Questions and Answers on Ending Free and Low-Cost Supplies

Prepared by BFHI Management Group
UNICEF, NYHQ, for UNICEF FIELD OFFICES

Q1. Does the International Code of Marketing of Breastmilk Substitutes (the Code) ban all free and low cost supplies of infant formula and other breastmilk substitutes?

A1. Yes, in almost all cases. Reading together the International Code and World Health Assembly Resolution 39.28, free or subsidized supplies are permitted for feeding orphaned and abandoned children, and for babies with certain rare disorders. All other breastmilk substitutes should be obtained through "normal procurement channels" so as not to interfere with the protection and promotion of breastfeeding. Procurement generally means purchase.

Q2. Should free supplies be donated for pre-term and low birth weight infants? Some argue that these infants need early supplementation and therefore free supplies should be permitted.

A2. No. Breastmilk is the medically indicated feeding of choice for almost all pre-term and low birth weight babies.(Reference 1) Obtaining free supplies for these babies encourages bottle (artificial) feeding, which further threatens their survival and healthy development. Moreover, once free supplies are available in postpartum wards and nurseries, it is extremely difficult to control their distribution and misuse.

Q3. What does "cessation" actually mean?

A3. Infant formula manufacturers and distributors stop offering and distributing free and low-cost supplies, and health care facilities and health workers stop requesting and using supplies provided free or at low-cost. Stopping a practice that has become routine, customary, and financially beneficial to hospitals and companies requires a significant effort by all parties. Health workers that request or accept free supplies are as much at fault as companies that offer them.

Q4. Who is a "health worker"?

A4. According to the Code, any person working in the health care system, whether professional or non-professional, including voluntary and unpaid workers, in public or private practice, is a health worker. Under this definition, ward assistants, sweepers, nurses, midwives, social workers, dieticians, counselors, in-hospital pharmacists, obstetricians, administrators, clerks, etc. are all health workers.

Q5. Should the prohibition extend to MCH and rural clinics?

A5. Yes. The Code defines the health care system as: "governmental, non-governmental or private institutions or organizations engaged, directly or indirectly, in health care for mothers, infants and pregnant women; and nurseries or child-care institutions. It also includes health workers in private practice."

Q6. Many manufacturers now produce and market "follow-on formulas" for babies older than 6 months. Should restrictions on free supplies apply to follow-on formulas?

A6. Yes. Follow-on formulas are bottle-fed other milk products which are included in the scope of the Code.(Reference 2) The 1986 World Health Assembly was sufficiently concerned with follow-on formulas to "specifically direct the attention of Member States and other interested parties to the facts that: (a) any food or drink given before complementary feeding is nutritionally required may interfere with the initiation or maintenance of breastfeeding and therefore should neither be promoted nor encouraged for use by infants during this period. And (b) the practice being introduced in some countries of providing infants with especially formulated milks (so-called "follow-up" milks) is not necessary."

Q7. Why not permit free supplies in paediatric wards, since older infants may already be using the feeding bottle?

A7. Because free supplies to paediatric services or other special services for sick infants can seriously undermine breastfeeding. The WHO/UNICEF guidelines suggest, in paragraph 50: "There will, of course always be a small number of infants in these services who will need to be fed on breastmilk substitutes. Suitable substitutes, procured and distributed as part of the regular inventory of foods and medicines of any such health care facility, should be provided for those infants.

Q8. Is there a working definition for "low-cost" supplies?

A8. Yes. There is a general agreement that ending "low-cost" or "low-price" sales means ending sales at prices below wholesale price or lower than 80 percent of the retail price, in the absence of a standard wholesale price. The reason for stopping low price sales is that low prices lead to overuse of breastmilk substitutes.

Q9. The International Association of Infant Formula Manufacturers (IFM) committed its members to the goal of ending free and low-cost supplies of infant formula only to hospitals and maternities and only in developing countries that have taken action to end such supplies. Are the limitations of the commitment problematic?

A9. The fact that the IFM did not commit to ending all free and low-cost supplies in all the world's health care facilities, with or without government action compelling them to do so, means that UNICEF and its partners have a lot more work and education to do. The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding; adopted by UNICEF's Executive Board and the World Health Assembly, calls upon all governments to give effect to the International Code of Marketing of Breastmilk Substitutes and relevant subsequent World Health Assembly resolutions in their entirety by 1995. Government actions ending the distribution of free and low-cost supplies of breastmilk substitutes to health care facilities, therefore, should be consistent with the Code and WHA 39.28.

 

References

(1)See WHO/UNICEF "Guidelines concerning the main health and socioeconomic circumstances in which infants have to be fed on breastmilk substitutes" (WHO, A39/8 Add.1, 10 April 1986). The 1986 World Health Assembly based its adoption of WHA 39.28 on this document.

(2)"The Code applies to the marketing, and practices related thereto, of the following products: breastmilk 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 breastmilk; and feeding bottles and teats. It also applies to their quality and availability, and to information concerning their use." Article 2, "Scope of the Code", International Code of Marketing of Breastmilk Substitutes (WHO, 1981).