Pediatrics Consultant Clinical nutritionist

Pediatrics Consultant Clinical nutritionist
Situational analysis of the International Code of Marketing of Breast milk Substitutes in Arab World Dr Ghada Sayed Pediatrics Consultant Clinical nutritionist IBFAN Arab World Regional coordinator

Introduction The level of Code implementation in the Arab region is very low compared to other Regions. In order to have a clear understanding of the situation and challenges in the Region, a regional assessment was conducted as a collaboration between EMRO and IAW.

History of Code implementation in the Arab region
1981 International Code 1983 Tunisia 1994 Egypt 1995 Bahrain & Iran 1998 Oman 2000 Syria 2002 Yemen 2004 Saudi Arabia 2005 Sudan 2009 Jordan 2010 Djibouti 2011 Lebanon & Palestine 2014 Kuwait 2015 Iraq

The main objectives of this study are:
• To assess the current situation of the Code and subsequent relevant WHA resolution • To identify the difficulties, gaps, loopholes and weaknesses in implementing the International Code of Marketing of Breastmilk Substitutes • To come with recommendations to formulate an action plan to implement the Code in Countries which has not implemented the Code.

Team of the study Dr Ayoub Aljawaldeh, Regional Nutrition Adviser in EMRO Dr Ghada Sayed

Methodology The module was translated to Arabic.
Member States responded to the assessment representing (91%) of Arab countries The nutrition focal persons filled the module 3 questionnaire with the legal department and relevant units in the Ministry of Health such as nutrition, maternal and child health, and Family Health to fill up all the parts of the questionnaire. A follow up by Teleconference with the national nutrition focal persons to provide assessment in filling the questionnaire and to clarify on the information provided in the questionnaires

Methodology Electronic copies of legislative documents were obtained from : IBFAN International Code Documentation Centre (IBFAN/ICDC) files WHO e-Library of Evidence for Nutrition Actions (eLENA) internet search engines government gazettes.

Partial implementation
Country Full implementation Partial implementation No implementation Algeria Bahrain Comoros Djibouti Egypt Iraq Jordan Kuwait Lebanon Libya Mauritania Morocco Oman Palestine Qatar Saudi Arabia Somalia Sudan Syria Tunisia UAE Yemen

Partial implementation
Full implementation Partial implementation No implementation Bahrain Kuwait Lebanon Yemen Djibouti Egypt Jordan Oman Palestine Saudi Arabia Sudan Syria Tunisia Algeria Comoros Iraq Libya Mauritania Morocco Qatar Somalia UAE 4 (18%) 9 (41%)

4 Information and education 5 The general public and mothers
Article 1 Aim 2 Scope 3 Definitions 4 Information and education 5 The general public and mothers 6 Health care systems 7 Health workers 8 Persons employed by manufacturers and distributors 9 Labelling 10 Quality 11 Implementation and monitoring Bahrain Djibouti Egypt Jordan Kuwait Lebanon Palestine Oman Saudi Arabia Sudan Syria Tunisia Yemen

Article 1. Aim of the Code Contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution. The International Code of Marketing of Breastmilk Substitutes, adopted by the World Health Assembly in 1981 is the only tool we have to level an uneven playing field. There was official recognition then that it was necessary to give different treatment to the marketing of commercial baby foods. Because of the vulnerability of infants and because of the risks involved when these products are used unnecessarily and improperly. So what is the Code all about? The overall aim is the safe and adequate nutrition of infants. It tries to ensure that unbiased information about infant feeding is provided to women free of commercial influence. It prevents a range of promotional practices from interfering with breastfeeding. The Code is clear that making safe and appropriate products available is acceptable but promoting them like shampoo or coffee is not on.

Article 1. Aim of the Code Ten (77%) out of 13 National Codes namely, Djibouti, Egypt, Jordan, Kuwait, Lebanon, Palestine, Saudi Arabia, Syria, Tunisia and Yemen, have mentioned the aim of the Code in their national legislations Some National Codes added more objectives to those mentioned in the International Code

Article 2. Scope of the Code
The Code applies to the marketing, and practices related thereto, of the following products: breast-milk substitutes, including infant formula; other milk products, foods and beverages, including bottlefed complementary foods, when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breast milk; feeding bottles and teats and related equipment It also applies to their quality and availability, and to information concerning their use.

