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Country implementationof the InternationalCode of Marketing of
Breast-milk Substitutes:Status report 2011
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WHO Library Cataloguing-in-Publication Data
Country implementation o the international code o marketing o breast-milk substitutes:
status report 2011.
1.Breast eeding. 2.Inant ood. 3.Bottle eeding. 4.Inant nutrition disorders prevention
and control. 4.Growth and development. 5.National health programs. I.World Health
Organization.
ISBN 978 92 4 150598 7 (NLM classication : WS 120)
World Health Organization 2013
All rights reserved. Publications o the World Health Organization are available on the WHO web site (www.who.int)or can be purchased rom WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland(tel.: +41 22 791 3264; ax: +41 22 791 4857; e-mail: bookorders@who.int). Requests or permission to reproduceor translate WHO publications whether or sale or or non-commercial distribution should be addressed to WHOPress through the WHO web site (www.who.int/about/licensing/copyright_orm/en/index.html).
The designations employed and the presentation o the material in this publication do not imply the expression o anyopinion whatsoever on the part o the World Health Organization concerning the legal status o any country, territory,city or area or o its authorities, or concerning the delimitation o its rontiers or boundaries. Dotted lines on mapsrepresent approximate border lines or which there may not yet be ull agreement.
The mention o specic companies or o certain manuacturers products does not imply that they are endorsed orrecommended by the World Health Organization in preerence to others o a similar nature that are not mentioned.Errors and omissions excepted, the names o proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to veriy the inormation contained inthis publication. However, the published material is being distributed without warranty o any kind, either expressed orimplied. The responsibility or the interpretation and use o the material lies with the reader. In no event shall the WorldHealth Organization be liable or damages arising rom its use.
Cover design by Alberto MarchPrinted in Switzerland
Suggested citationWHO. Country implementation o the International Code o Marketing o Breast-milk Substitutes: status report 2011.Geneva, World Health Organization, 2013.
Descargado el 02/08/2013, de.http://apps.who.int/iris/bitstream/10665/85621/1/9789241505987_eng.pdf
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Contents
Acknowledgements iv
Abbreviations v
Executive summary vii
1. Introduction 1
2. Data on country implementation of theInternational Code 4
2.1 Legislative status 6 2.2 Key provisions o national legal measures 7
2.3 Specifc issues and concerns 11
3. The Code: key elements for successfulimplementation 13
4. Why is it important to implement/monitor theimplementation of the Code? 16
5. How to strengthen implementation of the Code 19
References 22
Annexes
I: Legislative status and historical evolution by country or area 26
II: Key provisions in the legal measures by country 39
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Acknowledgements
The preparation o this report was coordinated by Dr Carmen Casanovas, Department o Nutritionor Health and Development and Mr Marcus Stahlhoer, Department o Maternal, Newborn, Child
and Adolescent Health under the supervision o Dr Francesco Branca, Director, Department o
Nutrition or Health and Development, World Health Organization (WHO), Geneva, Switzerland.
A preliminary drat was written by Mr Alessandro Iellamo and Mr Rene Raya, independent
consultants rom the Philippines. Most o the data presented in this document was shared directly
by WHO Member States, Associate Members and other countries or areas, as articulated in
individual country reports and completed questionnaires.
Technical inputs were provided by Dr Juan Pablo Pea-Rosas rom the Department o Nutrition
or Health and Development, and Dr Bernadette Daelmans and Dr Elizabeth Mason rom the
Department o Maternal, Newborn, Child and Adolescent Health, WHO, and rom Mr David
Clark, Nutrition Specialist (Legal), Programme Division, UNICEF, New York, USA. We would liketo thank internal and external reviewers, particularly Dr Peggy Henderson who edited the drat
version o this report. All individuals involved in the preparation o this publication completed a
WHO Declaration o Interest, and it was considered that none had a perceived or real confict o
interest.
Financial support
WHO thanks the Government o Luxembourg and Micronutrient Initiative or providing nancial
support or this work.
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Abbreviations
BMS Breast-milk substituteCode International Code o Marketing o Breast-milk Substitutes and subsequent
World Health Assembly Resolutions
CRC Convention on the Rights o the Child
DoH Department o Health
International Code International Code o Marketing o Breast-milk Substitutes
IRR Implementing rules and regulations
MoH Ministry o Health
NGO Nongovernmental organization
PAHO Pan American Health Organization
UNICEF United Nations Childrens Fund
WBTi World Breasteeding Trends Initiative
WHA World Health Assembly
WHO World Health Organization
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Globally, breasteeding has the potential to prevent 220 000 deaths among children under veeach year. Early initiation o breasteeding could prevent about one th o neonatal deaths, but
less than hal o inants are put to the breast within one hour o birth. WHO recommends that all
inants should be exclusively breasted or the rst six months o lie, but actual practice is low
(38%). Only about hal o children aged 2023 months are breasted despite the recommendation
that breasteeding continue or up to 2 years or beyond.
The implementation and enorcement o the standards and recommendations contained in the
International Code o Marketing o Breast-milk Substitutes and subsequent relevant Health
Assembly Resolutions (the Code) are critical or ensuring an environment that supports proper
inant and young child eeding and contributing to the attainment o Millennium Development
Goal 4 (reduce child mortality by two thirds).
This report summarizes the progress countries have made in implementing the Code. It is basedon data received rom WHO Member States between 2008 and 2010 and on inormation or
2011 rom UNICEF.
Thirty years ater its endorsement, only 37 out o 199 countries reporting (19%) have passed
laws refecting all o the recommendations o the Code. Sixty-nine countries (35%) ully prohibit
advertising o breast-milk substitutes; 62 (31%) completely prohibit ree samples or low-cost
suppplies; 64 (32%) completely prohibit gits o any kind rom relevant manuacturers to health
workers; and 83 (42%) require a message about the superiority o breasteeding on breast-
milk substitute labels. Only 45 countries (23%) report having a unctioning implementation and
monitoring system.
Key areas where urther eorts are needed which were raised by Member States include: 1) gapsin existing national legislation; 2) clarity on processes necessary or the adaptation o the Code;
3) diculty in gaining regulatory approval o drat measures; 4) weak implementation; 5) poor
monitoring systems; and 5) reported violations by the industry.
To ensure the successul implementation o the Code, the ollowing are considered critical by
government ocials or national authorities: 1) political commitment and advocacy; 2) a critical
mass o advocates; 3) legislation; and 4) knowledge about the Code and its implications.
Actions at both international and national levels are needed to ensure ull implementation o the
Code. Member States need additional support rom international agencies. Human rights treaty
monitoring bodies must step-up reviews o Code implementation as part o States obligations
under relevant human rights instruments. There is also a need to invest in eorts to disseminate
inormation on Code implementation and create capacity or Code monitoring. At the nationallevel, governments should pass legislation, set up unctional monitoring and enorcement
mechanisms, orge partnerships with civil society and set up documentation and reporting
systems or violations.
The Code remains a catalyst or change and a core element in which countries should invest to
curb child mortality through improved inant and young child nutrition.
Executive summary
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1.Introduction
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On 21 May 1981, the World Health Assembly (WHA) adopted the International Code o Marketing
o Breast-milk Substitutes (hereinater reerred to as the International Code) under Resolution
Number 34.22, with 118 votes or, 1 against and 3 abstentions.
The International Code took into account a WHO/UNICEF report on inant and young child
eeding which stressed the importance o an adequate basis on which women can have a trueand objective choice (1). It also emphasized the need or education and inormation about inant
and young child eeding and or the establishment o measures at government level to protectwomen against misinormation.1
The International Code also recognized that inappropriate eeding practices lead to inant
malnutrition, morbidity and mortality in all countries and that improper practice in the marketing
o breast-milk substitutes [BMS] and related products can contribute to this major public
health problem. Subsequent WHA Resolutions have rearmed and stressed the importance
o Member States promoting, protecting and supporting breasteeding through the passage o
meaningul legislation and/or regulations that would put the minimum standards recommended
by the International Code in place.
Ater 20 years o International Code implementation, the WHO/UNICEF Global strategy or
inant and young child eeding (2) clearly indicated that:
Breasteeding is an unequalled way o providing ideal ood or the healthy growth and development o
inants; it is also an integral part o the reproductive process with important implications or the health o
mothers. As a global public health recommendation, inants should be exclusively breasted or the frst
six months o lie to achieve optimal growth, development and health. Thereater, to meet their evolving
nutritional requirements, inants should receive nutritionally adequate and sae complementary oods
while breasteeding continues or up to two years o age or beyond.
