Postscript - Progress on monitoring and enforcing the Code in Cambodia: New developments to ban digital marketing

In 2005, the Government of Cambodia adopted many provisions of the International Code of Marketing of Breastmilk Substitutes (the ‘Code’). Through a sub-decree that addresses the marketing of products for infant and young child feeding (Sub-Decree 133), the national policy now supports breastfeeding by restricting the promotion of breastmilk substitutes (henceforth referred to as ‘commercial milk formula’). In 2007, a Joint Prakas¹ between four line ministries (Health, Information, Commerce and Industry) was adopted as guidance to implement this decree. An Oversight Board with two arms - a Control Committee and an Executive Working Group - was formed seven years later, in 2014, to oversee monitoring, compliance and enforcement of the legal provisions for the Code in Cambodia.

Despite regulations, there remains widespread marketing of commercial milk formula in Cambodia, with significant growth in online and social media platforms. This is outlined in the report reviewed by this article² , in which World Vision International Cambodia highlights the increase in commercial milk formula promotion via digital platforms. The advancement in digital marketing strategies adopted by commercial milk formula companies undermines the importance of breastfeeding and exploits young mothers and parents in Cambodia. As noted in the recent Lancet Series on Breastfeeding,³ commercial milk formula companies have profited, with an annual global revenue of USD 55 billion, externalising the costs to women and young children worldwide at an estimated loss of USD 350 billion per year. The Government of Cambodia, along with members of the Scaling Up Nutrition - Civil Society Alliance (including Helen Keller International, UNICEF, WHO, Alive & Thrive and World Vision International Cambodia), are collaborating to strengthen the Code regulations and their enforcement in Cambodia to protect the rights of women and young children. The authors therefore support the proposed updates of the Joint Prakas to explicitly ban digital marketing of commercial milk formula on social media and the internet, and to call for increased investments for appropriate training, monitoring and enforcement against such violations.

A major concern is that the marketing tactics of commercial milk formula companies not only increase sales of commercial milk formula, but also erode supportive breastfeeding norms, beliefs and practices. Uncontrolled marketing of commercial milk formula on digital platforms can cause Cambodian mothers to believe that commercial milk formula is superior to breastmilk. We are alarmed at the growing trend of social media influencers working as brand ambassadors and of health professionals endorsing and promoting commercial milk formula products in Cambodia. Formula feeding in urban areas is perceived to be a sign of modernisation and an up-to-date way of feeding children. In addition, there is a perception that mothers who give birth via caesarean section cannot breastfeed. There are an increasing number of maternity clinics in urban areas that do not promote breastfeeding due to their engagement with commercial milk formula companies. The decline in exclusive breastfeeding practices, particularly among vulnerable groups like female garment factory workers, has been documented in an unpublished assessment conducted by Helen Keller International, as well as in a published experience that describes World Vision International Cambodia’s work with grandmothers⁴ (Bauler et al, 2022). This urges immediate action to step up efforts to ensure effective implementation, monitoring and enforcement of Sub-Decree 133, as well as of other family-friendly policies related to parental leave.

UNICEF’s report (2021) highlighted existing gaps in Cambodia’s Code in terms of reflecting minimum standards and subsequent World Health Assembly resolutions. In addition to the lack of prohibition on the digital marketing of commercial milk formula products, there are major loopholes in Sub-Decree 133, including the absence of a strict prohibition on the promotion of infant and young child feeding products; the lack of provision to prevent the distribution of sample products, equipment and materials to health facilities, as well as of the sponsorship of events and scholarships to health workers by the manufacturers and distributors of commercial milk formula products; the absence of a ban on nutrition and health claims made by the infant and young child feeding products; and a lack of warning messages on labels regarding early introduction of commercial milk formula and its risk due to the presence of potential pathogens.

