Brazil’s Multi-Sectorial National Breastfeeding Committee

In 2012 Brazil’s National Breastfeeding Committee (CNAM) was reformulated to include representation from multiple sectors including government, universities, and civil organizations. Their objectives are to support and oversee the National Department of Child Health and Breastfeeding (responsible for nationally coordination of the promotion, protection and support of breastfeeding), mobilize and sensitize sectors of government and civil society for the development of breastfeeding-friendly actions, and inform the Ministry of Health (MoH) on breastfeeding issues. CNAM is a powerful group that uses evidence to strongly advocate for breastfeeding as a government health priority and support the MoH in their decision making. The many examples of the committee’s success include legislation to redefine the Baby Friendly Hospital Initiative (BFHI) criteria and the WBTI scores for National Policy, Programme, and Coordination have been 9.5 and 10 out of 10 for 2008 and 2014 respectively. This indicates a properly functioning, funded, implemented, and coordinated National Committee and Policy.

Description & Context

In 2012 Brazil’s National Breastfeeding Committee (CNAM) was reformulated to include representation from multiple sectors including government, universities, civil organizations, as well as specialists beyond health and nutrition whose presence is considered necessary to comply the provisions of the law (portaria 111, January 19, 2012). Their objectives were stipulated to (1) support the process of articulation of the newly created National Coordination of Child Health and Breastfeeding and (2) mobilize and sensitize sectors of government and civil society for the development of actions inherent to breastfeeding. Most importantly, this critical committee serves to inform the Ministry of Health of breastfeeding issues. The committee meets in person biannually (1).

Regarding the first objective of CNAM, the National Coordination of Child Health and Breastfeeding is composed of a core technical team under the umbrella of the Ministry of Health. It is responsible for nationally coordinating all issues related to the promotion, protection and support of breastfeeding. Thus, oversight from the multi-sectorial CNAM is critical to ensuring the function of this national coordination group. Biannually, CNAM meets in person to discuss priorities in breastfeeding, as well as any issues brought to their attention by the Ministry of Health. In addition, CNAM conferences online to discuss these issues throughout the year. In the first meeting, CNAM discusses the work plan developed by the Ministry of Health that sets specific time-bound breastfeeding objectives and actions. At the meeting at the end of each year, CNAM evaluates the progress in implementation and obtaining these objectives.

CNAM submits reports from these meetings directly to the Ministry of Health.

Main Components

The CNAM is composed of representatives, members and alternates of the following groups and are chosen by the officers of these respective groups (2):

• Technical Area of Child Health and Breastfeeding (DAPES / SAS / MS), which has the role of coordination of CNAM
• Women's Health Coordination (DAPES / SAS / MS)
• Primary Health Coordination (DAB / SAS / MS)
• Brazilian Network of Human Milk Banks
• Brazilian Society of Pediatrics (SBP)
• Brazilian Federation of Gynecology and Obstetrics (FEBRASGO)
• International Network in Defense of the Right to Breastfeed IBFAN-Brazil
• Federal Council of Nutritionists
• Non-governmental Entities Related to the Defense and Promotion of Breastfeeding
• Universities and / or Research Institutes

Evidence of Implementation Strategy

The WBTI scores for National Policy, Programme, and Coordination have been 9.5 and 10 out of 10 for 2008 and 2014 respectively (4). This indicates a properly functioning, funded, implemented, and coordinated National Committee and Policy. For example, the 2014 report cites excellent coordination and implementation oversight by the National Coordination of Child Health and Breastfeeding in matters such as Rede Amamenta Brasil (2008) and the National Strategy for Healthy Food Supplement (ENPACS-2009) that promote, protect, and support breastfeeding and proper complementary feeding.

The 2014 Brazilian management report lists significant gains in legislation such as redefining the criteria of the Baby Friendly Hospital Initiative (BFHI) to better promote, protect and support breastfeeding and the integral health of children and women. It also includes health facility accreditations/certifications; in 2014, 8 Primary Health Units were certified in the Brazilian Breastfeeding and Eating Healthy Strategy (EAAB). In addition, a substantial list of training is included in the management report. Just one example is that 50 training workshops were held on "The Strategy for Breastfeeding and Eating Health Brazil”. Finally, the report lists national events and meetings that occurred the past year, international coordination examples, and advertising campaigns. Overall, the report provides a wealth of information to improving child health. However, because this management report includes all child health, many topics discussed are not relevant to the ages of breastfeeding, and instead cover a much broader range of issues such as violence against children and childhood illnesses (3).

A member of CNAM cites that CNAM wrote and submitted a document proposing a formalized breastfeeding policy to the Ministry of Health. In 2017, this document was approved by legislation. The document gives the components of the national policy of promotion, protection, and support for breastfeeding, including institutional responsibilities at the federal, state, and municipal level (6).