Eective implementation and monitoring o the International Code is also supported by the United
Nations Convention on the Rights o the Child (CRC), and its monitoring body, the Committee
on the Rights o the Child, thus providing an additional normative and legal oundation. Article 24
o the CRC the childs right to health and health care requires countries to take appropriate
measures to combat disease and malnutrition through, inter alia, the provision o adequate
nutritious oods, and to ensure that all segments o society, in particular parents and children,are inormed () and supported in the use o basic knowledge o child health and nutrition,the advantages o breasteeding (). In addition, in its review o national implementation othe CRC and subsequent dialogue with governments, the Committee on the Rights o the Child
consistently calls upon countries to ensure ull protection, promotion and support to breasteeding,
and to give eect to the International Code and subsequent relevant WHA resolutions. This has
been reiterated in General Comment No. 15, The right o the child to the enjoyment o the highest
attainable standard o health (Article 24) (3).2
Globally, breasteeding has the potential to prevent 220 000 under-ve deaths per year (4). Over30 studies rom around the world, in developing and developed countries alike, have shown that
breasteeding dramatically reduces the risk o dying (5). A WHO pooled analysis (6) indicates
that breasteeding could prevent over three ourths o deaths in early inancy, and 37% o deathsduring the second year o lie. A cohort study in Brazil revealed that non-breasted children,
compared to those exclusively breasted, have 14 times the risk o dying rom diarrhoea, 3.6
times the risk o dying rom pneumonia, and 2.5 times the risk o dying rom other inections
(7). A pooled analysis o studies in Ghana, India and Peru showed that non-breasted inants
are 10 times more susceptible to dying, compared to predominantly or exclusively breasted
inants. The risk o death was 2.5 times higher comparing partially breasted inants with those
predominantly or exclusively breasted (8). A study in Ghana revealed that inants who were
1 International Code o Marketing o Breast-milk Substitutes. Geneva, World Health Organization, 1981 (http://w ww.who.int/nutrition/publications/inanteeding/9241541601/en/index.html, accessed 26 July 2013)
2 States are required to introduce into national law, implement and enorce internationally agreed standards concerningchildrens right to health, including the International Code o Marketing o Breast-milk Substitutes (Paragraph 44,page 11).
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exclusively breasted during the rst hour o lie were 9 times less likely to die than those who
were initiated to mixed ormula and breast milk within 72 hours o birth ( 9). Even in the United
States o America, where death rom inection is relatively uncommon, there were 21% to 24%
ewer deaths among children who were breasted (10).
Cognitive development is enhanced and the risk o some chronic diseases reduced by
breasteeding. Numerous studies, including a randomized trial (7), show that being breasted
enhances intelligence quotient; the randomized trial showed breasteeding promotion raisedintelligence quotient by about 6 points. There are also long-term benets o breasteeding in the
orm o lower blood pressure and total cholesterol, and lower prevalence o overweight/obesity
and type-2 diabetes (6).
With regard to mothers, high quality studies show that breasteeding reduces ovarian cancer by
27% to 40% (1113) and breast cancer by 40% to 80% (1417). Exclusive breasteeding has
an eect on birth spacing that is as e ective as contraceptives or the rst 6 months a ter delivery
(18). Breasteeding, which releases oxytocin ater delivery, also reduces uterine bleeding.
Despite the overwhelming short- and long-term benets o breasteeding or both the child and
mother, a large gap still separates current practices rom accepted recommendations (19).
Although early initiation could prevent about one th o neonatal deaths, less than hal o inants
are put to the breast within one hour o birth. Although WHO recommends 6 months o exclusivebreasteeding, current prevalence o this practice is low (36%). Only about 50% o children
2023 months old are breasted despite the recommendation that all children be breasted or
up to 2 years or beyond.
The implementation and enorcement o the standards and recommendations contained in the
International Code and subsequent WHA Resolutions (hereinater reerred to as the Code) by
Member States are critical in ensuring proper inant and young child eeding practices are in
place and contribute to the attainment o Millennium Development Goals 4 and 5.
WHO reports to the WHA on the status o Code implementation every other year. This report
is based on inormation provided by Member States, usually in a paragraph summarizing the
situation in the six WHO regions. WHA Resolution 65.6 rom May 20121 requested WHO to
support Member States in the monitoring and evaluation o policies and programmes, including
those o the Global strategy or inant and young child eeding , with the latest evidence onnutrition and to report, through the Executive Board, to the Sixty-seventh World Health Assembly
on progress in the implementation o the comprehensive implementation plan, together with the
report on implementation o the International Code o Marketing o Breast-milk Substitutes and
related Health Assembly resolutions.
This is the rst WHO publication documenting actions taken by countries; it is intended to support
Member States to develop or strengthen legislative, regulatory and/or other eective measures to
control the marketing o breast-milk substitutes, as requested by the WHA in May 2012.
1 Sixty-rth World Health Assembly. Resolution 65.6, 26 May 2012 (http://apps .who.int/gb/ebwha/pd_les/WHA65/A65_R6-en.pd, accessed 26 July 2013).
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2.Data on countryimplementation of theInternational Code
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The adoption o the International Code by the WHA in May 1981 through resolution WHA34.22
marked an historical step in eorts to protect breasteeding and contribute to the establishment
and support o appropriate inant and young child eeding practices.
Since the International Code was endorsed as a recommendation under resolution WHA34.22,
it is not legally binding upon WHO Member States. However, Member States are expected to
adhere to the aim and spirit o the International Code, and under Article 11.1 are requested to
take action to give eect to the principles and aim o this Code, as appropriate to their social andlegislative ramework, including the adoption o national legislation, regulation or other suitable
measures In addition, as previously mentioned, implementation and monitoring o the Code isurther supported by legal obligations under the CRC.1
Ater 30 years since its passage, Member States and other countries and areas rom all the
WHO regions have been working at dierent levels to translate the global recommendations into
eective local measures, to be able to put the comprehensive set o standards and policies into
practice. In line with Article 62 o the WHO Constitution, Member States are requested to update
WHO on the status o implementation o the Code regularly and at the same time, in compliance
with Article 11.7 o the International Code, WHO reports the status o implementation o the
Code to the World Health Assembly.
This report presents a summary o the progress made by countries in the implementation othe Code, limited to the ollowing set o inormation: a) legislative status; b) specic provisions:
advertising o BMS to the general public, sale or promotions to the general public, ree or low-
cost supplies o BMS, materials or gits to health workers and health acilities, labelling and
monitoring; and c) issues o concern.
Several sources were used to review the status o Code implementation:
WHO. Summary code survey or the report to the World Health Assembly on the
implementation o the International Code o Marketing o Breast-milk Substitutes. Geneva,
WHO, 2008.
WHO. Survey or the global nutrition policy review: module 3 on the International Code o
Marketing o Breast-milk Substitutes. Geneva, WHO, 2010.
UNICEF. National implementation o the International Code o Marketing o Breast-milk
Substitutes. New York, UNICEF, 2011.
Pan American Health Organization [PAHO]. 30 Aos del Cdigo en Amrica Latina [30
years o the Code in Latin America]. Washington DC, PAHO, 2011.
World Breasteeding Trends Initiative [WBTi]. Toolkit (2011) and website (or reports
where a ministry o health is indicated as a part o the monitoring process), http://www.
worldbreasteedingtrends.org/, accessed 12 May 2012.
European Union Project on Promotion o Breasteeding in Europe. Protection, promotion andsupport o breasteeding in Europe: a blueprint or action (revised) . Luxembourg, European
Commission, Directorate Public Health and Risk Assessment, 2008.
These reerences were used to generate the tables in this report, including those in Annex I and
Annex II, based on data or the period up to April 2011. Several issues and concerns were noted
during the review and processing o the data. The survey conducted by WHO clearly shows that
there is a need to clariy some o the language used in the Code, and develop a denition o terms
and/or a glossary to serve as a guide in lling out the questionnaire. In some cases, contradictions
between reerences were observed, mainly in relation to the actual legislative status o existing
measures in several countries and areas, as highlighted in Annex I.
1 The CRC has been ratied by all but two United Nations Member States Somalia and the United States andthus enjoys near-universal ratication and recognition as the principal legally binding treaty on the protection andpromotion o all aspects related to the overall well-being o children.
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2.1 Legislative status
As mentioned above, Article 11.1 o the International Code states that Governments should takeaction to give eect to the principles and aim o this Code, as appropriate to their social and
legislative ramework, including the adoption o national legislation, regulation or other suitablemeasures Table 1 shows actual progress as reported by countries and areas in their eorts
to apply the Code.
Table 1 Legislative status by WHO Region
WHO Region Fullintolaw
Manyintolaw
Fewintolaw
Voluntary
Fewvoluntary
Drafted
Stillstudying
Actiontoendfree
suppliesonly
Noaction
Noinformation
Total
Arican 13 6 5 9 1 6 3 0 2 2 47
Americas 8 54
(1)9 2 1 0 0
5
(2)1 35 (3)
Eastern
Mediterranean7 5 2 2 0 1 1 2 1 (1) 21 (1)
European 2 23 6 0 1 2 7 0 1 11 53
South-East Asia 4 2 0 3 1 0 0 0 0 1 11
Western Pacic 35
(1)3 8 1 0 0 0 1 6 27 (1)
Total 37 46 (1) 20 (1) 31 6 10 11 2 10 (2) 21 (1) 194 (5)
Note: The gures in parentheses indicate additional countries or areas that are not WHO Member States.