In June 2022, the Ministry of Health initiated an update to the Joint Prakas, which is yet to be endorsed by the relevant ministries. Since then, we have been anticipating positive developments that could limit the marketing of commercial milk formula through social/digital media platforms. UNICEF, Helen Keller International, Alive & Thrive, WHO and World Vision International are providing technical and/or financial support for this revision process. The key amendments to the legislation include limiting commercial milk formula promotion and supply in health facilities; expanding the targeted age groups for products under the purview of this legislation from zero to 24 months to zero to 36 months - including all products marketed or presented for feeding infants and young children, and commercially produced complementary foods; preventing false and misleading health and nutrition claims made by commercial milk formula companies; preventing advertisements and promotions made through social media platforms; and enacting strict penalties on manufacturers and distributors who undermine breastfeeding while promoting their products.

An essential part of our coordinated efforts has been the monitoring and enforcement of the Code legislation, which relies on promoting and supporting breastfeeding, as well as training monitors and healthcare staff on the contents of Sub-Decree 133. Alive & Thrive Cambodia’s team has supported the Ministry of Health and trained healthcare providers on breastfeeding and lactation counselling, especially midwives who work in maternity wards. The team has also incorporated the legal provisions within the Early Essential Newborn Care Quality Improvement Guideline 2022 and the Maternal and Child Health Nutrition Score card tool used in the national Cambodia nutrition project, which is used to assess health facility quality. Helen Keller International has oriented healthcare staff to Sub-Decree 133, including nurses and midwives, and pioneered some early work to improve the monitoring and enforcement mechanisms in the country (Hou et al, 2019). Helen Keller International, along with WHO, Alive & Thrive and UNICEF, supports the Ministry of Commerce to identify and report Code violations submitted through the Cambodian court system.

To address the alarming trend of digital marketing of commercial milk formula, in February 2021, World Vision International Cambodia’s technical team piloted an online reporting tool to capture any violations of Code legislation (including in retail stores and health facilities, as well as on social media). This tool has the option to share screenshots and links to online platforms that violate the legal provisions. This tool has been found to be effective in reducing paperwork according to the members of the Technical Working Group that provides recommendations to the Executive Working Group. Discussions are underway with the Ministry of Health to use this tool as an official government reporting system, as well as to allow the Executive Working Group to collate and analyse data and act on violations. This system has already been approved in principle by government representatives from the National Maternal and Child Health Centre, and the team is now checking for opportunities to build it into the ministry’s website, which could allow development partners and the public to file complaints directly.

We believe that civil society partners need to continue their advocacy efforts, especially to ensure appropriate financing. There is a need for intensive efforts and political will from different line ministries, including to mobilise funds and to firmly commit to improve national breastfeeding rates. Further, effective enforcement will require continuing improvements to specific budget allocation by the Ministry of Health to support the monitoring of the Code; increasing political will and coordinating the enforcement of the Code regulations; and addressing the major bottlenecks of institutional human resources and capacity to support Code monitoring (UNICEF, 2021).

It is the collective hope of the authors of this postscript that the additional legislation, along with the updated Joint Prakas and the collaboration of government and civil society to monitor and enforce the related Code legislations, will support progress on breastfeeding and deter unethical marketing of commercial milk formula, including on digital platforms. We do not want to lose the momentum of the successes so far, and we encourage the commitment of a greater range of organisations and government ministries to protect breastfeeding and promote the responsible marketing of commercial milk formula in Cambodia.

For more information, please contact Grana Pu Selvi Gnanaraj at Grana_Selvi@wvi.org

Bauler S, Reinsma K, Gnanaraj GPS et al (2022) Addressing child wellbeing among ‘skip-generation’ households in Cambodia. Field Exchange, 67. www.ennonline.net/fex/67/cambodiagarmentsandiycf

Hou K, Green M, Chum S et al (2019) Pilot implementation of a monitoring and enforcement system for the International Code of Marketing of Breast-milk Substitutes in Cambodia. Maternal & Child Nutrition, 15, 4, e12795. https://doi.org/10.1111/mcn.12795

UNICEF (2021) Strengthening Implementation of the Breast-milk Substitutes Code in Southeast Asia: Putting Child Nutrition First. UNICEF East Asia and Pacific Region.

www.unicef.org/eap/reports/strengthening-breast-milk-substitutes-code-southeast-asia