Cost and Cost-Effectiveness

The Ministry of Health covers the cost of airfare and lodging during the biannual meetings of CNAM members. Minimal meeting costs are associated as well. However, CNAM members are not paid, displaying the importance these members place on protecting and promoting breastfeeding as they volunteer their time and energy to serve on the committee. Thus, coordination is very cost-effective when members are invested in the topic.

Perceptions and Experiences of Interested People

The representative of Instituto de Saúde (Health Research Institute) that currently serves on CNAM emphasizes the importance of the committee in supporting the Ministry of Health to make evidence-based, informed decisions. They further cite that CNAM is a powerful group that strongly advocates to ensure breastfeeding is a priority in government health policy. Without CNAM, breastfeeding would not be a government priority (2).

While a strong committee currently, the representative believes the inclusion of other sectors outside of health, such as education and social development, as well as lower levels of the public health system such as the state and municipal level, would help to improve breastfeeding practices at all levels.

Communication during the meetings is another important factor cited by the representative; at the CNAM meetings, everyone presents their opinion and experience, and the discussion of breastfeeding priorities is conversational instead of rigid. This facilitates better communication and ultimate decision-making when all perspectives are considered by the Ministry of Health (2).

Benefits and Potential Damages and Risks

Potential risks include

• Not including important sectors on the committee, such as social development or education in Brazil’s case. Perspective on the committee may then be limited.
• Not including different levels of the public health system, such as the state or municipal level, on the committee. This potentially limits the reach of the committee and does not allow for perspective from a more local viewpoint.
• While not the case in Brazil, it is feasible that certain representatives may have more power on the committee due
  to capital or other influence. It is important to ensure the committee is balanced and all members have a say in discussion.

Scaling Up Considerations

Key components of scaling up include:

• Formalization of CNAM members and their objectives is extremely important to give credence to their meetings and actions. Ultimately, this strengthens the committee’s work.
• Inclusion of sectors outside the health sector, such as education or social development, on the committee.
• Inclusion of different levels of the public health system, such as state and municipal levels, on the committee.

Barriers to Implement

• While Brazil has been successful with a committee comprised of only health-sector representatives, representatives from other sectors such as education and social development bring an important perspective. Limiting this perspective is a barrier
• Ensuring biannual meetings could be a barrier, as members are not paid and have additional jobs outside of CNAM. Incentive to meet could be low if members do not have a strong commitment to breastfeeding.

Equity Considerations

Ensuring all levels of the public health system are represented on the committee is an important consideration, as the committee allows them to directly present their perspective on breastfeeding to the Ministry of Health. In addition, ensuring non-health sectors, such as education and social development, are represented on the committee also creates equality in presenting different perspectives to the Ministry of Health.

References:

1. Ministry of Health (2012). Redefines the National Breastfeeding Committee (CNAM). Portaria 111. Retrieved from http://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/prt0111_19_01_2012.html
2. Sonia Venancio, CNAM member. November 17, 2017. Personal interview.
3. Brazilian Ministry of Health (2014). Annual Management Report. Retrieved from http://portalarquivos.saude.gov.br/images/pdf/2015/maio/04/Relat--rio-de-Gest--o-da-SAS-2014-Final.pdf
4. World Breastfeeding Trends Initiative (2008, 2014). National Assessments of the State of Global Strategy for Infant and Young Child Feeding using WBTi – Brazil. 2008 and 2014 reports retrieved from http://www.worldbreastfeedingtrends.org/GenerateReports/countrysubmit.php?country=BR
5. UNICEF (2017). UNICEF Data: Monitoring the Situation of Children and Women – Brazil. Retrieved from https://data.unicef.org/country/bra/
6. Basis for Discussion of the National Policy Promotion, Protection, and Support to Breastfeeding (2017). Ministério de Saúde. Retrieved from http://bvsms.saude.gov.br/bvs/publicacoes/bases_discussao_politica_aleitamento_materno.pdf

Could it work?

The objectives of the Brazilian National Breastfeeding Committee (CNAM) were stipulated to (1) support the process of articulation of the newly created National Coordination of Child Health and Breastfeeding and (2) mobilize and sensitize sectors of government and civil society for the development of actions inherent to breastfeeding. The CNAM has positively impacted on breastfeeding policies development with the documentation and creation of a national breastfeeding strategy. The set-up of CNAM is dictated by the structures within Brazil’s government so a similar national committee is possible but the details of the structure will differ. This intervention is flexible and replicable within any context.

Will it work?

This is dependent on the political desire to have such a committee. Again, this will differ from country to country. The costs are negligible as members are not paid and they only meet twice a year. These members volunteer their time and expertise, so both they and their managers will need to agree on the commitment and see the benefits of the committee.

Is it worth it?

As the committee member said, without CNAM, breastfeeding would not be a government priority. It’s role is crucial to support national coordination and mobilize government activity. The risk of imbalance in representation and power can be managed. Turf war issues between government departments or NGOs might cause issues with setting up a national committee but these very conflicts are a good reason to form an effective coordinating body.