UNICEF categorizes the legislative status o the implementation o the Code into 10 levels (20),
which are used in this report:
1. ull into law, which means they have enacted legislation or other legal measures on all
provisions o the Code;
2. many into law, which means they have enacted legislation or other legal measures on
many provisions o the Code;
3. ew into law, which means they have enacted legislation or other legal measures on a ew
provisions o the Code;
4. voluntary, which means they have adopted all or most o the provisions o the Code
through non-binding measures;
5. ew voluntary, which means they have adopted some but not all provisions o the Codethrough non-binding measures;
6. drated, which means that there is a nal drat o a law or other measures, but it is still
awaiting approval;
7. still studying, which means they are still studying how to implement the Code;
8. action to end ree supplies only, which means they have taken some action to end ree andlow-cost supplies o BMS, but they have not implemented other provisions o the Code;
9. no action, which means they have not taken any steps towards the implementation o the
Code; and
10. no available inormation, which means there is no inormation to determine the legislativestatus o the Code in the country.
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As o April 2011, out o 199 countries reporting, 165 countries (83%) had translated the Code
into a national measure, a major milestone in the eorts towards the protection o breasteeding.
O these 165 countries, 105 (64%) have translated the Code into national legislation, but only
37 (22%) have been able to adapt in ull the various recommendations o the Code. While there
has been major progress in countries in adapting the Code, much still has to be done to support
countries in ensuring that all its provisions are translated into national legislation.
2.2 Key provisions o national legal measures
As stated earlier, Article 62 o the WHO Constitution requests Member States to update WHO
on the status o implementation o the Code regularly. At the same time, in compliance with
Article 11.7 o the International Code, WHO reports the status o implementation o the Code
to the World Health Assembly. WHO has disseminated to all Member States the Nutritionpolicy review survey, in which Module 3 is dedicated to key inormation and data on the status
o implementation o the Code as well as the key provisions o the legal measures in place in
each country. The data collected rom surveys carried out in 2007 (published in 2008) and 2010
helped generate the tables that present the key provisions o national legal measures.
The scope o the International Code, as set out in Article 2,
applies to the marketing, and practices related thereto, o the ollowing products: breast-milk substitutes ,including inant ormula; other milk products, oods and beverages, including bottle-ed complementary
oods, when marketed or otherwise represented to be suitable, with or without modifcation, or use as
a partial or total replacement o breast milk; eeding bottles and teats.
It also applies to their quality and availability, and to inormation concerning their use. Table 2
shows the age o inants to which the scope o national legal measures applies.
Table 2 Scope o the Code age range o inants (months) by WHO Region
WHO region
Age (months)
Noage
limit
Noanswer/
Noinformation
Total
04
06
012
024
030
036
060
Arican 0 2 2 4 1 4 2 1 31 47
Americas 0 0 2 6 0 1 0 0 26 (3) 35 (3)
Eastern
Mediterranean1 0 3 3 0 0 0 0 14 (1) 21 (1)
European 1 6 12 1 0 7 0 0 26 53
South-East Asia 0 1 2 3 0 0 0 0 5 11
Western Pacic 1 1 2 (1) 2 0 2 0 0 19 27 (1)
Total 3 10 23 (1) 19 1 14 2 1 121 (4) 194 (5)
Note: The gures in parentheses indicate additional countries or areas that are not WHO Member States.
O 199 countries, 125 (63%) did not answer or did not clearly state the scope o the legal
measure in terms o the age to which it applies. A total o 74 countries reported some age
limit in the scope o their measures. O these, 24 (32%) reported an age limit o 012 months,
19 (26%) reported an age limit o 024 months and 15 (20%) had an age limit o 036 months.
The data show that country-level adaptation o the Code and subsequent development o local
measures vary based on the interpretation and understanding o the recommendations o the
Code.
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2.2.1 Prohibition of advertising and sales promotions of BMS
Article 5.1 o the International Code states that there should be no advertising or other orm o
promotion to the general public o products within the scope o the Code.1 Article 5.3 urther
states that there should be no point-o-sale advertising, giving o samples, or any other promotion
device to induce sales directly to the consumer at the retail level, such as special displays,
discount coupons, premiums, special sales, loss-leaders and tie-in sales.
O 199 countries responding, only 80 (40%) provided inormation on advertising products withinthe scope o the Code (Table 3). In all, 69 countries (35%) ully prohibited advertising. A total
o 119 countries (60%) did not answer or did not clearly state whether there was a prohibition.
Table 3 Prohibition o advertising o BMS by WHO Region (21)
WHO Region Full Partial NoNo answer/
No informationTotal
Arican 16 0 0 31 47
Americas 12 0 1 22 (3) 35 (3)
Eastern
Mediterranean5 0 1 15 (1) 21 (1)
European 22 4 4 23 53
South-East Asia 6 0 0 5 11
Western Pacic 7 (1) 1 0 19 27 (1)
Total 68 (1) 5 6 115 (4) 194 (5)
Note: The gures in parentheses indicate additional countries or areas that are not WHO Member States.
Table 4 shows that 199 countries also provided inormation on the prohibition o sales promotions,
o which 68 (34%) ully prohibited them. However, 119 (60%) did not answer or did not clearly
state their stand on their prohibition.
Table 4 Prohibition o sale promotions by WHO Region (21)
WHO Region Full Partial NoNo answer/
No informationTotal
Arican 16 0 0 31 47
Americas 12 0 1 22 (3) 35 (3)
Eastern
Mediterranean4 0 2 15 (1) 21 (1)
European 22 4 4 23 53
South-East Asia 6 0 0 5 11
Western Pacic 7 (1) 1 0 19 27 (1)
Total 67 (1) 5 7 115 (4) 194 (5)
Note: The gures in parentheses indicate additional countries or areas that are not WHO Member States.
1 The scope o the International Code as set out by Article 2 states that the Code applies to the marketing, andpract ices related thereto, o the ollowing products: breast-milk substi tutes, including inant ormula; other milk
products, oods and beverages, including bottle ed complementary oods , when marketed or otherwise representedto be suitable, with or without modifcation, or use as a partial or total replacement o breast milk; eeding bottlesand teats. It also applies to their quality and availability, and to inormation concerning their use.
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2.2.2 Prohibition of free or low-cost supplies of BMS and materials/gifts to healthworkers and health facilities
Article 6.6 o the International Code states that ree or low-cost supplies o BMS to health
care acilities should be prohibited. This article applies to both use o such products within a
acility and to the distribution o such products or use outside o a acility. This article is urther
supported by WHA Resolution 47.5. Free or low-cost supplies may only be given or distribution
to those inants who must be ed with BMS, and may only be distributed by the institution itsel.
Such donations or low-price sales should not be used by manuacturers or distributors as a sales
inducement.
Table 5 illustrates that out o 199 countries, 119 (60%) did not answer or did not clearly state
their stand on the prohibition o ree or low-cost supplies o BMS. O the 79 that provided this
inormation, 62 completely prohibited ree samples or low-cost supplies. Only 10 countries (5%)
reported that they did not prohibit ree or low-cost supplies o BMS.
Table 5 Prohibition o ree/low-cost supplies o BMS by WHO Region (21)
WHO Region Full/Yes Partial NoNo answer/
No informationTotal
Arican 15 1 0 31 47
Americas 12 0 1 22 (3) 35 (3)
Eastern
Mediterranean5 1 1 14 (1) 21 (1)
European 15 6 8 24 53
South-East Asia 6 0 0 5 11
Western Pacic 8 (1) 0 0 19 27 (1)
Total 61 (1) 8 10 115 (4) 194 (5)
Note: The gures in parentheses indicate additional countries or areas that are not WHO Member States.
According to Article 7.3 o the International Code, neither nancial nor material inducements topromote products within the scope o the Code should be oered by manuacturers or distributors
to health workers or members o their amilies, nor should they be accepted by health workers or
members o their amilies.
Table 6 shows that 64 countries (32%) reported completely prohibiting gits to health workers,
in ull compliance with the Code, but 12 countries (6%) said they did not. Out o 199 countries,
120 did not answer or did not clearly state whether they prohibited materials or gits to health
workers and health acilities.
Table 6 Prohibition o materials/gits to health workers and health acilities by
WHO Region (21)
WHO Region Full/yes No PartialNo answer/
No informationTotal
Arican 16 0 0 31 47
Americas 12 1 0 22 (3) 35 (3)
Eastern
Mediterranean6 1 0 14 (1) 21 (1)
European 15 10 3 25 53
South-East Asia 6 0 0 5 11
Western Pacic 8 (1) 0 0 19 27 (1)
Total 63 (1) 12 3 116 (4) 194 (5)
Note: The gures in parentheses indicate additional countries or areas that are not WHO Member States.
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2.2.3 Labelling
According to Article 9.2(b) manuacturers and distributors o inant ormula should ensure that
each container has a clear, conspicuous, easily readable and understandable message either
printed on it or on a tightly-sealed label attached, in an appropriate language, which includes a
statement o the superiority o breasteeding.