0-4 0-6 0-12 0-24 0-30 0-36 Bahrain Djibouti Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Yemen

Article 3. Definitions "Breast-milk substitute“ "Infant formula“
"Complementary food“ "Container“ "Distributor“ "Health care system“ "Health worker“ "Infant formula“ " Label“ "Manufacturer" "Marketing“ "Marketing personnel“ "Samples“ "Supplies"

BMS Complementary food Container Distributor HC system Health worker Infant formula Label Manufacturer Marketing Marketing personnel Samples Supplies Bahrain Djibouti Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Sudan Syria Tunisia Yemen

Article 4. Information and education

Bahrain Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Sudan
Country Governments responsibility Donations of equipment or materials should be made only at request Donated equipment or materials should not refer to proprietary product Bahrain Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Sudan Syria Tunisia Yemen

Bahrain Djibouti Egypt Jordan Kuwait Lebanon Oman Palestine
Benefits & superiority of BF Maternal nutrition Negative Effect of partial bottle feeding Difficulty of reversing decision not to BF Proper use of infant formula Bahrain Djibouti Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Sudan Syria Yemen

Social and financial implications
Country Social and financial implications Health hazards of inappropriate foods or feeding methods Health hazards of unnecessary or improper use of BMS No pictures or text which encourage artificial feeding Bahrain Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Sudan Syria

Article 5: The general public and mothers

Pregnant, mothers or their families No Advertising
General public Pregnant, mothers or their families No Advertising or other form of promotion No point-of-sale advertising, giving of samples, or any other promotion device * No samples No gifts which may promote the use of BMS or bottle feeding. Marketing personnel, should not seek contact of any kind Bahrain Djibouti Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Sudan Syria Tunisia Yemen

Supermarkets Special offers Special displays Shelf talkers Leaflets

Pharmacies Tie in sales Shop windows Company reps Posters
Special displays Company reps Posters

Billboards

Avent Shop windows

TV program sponsored by Nestle

Mothers gifts Samples SMSSMSMS Gifts

Article 6: Health care systems
Gifts Company materials Article 6: Health care systems free and low cost supplies Posters Company reps

and protect Breastfeeding Encourage Give information and advice to HW in regard to their responsibilities Not used for Promotion placards or posters for display Not used No use of personnel, provided by manufacturer No free or low-cost supplies Bahrain Djibouti Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Sudan Syria Tunisia Yemen

or CW to mothers or family members who need it
Demonstrated by HW, or CW to mothers or family members who need it hazards of improper use. Bahrain Djibouti Egypt Jordan Kuwait Lebanon Palestine Saudi Arabia Syria Tunisia

Article 7: Health workers
Educational materials Misleading information Gifts Samples

Encourage and protect Breastfeeding Information scientific and factual No financial or material inducements to promote products No Samples except for professional evaluation or research Disclose any contribution made from Manufacturers and distributors Bahrain Djibouti Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Sudan Syria Yemen

Article 8: Persons employed by manufacturers and distributors

No Volume of sales included in calculation of bonuses &
No quotas set specifically for sales Do not perform educational functions Egypt Jordan Kuwait Lebanon

Article 9: Labelling

Information about appropriate use of the product
Clear, conspicuous, easily readable understandable Appropriate language Bahrain 4 Egypt 9.1 9.2 Jordan 9a Kuwait Lebanon 11 OPT 8.1 Oman 3 Pakistan 8.2 8.3 Saudi Arabia 10.1 Sudan 16 16 d Syria Tunisia Yemen 7

Bahrain Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Sudan
”Important Notice” Statement of the superiority of Breastfeeding Used only on the advice of a health worker Instructions for appropriate preparation Warning against health hazards of inappropriate preparation. Photos of method of preparation Bahrain Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Sudan Syria Tunisia Yemen

