promote and BF (1) – Legislation and regulation Currently no legislation to promote/support BF, only legislation for Maternity leave – Code to be completed, adopted and implemented, clear timeline (2 months, & penalties) – Comprehensive policy review & update –coherent integrated promotion of BF (integration of policies, e.g. Nutrition and PMTCT) – Community outreach- framework utilized to ensure BF initiatives at community level – NDOH to issue one PMTCT/IYCF provision of RF directive- do not leave to provinces – Clear guidelines for medical provision of RF 3

Critical policy issues - 2 Clear national social mobilization & advocacy campaign/ initiative – to promote revised policy, so all stakeholders are aware e.g. grandmothers Hosp admission policy procedures reviewed =e.g. avoid separation of mother baby pair Rights of baby vs. right of mother to choose e.g. young's school going mums choice not BF, DBE,DOH,DSD need to review (note not just HIV issue) BF education for CHW School health policies: orientation and life skills for boy learners to include BF 4

WHO recommends that national authorities promote a single infant feeding strategy for all HIV-infected mothers and their infants WHAT DOES THIS MEAN FOR SA? Current policy of choice - providing RF stigmatizes HIV positive women Evidence global and local that BF is best, SA should be in line with international evidence base SA need to re educate public and HW about risks of not BF BF must be promoted for all mothers Promotion/Marketing of EBF- need to market EBF more aggressively Gov policy should avoid ambiguity of messages Choice to RF can be made by those that wish to, but should not be general policy of SA Mindset of HW- is key challenge, need training/ re-training, get BF counselors, lactation nurses back on board 5

What does this mean to SA contd. A national Single feeding option for HIV +ve women is necessary Ensure funding is aligned to promotion of EBF, HIV funds must be used to promote BF Strengthen education in ANC period Community health practitioners ( formal and lay) are a key resource, and must be capacitated to support & promote BF Hospital policies, procedures and infrastructure can be significantly improved to e.g. critically ill child, BF can still be appropriate, Post natal early discharge Kalafong experience SA should adopt ‘Baby friendly health facility ‘ and ensure all HW all levels 6

Final message Communities/mothers need to be empowered – then they will demand appropriate services 7

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Declarations of interest and role Any employees or staff in receipt of grants, or other financial incentives form marketers of Breast Milk Substitutes are asked to identify themselves. They are asked to step aside from any work group processes as they are not able to develop recommendations 10

Issues from plenary Regulatory Framework -BMS CODE NECESSARY Clear single position of GoSA needed BF as critical CS intervention Promote understanding of Risks of RF Avoid RF in health facilities Avoid mixed messages Stop subsidizing RF Need BF promoting workplace and health system Address (mis)perceptions of BF 11

Health system building blocks WORK FORCE LEADERSHIP & GOVERNANCE MEDICAL SUPPLIES SOCIAL MOBILISATION FINANCING HEALTH INFORMATI ON SYSTEMS SERVICE DELIVERY 12

National (or sub-national) health authorities should decide whether health services will principally counsel and support mothers known to be HIV-infected to: - breastfeed and receive ARV interventions, or, - avoid all breastfeeding, as the strategy that will most likely give infants the greatest chance of HIV-free survival. This decision should be based on international recommendations and consideration of the socio-economic and cultural contexts of the populations served by Maternal and Child Health services, the availability and quality of health services, the local epidemiology including HIV prevalence among pregnant women and main causes of infant and child mortality and maternal and child under-nutrition 13

IYCF- critical contextual factors FactorCurrent situation South Africa IMR Causes High & not declining HIV, neonatal, sepsis, diarrhoea, pneumonia & malnutrition U5MR Causes High & not declining HIV, diarrhoea, pneumonia & malnutrition HIV prevalence Very high - but appears to be stable/declining (except MP) Access to quality health services for child health Decline in access to routine child health services incl. EPI Inequitable access Poor quality services at district level key factor in hospital deaths Access to quality PMTCT ARV interventions Improving, decentralizing. Good access ARVs, but poor access to CD4, poor infant follow up Access to water/sanitation hygiene & cooking Poor for many children, esp. poorer children and families with HIV Feeding practices High rates of initiation, predominantly mixed feeding, very early introduction of solids Values BF seen as desirable & valuable, but for HIV +ve confusion exists, stigma associated with RF Costs Providing RF is estimated > 60% of PMTCT programme costs 14

Policy landscape - opportunities 15 PHC reengineering- community outreach NHI NSP Integrated School Health Programme District Specialist teams Requirement-integration within programming (mainstreaming)