Table 7 shows that 83 countries (42%) reported requiring a message on the superiority o
breasteeding on BMS labels, while one country (1%) reported that there is no requirement. Othe total o 199 countries, 115 did not answer or did not clearly state whether having a message
on the superiority o breasteeding on the label was required.
Table 7 Labelling: message on superiority o breasteeding by WHO Region (21)
WHO Region Yes NoNo answer/
No informationTotal
Arican 15 0 32 47
Americas 12 1 22 (3) 35 (3)
Eastern Mediterranean 8 0 13 (1) 21 (1)
European 31 0 22 53
South-East Asian 6 0 5 11
Western Pacic 10 (1) 0 17 27 (1)
Total 82 (1) 1 111 (4) 194 (5)
Note: The gures in parentheses indicate additional countries or areas that are not WHO Member States.
As shown in Table 8, 79 countries (40%) reported that there should be a recommended age or
the designated product on the label, in ull compliance with the recommendations o the Code,
while 4 countries (2%) reported none. Out o 199 countries, 116 did not answer or did not clearly
state whether or not they require a recommended age on the label o BMS.
Table 8 Labelling: recommended age or designated product by WHO Region (21)
WHO Region Yes NoNo answer/
No informationTotal
Arican 16 0 31 47
Americas 12 0 23 (3) 35 (3)
Eastern Mediterranean 7 1 13 (1) 21 (1)
European 30 1 22 53
South-East Asian 5 1 5 11
Western Pacic 8 (1) 1 18 27 (1)
Total 78 (1) 4 112 (4) 194 (5)
Note: The gures in parentheses indicate additional countries or areas that are not WHO Member States.
2.2.4 Functioning implementation and monitoring system
Article 11 o the International Code includes a requirement or governments to take necessary
measures to give eect to the provisions o the Code within their legal and social inrastructure,
including the adoption o national legislation, regulations or other appropriate measures. The
responsibility or monitoring the implementation o the Code rests with governments, both
individually and in collaboration with other parties (e.g. WHO, nongovernmental organizations
[NGOs], proessional groups). Criteria or monitoring mechanisms to ensure ecacy include:
independence and transparency
reedom rom commercial infuence
empowerment to investigate code violations
empowerment to impose legal sanctions.
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Responses related to implementation and monitoring mechanisms are summarized in Table 9.
Table 9 Functioning implementation and monitoring system by WHO Region (21)
WHO Region Full/Yes Partial NoNo answer/No
informationTotal
Arican 10 1 4 32 47
Americas 6 0 7 22 (3) 35 (3)
Eastern
Mediterranean5 0 2 14 (1) 21 (1)
European 13 9 8 23 53
South-East Asian 3 0 3 5 11
Western Pacic 7 0 3 17 27 (1)
Total 44 (1) 10 27 113 (4) 194 (5)
Note: The gures in parentheses indicate additional countries or areas that are not WHO Member States.
Only 45 countries (23%) reported having a unctioning implementation and monitoring system.
Twenty-seven countries (14%) reported having no such system in place. Out o 199 countries,117 did not answer or did not clearly state whether they had a unctioning implementation and
monitoring system.
2.3 Specifc issues and concerns
Table 10 presents the specic issues and concerns raised by countries in relation to the
implementation o the Code. The issues clustered into the sub-groups shown in the table.
Table 10 Specifc issues and concerns by WHO Region (21,22,23)
WHO Region Totalwith
report
Lawsand
regulation
s
andinfo
dissemina
tion
Problems
with
provisions
Training
Code
monitors
Industry
Regulatory
mechanisms
Arican 13 10 3 6 5 3 1
Americas 14 12 1 9
Eastern
Mediterranean5 5 1 1
European 3 3
South-East Asian 9 9 3 3 1
Western Pacic 9 9 2 4 1
TOTAL 53 48 3 12 14 14 1
2.3 .1 Laws, regulations and information dissemination
O the 53 countries reporting issues and concerns, 48 mentioned the law, regulations and
their dissemination. Key concerns are related to the identication o gaps in existing national
legislation, which does not contain all the recommendations o the Code. Issues raised are also
related to the processes and procedures necessary or the adaptation o the Code into national
measures. Countries expressed diculty in having their drat measures passed and approved or
implementation.
The need to review the actual implementation o the Code and identiy areas that should be
strengthened and updated were also identied.
Generally, all countries reported poor inormation dissemination among health care providers as
well as district ocials, and a ew countries added that inormation dissemination is insucient
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even at the level o proessional groups, policy planners, law enorcers and other stakeholders.
There was a call or the development o clear guidelines or service providers, as well as the
design o a more eective advocacy strategy among concerned agencies.
Countries voiced the need to ensure a wider target audience, with the general public included, in
a systematic education programme.
2.3.2 Provisions and regulatory mechanismsCountries reported weak implementation or implementation gaps related to low technical
capacity, as well as the diculties that ministries o health (MoHs) may have in the enorcement
o measures.
At the same time, countries reported delays and diculties in the setting up o national oversight
committees or monitoring bodies that would support MoHs. They also noted that there is a need
to obtain the support o all line ministries.
Countries reported limitations in the reach/coverage o measures. Poor or weak enorcement was
mentioned by several countries, and there is a clear call to identiy ways to enorce or strengthen
enorcement.
2.3.3 Training
Countries called or the setting-up o common procedures or training, providing training to health
workers and, when possible, also to other stakeholders.
2.3.4 Code monitors
Weak or poor monitoring systems as well as irregular monitoring activities have been identied by
countries as key issues that need to be addressed. Countries identied inadequate mechanisms
or reporting violations at national, state and district levels. The causes were linked to lack o
appropriate unding as well as the capacity o assigned sta to conduct monitoring activities.
The majority o countries reported that NGOs have a role in advocacy, monitoring and educating
legislators.
2.3.5 Industry
Reported consistent, repeated, systematic violations by the industry are common concerns
o countries. Very aggressive direct marketing or indirect advertisements to mothers exist. In
some instances countries reported that the industry resisted all provisions o regulations, and
this resistance is sometimes expressed as pressure on government to limit implementation or
upgrading/updating o the law.
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3.The Code: key elements forsuccessful implementation
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As stated earlier, Member States and other countries and areas have made major progress in
their eorts to translate the Code into national measures. At the same time, some key issues and
concerns were raised that will need to be addressed. For successul implementation, the Code
needs international and national support and commitment.
During the review o the data collected through various sources (see Section 2), key elements
were identied, both at the international and national levels, to ensure successul implementation
o the Code:
International level
At the international level, monitoring and tracking eorts need to be systematized. The data
collected by WHO in 2008 and 2010 have provided great insights on the actual status o
implementation o the Code, but at the same time have shown countries limitations and diculties
in identiying, collecting and reporting key inormation.
In line with the Global strategy or inant and young child eeding (2), international organizations
need to ensure that:
inant and young child eeding is placed at the top o the global public health agenda;
consistent technical support is given to Member States on the implementation o the Code;
the Code is given ull consideration in trade policies and negotiations;
updated research is carried out on marketing practices and the status o implementation o
the Code.
National level
For many countries, there are important gaps in knowledge with regard to various aspects o Code
implementation. A country analysis on the status o implementation o the Code is recommended,
to help guide a constructive process towards the ollowing:
Political commitment and advocacy are key elements where there is no law or rules and
regulations to push or enactment and implementation, enorcement and monitoring, and
where the law, rules and regulations or implementation is too weak to push or amendment
and/or improved implementation, enorcement, monitoring and oversight;
Creating a critical mass o Code advocates and supporters is crucial or ensuring an
enabling and supportive environment or Code implementation, enorcement and monitoring.
Awareness and sensitization eorts on the importance o the Code as a tool and mechanism
or the protection, promotion and support to breasteeding must be aimed at a wide audience,
and be tailored to the specic responsibilities and mandates o relevant stakeholders.
Eorts should be made to systematically apply existing tools or capacity building in Code
implementation and monitoring processes. Such tools include training on ormulation o
national Code legislation organized by the International Baby Food Action Network (IBFAN),
and the comprehensive e-course on the Code, developed by WHO and UNICEF (24).
Member States need to translate the Code and subsequent relevant WHA
resolutions into legislation and/or other suitable legal measures. The legislation
needs to be clear, with appropriate rules and regulations complete with guidelines and/or a
manual o operations, including what and how to monitor, and sanctions in terms o processes
and application.
Knowledge and understanding o the legal measures and the Code by health care
providers (including private practitioners), relevant ocials, enorcers, Code monitors and
planners, including at district and other local levels, is key or the implementation, enorcement
and monitoring o law. For policy-makers, this knowledge and understanding are critical to
enacting a law where there is none and amending or providing oversight where the law or itsimplementation is weak. The public, particularly women, mothers, and private practitioners,
should appreciate the law and ollow it, as well as promote breasteeding.
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Functional monitoring and enorcement mechanisms strengthen implementation,
enorcement, monitoring and sanctions because weak laws and implementation and lack o
or weak sanctions and monitoring result in systematic violations and aggressive marketing by
the industry.