Bahrain Egypt Jordan Kuwait Lebanon Palestine Saudi Arabia Sudan Syria
No Pictures of infants No Pictures or text which may idealise the use of infant formula No "Humanised Maternalised" Or 3Unmodified products cannot be used as the sole source of nourishment of an infant. Complementary foods is suitable for use by infants from six months No Health and nutrition claims Bahrain Egypt Jordan Kuwait Lebanon Palestine Saudi Arabia Sudan Syria Tunisia Yemen

Appropriate age for use of product
Ingredients Composition/ analysis Storage conditions Batch number Expiry date Appropriate age for use of product Bahrain Egypt Jordan Kuwait Lebanon Oman Palestine Saudi Arabia Sudan Syria Tunisia Yemen

Article 10: Quality

Quality of products Bahrain Local standards and conditions set by the Minister ofHea1th in agreement with the Minister of Agriculture and Commerce. Codex Alimentarius commission Egypt Egyptian Food Code or Codex Alimentarius Commission and the Code of Hygienic Practice for Foods for Infants and Children Jordan a high standard for the protection of the health of infants-The applicable standards in Jordan. Kuwait International Codex Alimentarius & GCC standards and specifications. Lebanon Code of Practice of infant and child food products-Codex Alimentarius Commission Oman Standards applicable in the Sultanate of Oman Saudi Arabia Saudi Standards of packaged foods (SASO 1995 /1)-International Food Codex (International Codex Alimentarius) and Saudi Arabian Standards Organization Syria standard specifications applicable in the Syrian Arab Republic. Tunisia Conditions of hygiene and quality must conform to Tunisian regulations in the area failing these, they shall conform to those determined by International standards Yemen Certified specifications and standards of the Yemen Authority of Specifications, Standards, and Quality Control, or in the absence of any national standards, the standards of Codex Alimentarius on baby foods,

Article 11: Implementation and monitoring

give effect to the principles and aim of the Code Governments
Monitoring by Manufacturers & distributors apprise marketing personnel of their responsibilities. Government Manufacturers distributors, NGO's, professional groups, and consumer organizations Bahrain Egypt Jordan Kuwait MOH Lebanon Oman Palestine Saudi Arabia Syria

Authorities Responsibilities
Forming a committee Composition Authorities Responsibilities Registration of products Inspectors duties Bahrain Kuwait promotion and support of breastfeeding Lebanon National Committee for the promotion and Protection of Breastfeeding Palestine Saudi Arabia National Committee of the Breastfeeding Promotion Program Sudan National Commission for Registration of BMS Syria Monitoring Committee for the Protection of Breastfeeding Tunisia

Independent and transparent Free from commercial influence
Country Independent and transparent Free from commercial influence Empowered to Investigate Code violations Impose legal sanctions Bahrain Jordan Kuwait Lebanon Palestine Syria Tunisia Yemen

Recommendations Countries having national legislations should improve and enforce existing legislation Countries having some Code provisions in their national legislations should update the national laws to include all International Code provisions and subsequent relevant WHA resolutions. Countries working on the Code or waiting for approval should finalize it . Investments have to be made in forming partnerships, political buy-in, advocacy and monitoring mechanisms to reinforce implementation and enactment of legislations in countries that lack them. establish national monitoring and reporting mechanisms to support the implementation, monitoring and enforcement of the legislation on the Code.

Recommendations Training for health care providers and decision makers on the specifics of the Code will enhance enactment of the right laws, effective follow up, reporting and enforcement in case of violations. Implement measures supporting the implementation of the International Code as Maternity protection measures and Baby-Friendly Hospitals Initiative Advocacy at various levels to influence policy makers and governments to establish laws and monitoring systems. A critical mass of civil society organizations is necessary to engage and influence enactment of the proper laws and make amendments in existing laws to address salient issues impending code implementation and enforcement.

THANK YOU

E mail: ghadasay@yahoo.com Facebook: IBFAN Arab World

Pediatrics Consultant Clinical nutritionist

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