Partnerships with civil society and nongovernmental organizations help governments
in advocating or the enactment, implementation, enorcement and monitoring o the Code, as
well as providing practical breasteeding support at the community level. Documentation and reporting o Code violations or eective tracking, compilation and
systematization o inormation and evidence is needed or uture action and advocacy.
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4.Why is it importantto implement/monitorthe implementationof the Code?
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Evidence shows that advertising directly to the consumer and other marketing techniques
infuence mothers and amilies in their decisions on how to eed their inants and young children.
For example, distribution o educational materials on breasteeding produced by manuacturers
o inant ormula had a negative impact on exclusive breasteeding (25,26). These educational
materials were most likely to infuence those at higher risk o stopping breasteeding, including
the mothers o rst-born children and those with less ormal education. The distribution o samples
also had an adverse impact on breasteeding (27).
Evidence shows that nearly all mothers are able to breasteed and will do so i they have accurate
inormation and support. However, direct industry infuence through advertisements, inormation
packs and sales representatives, and indirect infuence through the public health system, inundate
mothers with incorrect and biased inormation.
The implementation o the Code is critical towards reducing or eliminating all orm o promotion
o BMS, including direct and indirect promotion to pregnant women and mothers o inants and
young children.
At the same time, the Code can help governments to ensure that the health system is ree rom
commercial infuences, through the elimination o ree sample distribution in health care acilities,
as well as other gits and inducements to health workers.
The Code is instrumental in helping governments reduce risks associated with the use and
distribution o inant ormula in situations where there is need or them, or example or orphans
ater an emergency. At the same time, the implementation o the Code increases awareness by
Member States and communities o the intrinsic and extrinsic risks o contamination o BMS.1
The successul implementation o the Code requires a clear and unctioning monitoring mechanism
or accurate assessment and tracking o the extent o implementation across countries and
regions specically or the ollowing:
determine progress and gains in the implementation o the Code
validate strategies that are eective and appropriate or specic country contexts
identiy common issues, problems and challenges ahead
identiy actors that acilitate or hinder the implementation o the Code.
Monitoring provides a wealth o valuable inormation or benchmarking practices that have been
successully carried out and institutionalized in specic countries and which can be replicated
by others. It acilitates sharing o experiences and lessons and thus supports the eorts o
governments and other stakeholders in the implementation o the Code.
There is a need to inorm all stakeholders, both government and non-government entities, to
keep them updated with important issues related to the implementation o the Code. In this
way, interest and vigilance about the Code can be sustained. Inormation about the progress
and achievements made by dierent countries provides inspiration or others to emulate. It also
encourages and strengthens the commitment o governments to pursue eorts to mainstream theimplementation o the Code.
Monitoring also sends a clear and strong signal to all stakeholders and the industry that the
international community and governments are serious about and committed to ully implement
the spirit and letter o the Code. Monitoring tracks the actions and strategies o companies and
advertisers in countries and provides lessons on how to best handle dierent situations. The
results o monitoring also provide important inputs or urther developing and rening a global
strategy or more eective implementation o the Code.
1 Contamination can occur intrinsically or rom extrinsic sources. Intrinsic contamination occurs at some stage duringmanuacture (e.g. rom the manuacturing environment, or rom raw ingredients). Extrinsic contamination is possiblerom the person preparing the ormula and the environment the ormula is prepared in.
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Monitoring inorms policy and acilitates the ollowing:
determining policy gaps and weaknesses in communication strategy
identiying needs o Members States or inormation and capacity building
estimating resource requirements or the ull implementation o the Code.
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5.How to strengthenimplementationof the Code
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Thirty years ater its endorsement by the WHA as Resolution 34.22, the International Code and
subsequent WHA resolutions remain key instruments or the protection o breasteeding globally.
Since 1981, major progress has been documented in relation to the actions taken by Member
States on implementation at the country level through national legislation and other measures.
This report presents major milestones in the implementation o the Code globally, but more needs
to be done, both at the international and national levels.
The ollowing are key practical suggestions aimed at providing a concrete direction to the globaleort to protect breasteeding, and improve inant and young child nutrition. They are based in the
responses provided by 73 Member States to the WHO 2010 survey on Code implementation.
International
1. UNICEF and WHO:
to establish sustainable support mechanisms or Member States in their eorts to
translate the Code into national legal measures.
to develop a database on national legal measures, based on an agreed standard classi-
cation or levels o compliance with all the articles o the Code.
to build the capacity o their sta to support countries in the implementation and monitor-
ing o the Code, and provide support or capacity-building activities at the country level.
to provide support to the United Nations human rights mechanisms in reviewing
governments eorts towards eective Code implementation and monitoring.
2. United Nations human rights mechanisms:
Relevant United Nations treaty monitoring bodies (i.e. the Committee on the Rights o the Child
and the Committee on Economic, Social and Cultural Rights) to pay sustained attention to Code
implementation and monitoring in countries, and to issue explicit concluding observations and
recommendations.
The United Nations Human Rights Council to review governments eorts towards Codeimplementation and monitoring through its Universal Periodic Review process.
3. International accreditation bodies:
to incorporate key provisions o the Code as requirements or international accreditation o their
health acilities and health care systems (e.g. International Standards Organization certication).
4. Donors:
to support Civil Society organizations in the independent monitoring, reporting, and dissemination
o inormation and reports on the status o compliance to the Code, and on national measures
and actions taken by manuacturers and distributors, health proessionals and other concerned
groups.
to support the translation wherever possible into relevant local languages o all national Code,
rules and regulations, research and reports.
5. Civil Society:
to conduct sustained advocacy and lobbying in countries where there is still no acceptable Code,
targeting policy-makers and planners, including at local government levels.
National
1. Governments to:
request WHO country oces to contribute to ensuring thorough and substantive reports
on Code implementation, especially in areas where inormation is lacking. develop a critical mass o Code advocates to promote and disseminate inormation on
the importance and key provisions o the Code.
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strengthen and strictly monitor violations and impose the corresponding sanctions to
such violations;
actively disseminate inormation concerning actions taken and sanctions imposed on
Code violators or public awareness building;
acilitate the mobilization o civil society organizations to support the monitoring and
documentation o violations o the Code and assist in eorts or strong evidence-based
advocacy; and
involve national human rights institutions in Code monitoring and evaluation activities.
2. Government and other national partners to:
provide in-depth training to health care providers, relevant ocials, enorcers, Code
monitors and planners down to local level or implementation and monitoring.
provide direct sustained education and inormation using multimedia channels to the
general public down to community level, including in schools, colleges and universities.
incorporate the essential provisions o the Code into school curricula, particularly at the
tertiary level or health proessions. The quality o education and training on breasteeding
should be reviewed and upgraded, specically on the law and its application andmonitoring. This would require translating materials into the appropriate languages and
adapting them to local cultures and practices. Through sustained public awareness, the
general public may be enjoined to actively participate in community monitoring, including
through the use o appropriate technology (such as email, mobile phone messaging and
social networking).
undertake eective tracking and documentation o violations or administrative action,
legislative measures and judicial sanctions. The actions taken by industry players must
be monitored and checked, especially where there are systematic violations o the Code,
such as cases o aggressive resistance to compliance.
link the Code and its implementation to overall public health concerns to ensure
reinorcement and synergy.
Member States and other countries and areas have shown that the Code is still a dynamic and
critical reerence even ater its 30 years o existence. It remains a catalyst or change and a core
element in which countries need to invest in their eorts to curb child and maternal mortality
through improved inant and young child nutrition.
Key gaps and limitations were identied by the countries themselves, as well as uture directions
and eorts. This review should help international agencies, as well as other groups and
organizations, in identiying and prioritizing a key set o strategies and interventions that can
support and contribute to the ongoing work being done at country level.
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References
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1. Joint WHO/UNICEF meeting on inant and young child eeding. Geneva, 912 October
1979: statement, recommendations, list o participants. Geneva, World Health Organization,
1979.
2. WHO/UNICEF. Global strategy or inant and young child eeding. Geneva, World HealthOrganization, 2003.
3. CRC/C/GC/15 General Comment No. 15, United Nations Committee on the Rights o the
Child. 2013.
4. Bhutta ZA et al. Evidence-based interventions or improvement o maternal and child
nutrition: what can be done and at what cost? Lancet, 2013, published online 6 June (http://dx.doi.org/10.1016/S0140-6736(13)60996-4).
5. Len-Cava N et al. Quantiying the benefts o breasteeding: a summary o the evidence.Washington DC, PAHO, 2002.
6. WHO Collaborative Study Team on the role o breasteeding on the prevention o inant
mortality. Eect o breast-eeding on inant and child mortality due to inectious disease in
less developed countries: a pooled analysis. Lancet, 2000, 355:451455.
7. Victora CG et al. Evidence or protection by breast-eeding against inant deaths rom
inectious diseases in Brazil. Lancet, 1987, 2:319322.
8. Bahl R et al. Inant eeding patterns and risks o death and hospitalization in the rst hal
o inancy: multicentre cohort study. Bulletin o the World Health Organization, 2005,83:418426.
9. Edmond KM et al. Delayed breasteeding initiation increases risk o neonatal mortality.
Pediatrics, 2006, 117:380384.
10. Chen A, Rogan W. Breasteeding and the risk o postneonatal death in the United States.
Pediatrics, 2004, 113(5):e435e439.
11. Ness RB et al. Factors related to infammation o the ovarian epithelium and risk o ovarian
cancer. Epidemiology, 2000, 11:111117.12. Whittemore AS, Harris R, Itnyre J. Characteristics relating to ovarian cancer risk:
collaborative analysis o 12 US case-control studies. American Journal o Epidemiology,1992, 136:11841203.
13. Gwinn ML et al. Pregnancy, breasteeding and oral contraceptives and the risk o epithelial
ovarian cancer. Journal o Clinical Epidemiology, 1990, 43:559568.
14. Zheng T et al. Lactation reduces breast cancer risk in Shandong Province, China. AmericanJournal o Epidemiology, 2000, 152:11291135.
15. Lipworth L, Bailey R, Trichopoulos D. History o breast-eeding in relation to breast cancer
risk: a review o the epidemiologic literature. Journal o the National Cancer Institute, 2000,
92:302312.
16. Romieu I et al. Breast cancer and lactation history in Mexican women. American Journal o
Epidemiology, 1996, 143(6):543552.
17. Yoo K-Y et al. Independent protective eect o lactation against breast cancer: a case-
control study in Japan. American Journal o Epidemiology, 1992, 135(7):726733.
18. Labbok M, Cooney K, Coly S. Guidelines: breasteeding, amily planning, and the Lactational
Amenorrhea Method-LAM. Washington DC, Institute or Reproductive Health, 1994.
19. Lutter CK et al. Undernutrition, poor eeding practices and low coverage o key nutrition
interventions. Pediatrics, 2011, 128: e1e10.
20. UNICEF. National implementation o the International Code o Marketing o Breast-milkSubstitutes. UNICEF, New York, 2011.
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21. Survey or the global nutrition policy review: Module 3 on the International Code o
Marketing o Breast-milk Substitutes. Geneva, World Health Organization, 2010.
22. PAHO. 30 Aos del Cdigo en Amrica Latina [30 years o the Code in Latin America].Washington DC, PAHO, 2011.
23. World Breast-eeding Trends Initiative (WBTi), 2011. WBTi. Toolkit (2011) and website, (orreports where a ministry o health is indicated as a part o the monitoring process), http://
www.worldbreasteedingtrends.org/, accessed 12 May 2012.
24. WHO/UNICEF. Introduction to the International Code o Marketing o Breast-milk
Substitutes. In press.
25. Howard C et al. Oce prenatal ormula advertising and its eect on breasteeding patterns.
Obstetrics and Gynecology, 2000, 95(2):296303.
26. Shealy KR et al. The CDC guide to breasteeding interventions. Atlanta, United States
Department o Health and Human Services, Centers or Disease Control and Prevention,
2005.
27. Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact or mother and
their healthy newborn inants. Cochrane Database o Systematic Reviews 2012. Issue 5.Art No.: CD003519. DOI : 10.1002/14651858.CD003519.pub3.
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Annexes
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ANNEX ILegislative status and historicalevolution by country or area1
Table 1.1 Legislative status in countries and areas o the WHO Arican Region
No. Country or area Legislative status Progress Source
1 AlgeriaFew provisions o theCode into law
No availableinormation
UNICEF, 2011
2 AngolaImplementation othe Code still beingstudied.
No availableinormation
UNICEF, 2011
3 Benin Full into lawNo availableinormation
UNICEF, 2011; WHO,2008
4 Botswana Full into lawNo available
inormation
UNICEF, 2011; WHO,
2008
5 Burkina Faso Full into lawNo availableinormation
UNICEF, 2011
6 BurundiMeasures drated stillawaiting nal approval
No availableinormation
UNICEF, 2011
7 Cameroon Full into lawNational Code enactedin 2005
UNICEF, 2011; WBTi,2011; WHO, 2008
8 Cape Verde Full into lawNo availableinormation
UNICEF, 2011; WBTi,2011; WHO, 2008
9Central AricanRepublic
No actionNo availableinormation
UNICEF, 2011
10 Chad No actionNo availableinormation UNICEF, 2011
11 ComorosVoluntary and othernational measures
No availableinormation
WHO, 2008
12 CongoMeasures drated stillawaiting nal approval
No availableinormation
UNICEF, 2011
13 Cte dIvoreMeasures drated stillawaiting nal approval
No availableinormation
UNICEF, 2011
14DemocraticRepublic o theCongo
Few provisions into lawNo availableinormation
UNICEF, 2011
15Equatorial
Guinea
No available
inormation
16 EritreaImplementation oCode still beingstudied
No availableinormation
UNICEF, 2011
17 EthiopiaFew provision o Codeinto law
No availableinormation
UNICEF, 2011; WHO,2010
18 Gabon Full into lawNo availableinormation
UNICEF, 2011
19 Gambia Full into lawNo availableinormation
UNICEF, 2011; WHO,2008
20 Ghana Full into lawBreasteedingpromotion regulation
2000
UNICEF, 2011; WBTi,2011; WHO, 2008 & 2010
1 Sources or Annex 1 are shown in Section 2.
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No. Country or area Legislative status Progress Source
21 GuineaFew provisions oCode into law
No availableinormation
UNICEF, 2011; WHO,2008
22 Guinea-BissauFew provisions oCode into law
Decree passed in April2005
UNICEF, 2011; WHO,2008 & 2010
23 Kenya Voluntary measures
Country reportedvoluntary measures aso 2007. Since 2008, alaw was being dratedbut is not yet enacted.
UNICEF, 2011; WHO,2008 & 2010
24 LesothoImplementation othe Code still beingstudied
No availableinormation
UNICEF, 2011
25 LiberiaSome provisions o theCode translated intovoluntary measures
No availableinormation
UNICEF, 2011; WHO,2008
26 Madagascar Full into lawNo availableinormation
UNICEF, 2011; WHO,2008
27 Malawi Many provisions o theCode into law
Public Health Act
(34:01), no dateavailable
UNICEF, 2011; WBTi,2011
28 MaliMany provisions o theCode into law
No availableinormation
UNICEF, 2011
29 Mauritania
Voluntary and othernational measures.Implementation othe Code still beingstudied
No availableinormation
UNICEF, 2011; WHO,2008
30 Mauritius
Voluntary and othernational measures.Implementation o
the Code still beingstudied
No availableinormation
UNICEF, 2011; WHO,2008 & 2010
31 Mozambique Full into law
Law was passed18 November 2005(Diploma MinisterialNo. 129/2007 de 3 deOutubro, Cdigo deComercializao dosSubstitutos do LeiteMaterno)
UNICEF, 2011; WBTi,2011; WHO, 2008 &2010;
32 NamibiaMeasures drated stillawaiting nal approval
No availableinormation
UNICEF, 2011
33 Niger Many provisions intolaw
Law was passed
27 July 1998 (ArreteNo. 00215/msp/portant reglementation)
UNICEF, 2011; WHO,2008 & 2010
34 NigeriaMany provisions intolaw
Country passed theMarketing o BMSAct 41 o 1990, thenamended by Act 22o 1999. Act wasreplaced by NAFDAC-Marketing o Inantand Young ChildrenFood and OtherDesignated Products
(Registration, Sales,etc.) Regulations 2005
UNICEF, 2011; WHO,2010
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No. Country or area Legislative status Progress Source
35 RwandaMeasures drated stillawaiting nal approval
No availableinormation
UNICEF, 2011
36Sao Tome andPrincipe
Voluntary and othernational measures
No availableinormation
WHO, 2008
37 SenegalMany provisions oCode translated intolaw
No available
inormationUNICEF, 2011
38 SeychellesVoluntary and othernational measures
No availableinormation
WHO, 2008
39 Sierra Leone
Voluntary and othernational measures.Drated measures stillawaiting approval
No availableinormation
UNICEF, 2011; WHO,2008
40 South Arica Voluntary measuresNo availableinormation
UNICEF, 2011
41 Swaziland Voluntary measuresNo availableinormation
UNICEF, 2011; WBTi,2011
42 Togo Not clear rom surveyresponse. Dratedmeasures or approval
Government adoptedthe Code in 2003.
UNICEF, 2011; WHO,2010
43 Uganda Full into law
Adopted the Code inthe Food and DrugsAct o 1997 (Marketingo Inant and YoungChild Foods) and adrat amendment inthe Food Saety Acto 2005, but not yetenacted
WBTi, 2011
41United Republic
o Tanzania
Full into lawNo available
inormation
UNICEF, 2011; WHO,
2008
45 ZambiaMany provisions intolaw
Adopted a voluntarymeasure in 1982which was revisedin 1994. In 2006the country passedthe Food & Drugs,Marketing o BreastMilk Substitutes,Regulations
UNICEF, 2011; WBTi,2011; WHO, 2008
46 Zimbabwe Full into lawNo availableinormation
UNICEF, 2011; WHO,2008
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Table 1.2 Legislative status in countries and areas o the WHO Region o
the Americas
No. Country or area Legislative status Progress Source
1 Antigua andBarbuda
No action No available inormation WHO, 2010
2 Argentina Many provisions
into law
Has been active in regulating
the production o BMSsince 1969. In 1997, MoHsigned Resolution No. 54/97approving implementation othe Code. This new resolutionneeded joint support o otherministries, which was providedwith Resolutions No. 97 and301 o 2007.
PAHO, 2011; UNICEF,
2011; WHO, 2008
3 Bahamas No availableinormation
UNICEF, 2011
4 Barbados No action No available inormation WHO, 2010
5 Belize Voluntary and
other nationalmeasures
No available inormation WHO, 2008
6 Bolivia (Pluri-national Stateo)
Many provisionsinto law
Law passed 15 August 2006.Working on a regulation toimpose sanctions that or noware not yet part o the law.
PAHO, 2011; UNICEF,2011; WBTi, 2011;WHO, 2010
7 Brazil Full into law Regulation or the Marketing oInant Food (NCAL) approved in1988. This was later amendedinto the Brazilian Regulation orMarketing o oods or inants(NBCAL) in October 1992.Due to the increased numbero reports o alleged violationso the regulation, in 2000, theMoH established a technicalworking group to strengthenit. In 2001, a Ministerial Orderwas issued. On 4 January2006 a law (Ley 11.265) waspassed that aims at regulatingthe marketing o products orinants and young children.
PAHO, 2011; UNICEF,2011; WBTi, 2011;WHO, 2008
8 British VirginIslands
No action taken No available inormation WHO, 2010
9 Canada Few provisionsinto law No available inormation UNICEF, 2011
10 Chile Mainly voluntarymeasures. Fewprovisions intolaw.
Not all provisions o Code arelaw. Recently, the Presidentvetoed a provision in a newnutrition law that aimed atprohibiting promotion o BMS.
PAHO, 2011; UNICEF,2011; WHO, 2008 &2010
11 Colombia Many provisionsinto law
Beore the WHA in 1980, aproposal to regulate marketingo BMS was made, withMinisterial Decree 1220, butit was not approved. In 1992,the proposed decree was
amended into Decree 1397 andeventually approved.
PAHO, 2011; UNICEF,2011; WBTi, 2011
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No. Country or area Legislative status Progress Source
12 Costa Rica Full into law A technical working group wascreated in 1985 to work onimplementation o the Code. Itsproposal was rejected by theLegislative Assembly. Law 7430o 1992, to oster and support
breasteeding, and RegulationN 24576-S, 1995, were notapproved immediately. It tookthe intervention o the First Ladyto convince the legislative bodyto support and endorse theproposed law. It was eventuallypassed in September 1994 andgazetted in October 1994, aslaw No. 7430. Its regulationswere published in September1995.
UNICEF, 2011; WBTi,2010; WHO, 2008 &2010
13 Cuba Few provisionsinto law
No available inormation PAHO, 2011; UNICEF,2011
14 Dominica Few provisionsinto law. Voluntarymeasures
Breasteeding policy adopted in1993 and revised in 1999.
WHO, 2008 & 2010
15 DominicanRepublic
Full into law Law 8-95 passed 19September 1995, and itsregulations 20 January 1996.
PAHO, 2010; UNICEF,2011; WBTi, 2011;WHO, 2008
16 Ecuador Mainly voluntarymeasures (Codeo conduct).Existing lawor support obreasteeding
does not containany article o theCode.
First regulation o marketingo BMS, limited to inants,approved in 1983. In 1993,manuacturers signed Code oConduct, voluntary measureto sel-regulate their own
marketing activities. Law 101o 1995, or the promotion,support and protection obreasteeding, does not containany article o the Code.
PAHO, 2011; UNICEF,2011; WBTi, 2011;WHO, 2010
17 El Salvador Measure drated Since 2002, a drated law hasbeen supported by civil societyand international organizations,but still not approved.
PAHO, 2011; UNICEF,2011; WHO, 2008 &2010
18 Grenada No actiontaken. Voluntarymeasures limitedto guidelines.
No available inormation WHO, 2010
19 Guatemala Full into law, withother voluntarymeasures
Law No. 66-83 o 7 June 1983 UNICEF, 2011; WBTi,2011; WHO, 2008 &2010
20 Guyana Some provisionsvoluntary
No available inormation UNICEF, 2011
21 Haiti Drated measuresawaiting nalapproval
No available inormation UNICEF, 2011
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No. Country or area Legislative status Progress Source
22 Honduras Norm, regulation,voluntarymeasures
Norm (Agreement 4780) orpromotion and protectiono breasteeding passed 8November 2005. Instrument(it is not a law) does notcontain any sanctions or legal
procedure or prosecutingalleged violations.
PAHO, 2011; UNICEF,2011; WHO, 2008 &2010
23 Jamaica Some provisionsvoluntary
No available inormation UNICEF, 2011; WHO,2008
24 Mexico Many provisionsinto laws andregulations
In 1992, manuacturers oBMS and MoH enteredinto agreement to regulatepromotion and distributiono BMS to health workers.Agreement was ratied in1995 and 2000. Law on Health(amended 31 May 2009) clearlyadopts some standards o the
Code in relation to promotion tothe general public.
PAHO, 2011; UNICEF,2011; WBTi, 2011;WHO, 2008 & 2010
25 Montserrat No action No available inormation WHO, 2010
26 Nicaragua Many provisionsinto law
On 12 December 1981, rstto pass Decree on promotion,support and protection obreasteeding ater WHAendorsement o the Code.Law No. 295 passed in 1999.MoH studying possibility ostrengthening law.
PAHO, 2011; UNICEF,2011; WBTi, 2010
27 Panama Full into law Law No. 50 was passed23 November 1995.
PAHO, 2011; UNICEF,2011; WHO, 2008
28 Paraguay Few provisionsinto law
Law 1478 on marketing o BMSpassed 8 October 1999.
PAHO, 2011; UNICEF,2011; WHO, 2008
29 Peru Full into law Decree No. 020-82-SAapproved in 1982, making ita leading country in adoptingthe Code. Ater several yearsand some reviews, proposalsor its amendment were made,and a new Decree No. 007-2005-SA was created. Despitebeing approved, industryexerted major eorts callingor government to negotiatethe decree and amend it again.Finally, decree 009-2006 SAwas approved.
UNICEF, 2011; WBTi,2011; WHO, 2008 &2010
30 Puerto Rico Few provisionsinto law. No law orregulations dealwith marketing oBMS.
Law 79 passed in 2004. PAHO, 2011
31 Saint Kit ts andNevis
Voluntary andother nationalmeasures
No available inormation WHO, 2008
32 Saint Lucia No action No available inormation WHO, 2010
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No. Country or area Legislative status Progress Source
33 Saint Vincentand theGrenadines
Voluntarymeasures(guidelines)
No available inormation WHO, 2010
34 Suriname Voluntary andother nationalmeasures
No available inormation WHO, 2008
35 Trinidad andTobago
Voluntary andother nationalmeasures
No available inormation UNICEF, 2011; WHO,2008
36 United States oAmerica
No action No available inormation UNICEF, 2011; WHO,2010
37 Uruguay Full into law Decree 315 passed in 1994. In2009, MoH issued MinisterialOrdinance containing oneprovision regarding role oMoH in relation to monitoringpractices o manuacturers.
PAHO, 2011; UNICEF,2011; WBTi, 2011;WHO, 2010
38 Venezuela
(BolivarianRepublic o)
Full into law Resolution No. 405 issued
on 17 August 2004 requiringmandatory labelling or BMS. Insame year, Resolution No. 444,calling or promotion, supportand protection o breasteedingwas signed. Law or promotion,support and protection obreasteeding passed in 2007.
PAHO, 2011; UNICEF,
2011
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Table 1.3 Legislative status in countries and areas o the WHO Eastern
Mediterranean Region
No. Country or area Legislation status Progress Source
1 Aghanistan Full into law No available inormation UNICEF, 2011;WBTi, 2011; WHO,2008
2 Bahrain Full into law No available inormation UNICEF, 20113 Djibouti Many provisions into law No available inormation UNICEF, 2011
4 Egypt Many provisions intodierent laws anddecrees
No inormation available UNICEF, 2011;WBTi, 2011; WHO,2008
5 Iran (IslamicRepublic o)
Full into law withvoluntary and othernational measures
No inormation available UNICEF, 2011;WHO, 2008
6 Iraq Voluntary and othernational measures.Measures drated stillawaiting approval.
No available inormation UNICEF, 2011;WHO, 2008
7 Jordan Many provisions into law No available inormation UNICEF, 2011;WHO, 2008
8 Kuwait Voluntary measures Set o standards onlyimplemented in MoHacilities. Ongoing initiativeto integrate the Code intoKuwait child rights law.
UNICEF, 2011;WBTi, 2011
9 Lebanon Full into law Law enacted 11 December2008
UNICEF, 2011;WBTi, 2011
10 Libya Action limited to endree supplies
No available inormation UNICEF, 2011
11 Morocco Drated measures
awaiting approval
No available inormation UNICEF, 2011
12 Oman Many provisions intolaw. Voluntary and othernational measures.
Code o Marketing o BMSpassed 16 March 1998.
UNICEF, 2011;WHO, 2008 & 2010
13 Pakistan Full into law Breasteeding ordinancepassed in 2002, but itsrules and regulations onlyin 2009.
UNICEF, 2011;WBTi, 2011
14 Qatar Few provisions into law No available inormation UNICEF, 2011
15 Saudi Arabia Full into law No available inormation UNICEF, 2011
16 Somalia No action No available inormation UNICEF, 2011
17 Sudan Only actions limitedto end ree supplies.Voluntary and othernational measures.
No available inormation UNICEF, 2011;WHO, 2008
18 Syrian ArabRepublic
Measures being studied No available inormation UNICEF, 2011
19 Tunisia Many provisions into law No available inormation UNICEF, 2011
20 United ArabEmirates
Few provisions into law No available inormation UNICEF, 2011
21 West Bank andGaza Strip
No available inormation
22 Yemen Full into law No available inormation UNICEF, 2011
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Table 1.4 Legislative status in countries and areas o the WHO European Region
No. Country or area Legislation status Progress Source
1 Albania Full into law No available inormation UNICEF, 2011; WHO,2008 & 2010
2 Andorra No available inormation UNICEF, 2011
3 Armenia Few provisions into law No available inormation UNICEF, 2011; WHO,
20104 Austria Many provisions into law No available inormation UNICEF, 2011; WHO,
2008 & 2010
5 Azerbaijan Many provisions into law No available inormation UNICEF, 2011; WHO,2008
6 Belarus Measures being studied No available inormation UNICEF, 2011; WHO,2008
7 Belgium Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2010
8 Bosnia andHerzegovina
Drated measuresawaiting approval
No available inormation UNICEF, 2011; WHO,2008 & 2010
9 Bulgaria No available inormation WHO, 2008
10 Croatia Measures being studied No available inormation UNICEF, 2011; WHO,2008 & 2010
11 Cyprus No available inormation No available inormation
12 Czech Republic Many provisions into law No available inormation UNICEF, 2011
13 Denmark Many provisions into law No available inormation UNICEF, 2011
14 Estonia Few provisions into law No available inormation UNICEF, 2011; WHO,2008
15 Finland Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2010
16 France Many provisions into law No available inormation UNICEF, 2011
17 Georgia Full into law No available inormation UNICEF, 2011; WHO,2008
18 Germany Many provisions into law No available inormation UNICEF, 2011; WHO,2008
19 Greece Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2010
20 Hungary Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2010
21 Iceland No available inormation WHO, 2008
22 Ireland Many provisions into law No available inormation UNICEF, 2011; WHO,2010
23 Israel Few provisions into law No available inormation UNICEF, 2011
24 Italy Many provisions into law No available inormation UNICEF, 2011; WHO,2008
25 Kazakhstan No action No available inormation UNICEF, 2011; WHO,2008
26 Kyrgyzstan Many provisions into law No available inormation UNICEF, 2011
27 Latvia Many provisions into law No available inormation UNICEF, 2011; WHO,2010
28 Lithuania Measures being studied No available inormation UNICEF, 2011; WHO,2010
29 Luxembourg Many provisions into law No available inormation UNICEF, 2011
30 Malta Drated measures
awaiting approval
No available inormation UNICEF, 2011; WHO,
2008 & 2010
31 Monaco No available inormation
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No. Country or area Legislation status Progress Source
32 Montenegro No available inormation
33 Netherlands Many provisions into law No available inormation UNICEF, 2011
34 Norway Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2011
35 Poland No available inormation
36 Portugal Many provisions into law No available inormation UNICEF, 201137 Republic o
MoldovaNo available inormation
38 Romania Measures being studied No available inormation UNICEF, 2011; WHO,2010
39 RussianFederation
Measures being studied No available inormation UNICEF, 2011
40 San Marino No available inormation
41 Serbia No available inormation
42 Slovakia Measures being studied No available inormation UNICEF, 2011; WHO,2008 & 2010
43 Slovenia Many provisions into law No available inormation UNICEF, 201144 Spain Many provisions into law No available inormation UNICEF, 2011; WHO,
2008 & 2010
45 Sweden Many provisions into law No available inormation UNICEF, 2011; WHO,2008 & 2010
46 Switzerland Some provisionsvoluntary
No available inormation UNICEF, 2011
47 Tajikistan Many provisions into law No available inormation WHO, 2010
48 The ormerYugoslavRepublic oMacedonia
Few provisions into law No available inormation WHO, 2008
49 Turkey Few provisions into law No available inormation UNICEF, 2011
50 Turkmenistan Few provisions into law No available inormation UNICEF, 2011; WHO,2010
51 Ukraine No available inormation
52 United Kingdomo Great Britainand NorthernIreland
Many provisions into law No available inormation UNICEF, 2011
53 Uzbekistan Measures being studied No available inormation UNICEF, 2011; WHO,2008 & 2010
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Table 1.5 Legislative status in countries and areas o WHO South-East Asia Region
No. Country or area Legislation status Progress Source
1 Bangladesh Many provisionsinto law
Ordinance on Breast-milkSubstitutes (Regulation oMarketing) passed 12 May1984. Ongoing eort toamend existing regulation.
UNICEF, 2011; WBTi,2011; WHO, 2010
2 Bhutan Some provisionsvoluntary
No available inormation WBTi, 2011; UNICEF,2011
3 DemocraticPeoplesRepublic oKorea
No availableinormation
4 India Full into law Inant Milk Substitutes,Feeding Bottles andInant oods (Regulationo production, supply anddistribution) Act passedin 1992 (IMS Act). It was
amended in 2003.
UNICEF, 2011; WBTi,2011; WHO, 2008 & 2010
5 Indonesia Many provisionsinto law, withvoluntary and othernational measures
Decree o MoH No. 237passed in 1997. Ongoingeort to pass new law thatwill adopt the Code.
UNICEF, 2011; WBTi,2011; WHO, 2008
6 Maldives Full into law Regulation on Import,Production and sale oBMS passed in 2008.
UNICEF, 2011; WBTi,2011; WHO, 2008 & 2010
7 Myanmar Being studied No available inormation UNICEF, 2011; WHO,2008
8 Nepal Full into law BMS Act 2049 passed in1992.
UNICEF, 2011; WBTi,2011; WHO, 2008 & 2010
9 Sri Lanka Full into law Regulation under DirectiveNo. 107 o ConsumerProtection Act passed 23March 2004.
UNICEF, 2011; WBTi,2011; WHO, 2008 & 2010
10 Thailand Voluntary measures No available inormation UNICEF, 2011; WBTi,2011; WHO, 2008 & 2010
11 Timor-Leste Voluntarymeasures. Lawdrated, awaitingapproval.
No available inormation WHO, 2010
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Table 1.6 Legislative status in countries and areas in the WHO Western Pacifc
Region
No. Country or area Legislation status Progress Source
1 Australia Voluntary measures No available inormation UNICEF, 2011; WHO,2008
2 Brunei
Darussalam
Voluntary and other
national measures
No available inormation WHO, 2008
3 Cambodia Many provisions intolaw
Sub-decree passed 17August 2009
UNICEF, 2011; WHO,2008 & 2010
4 China Many provisions intolaw
Regulations o Marketingo BMS passed 13 June1995. Since 2009, MoHreported to be workingon amendments oregulations.
UNICEF, 2011; WBTi,2011; WHO, 2008 &2010
5 Cook Islands No availableinormation
6 Fiji Full into law Marketing control or oods
passed 2 October 2002
UNICEF, 2011; WHO,
2008 & 20107 French
PolynesiaSame as France
8 Japan Few provisions into law No available inormation UNICEF, 2011
9 Kiribati Voluntary and othernational measures
No available inormation WHO, 2010
10 Lao PeoplesDemocraticRepublic
Many provisions intolaw
Decision o MoH onControl o Marketing oInant and Young ChildFood Products approved 3August 2007.
UNICEF, 2011; WHO,2008 & 2010
11 Malaysia Voluntary and other
national measures
UNICEF, 2011; WHO,
2008 & 201012 Marshall Islands Voluntary and other
national measuresNo available inormation WHO, 2008
13 Micronesia(FederatedStates o)
No availableinormation
14 Mongolia Few provisions into law National law approved byParliament in July 2005.In 2008, MoH approvedregulations necessary orimplementation o law
UNICEF, 2011; WBTi,2011; WHO, 2008 &2010
15 Nauru No available
inormation
16 New Zealand Voluntary and othernational measures
No available inormation UNICEF, 2011; WHO,2008
17 Niue No action UNICEF, 2011
18 Palau Full into law No available
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