Viet Nam Fortifies Legislation

In 2006, Viet Nam adopted Decree 21, based on the International Code of Marketing of Breast Milk Substitutes. This legislation did not include all provisions of the Code as it allowed for advertisements of milk products for children over one year of age and for feeding bottles, teats, and dummies. So, in 2014, the government passed additional legislation to limit these and further stipulate proper labeling, information dissemination, education, and advertising. Exclusive breastfeeding rates have increased slightly in Viet Nam from 16.9% in 2006 to 24.3% in 2014. There is progress to be made, specifically in consistently monitoring and enforcing the law.

Description and Context

In 2006, Viet Nam adopted Decree 21, based on the International Code of Marketing of Breast Milk Substitutes (1). The decree prohibited all advertising of complementary foods for children under six months, advertising milk for
children under one year, and promoting feeding bottles with teats and pacifiers. It also required that labels on breast milk substitutes for children over one year have statements that breastfeeding is the superior option. Finally, it stipulated where infant foods can be provided or sold and identified the role that product manufacturers and the health community play in upholding the regulations (1).

However, the decree did not include all measures of the Code, allowing for advertisements of milk products for children over one year of age and for feeding bottles, teats, and dummies (2). In 2014, the government passed additional legislation to limit these and further stipulated proper labeling, information dissemination, education, and advertising (3). In addition, interdisciplinary cooperation began between the Ministry of Health and the Ministry of Industry and Trade in monitoring the labels of imported milk companies in Viet Nam (4).

In 2016, the French company Danone, which sells the children’s formula Dumex in Viet Nam, announced it would be leaving the country due to low sales (5). Other formula companies report similar decreases in profit due to the effects of the legislation, but many still remain in the market (5). Exclusive breastfeeding rates have increased slightly in Viet Nam from 16.9% in 2006 to 24.3% in 2014 (6). Viet Nam has more progress to make, particularly with monitoring and sanctioning violators (4).

Main Components

The following are selected general shared stipulations of the 2006 and revised 2014 law, No. 100/2014/ND-CP (3):

Information, Education, Communication, and Advertising:

• Information on the benefits of breastfeeding must be prioritized in programs regarding mother and child health as well as infant nutrition improvement
• Information regarding infant nutrition must clearly include the benefits and superiority of breastfeeding and the disadvantages of feeding infants with breast milk substitutes over breast milk.
• Banned personal or commercial encouragement to use breast milk substitutes
• Trading and Use of Nutritious Products for Infants, Feeding Bottles, and Teats:
• Stipulated conformity with regulation and with food safety laws
• Clear labeling of breast milk substitutes, complementary foods, feeding bottles, and teats with the benefits and superiority of breastfeeding and the disadvantages of feeding infants with breast milk substitutes over breast milk.

Responsibilities in Trading and Use of Nutritious Products for Infants:

• Among other stipulations, companies producing breast milk substitutes must meet food safety and quality regulations and provide accurate scientific and nutritious information. They are not allowed to contact pregnant or young mothers, use sales promotion techniques, or advertise to this subgroup in supermarkets or health facilities.
• Established the responsibilities of medical establishments and its physicians and workers to provide counseling on breastfeeding to pregnant women, disseminate and display information on this law in their facilities, and to create conditions to facilitate breastfeeding. They are prohibited from selling or permitting the sale of breast milk substitutes.
• Established the responsibilities of management by the Ministry of Health: to work with other sectors to monitor the sale and advertising of breast milk substitutes, disseminate information and guide pregnant women regarding these laws and the benefits of breastfeeding.

Evidence of Implementation Strategy

The 2015 WBTi report for Viet Nam found score of 9/10 for the implementation of the Code (4). The report concludes that the 2014 decree has more power and is stricter than before, particularly in prohibiting the advertising of breast milk substitutes for children under one year old. In addition, it praises the interdisciplinary cooperation within government to check the labels of milk substitutes (4).

Reports from formula companies of decreased sales seem likely to be an effect of the legislation, though many still remain in the market (5), and exclusive breastfeeding rates have increased slightly from 2006 to 2014.

Cost and Cost-Effectiveness

Legislation costs are low but monitoring requires funding for staff and overheads. On its section on budgeting and costs of monitoring, the WHO’s NetCode Toolkit for monitoring the marketing of breast milk substitutes stipulates that costs can be decreased in the following ways (10):

• Government monitors are existing salaried employees
• Logistical support of government monitors (transportation, for example) is already provided based on their existing functions
• Existing office spaces and buildings of agencies involved are used to reduce infrastructure costs
• Existing digital and communication equipment is used

Perceptions and Experiences of Interested People

A personal article in the Viet Nam News by Thu Vân illustrates the situation: she cites that the low rate of breastfeeding is due to personal choice, as well as the perception that formula is just as good as breast milk from historically aggressive marketing by formula companies. Vân vehemently denies this, stating breast milk gives their “baby the best start in life” (8). She praises mothers who go through pain to give this best to their baby: “I adore those who can patiently feed her baby every one and a half or two hours despite all the fatigue of the post-birth period” (8).

UNICEF Viet Nam’s representative, Lotta Sylwander, had praise for the new law, stating “a vote for the Law on Advertisement is a vote for Vietnamese children’s health” (9).

Benefits and Potential Damages and Risks

• Many countries have enacted a national code on breast milk substitutes into law, but monitoring and enforcement of this law is very weak due to low financial, technical, and personnel capacity, and the power of the formula companies. There is a risk that while legislation may be passed, it will serve no purpose without proper monitoring and evaluation (2). The WHO 2016 report on the implementation of the International Code of Marketing of Breast-Milk Substitutes states that monitoring in Viet Nam is done by the Food Administration and Health Inspection Unit, but it is not budgeted and not free from commercial influence. However, for the last monitoring period, they cite violations were identified and sanctions imposed, although no formal report was published (2).
• There is a risk that a monitoring body may be bought off by the formula companies, and instead serve to perpetuate or increase their sales.

Scaling Up Considerations

• Political will at the highest level is crucial for both effective legislation and enforcement of the legislation. In addition, political agreement on the national code must be adapted to a country’s specific conditions and supported by local actors in order to enforce on the ground.
• Legislation must designate a monitoring body for the law to be enacted effectively on the ground. There also must be evaluation of these monitoring bodies.
• The WHO’s 2017 NetCode Toolkit is an excellent step-by-step guide to establishing a national monitoring system and is easily accessible online. It includes sections on determining the coverage and extent of monitoring, costs and budgeting, developing standard monitoring and a database, monitoring and enforcement, and evaluation and assessment.
• Monitoring bodies must be protected under the law.
• Financial resources to fund monitoring and implementation of legislation is necessary.

Barriers to Implement

While the new decree restricted breast milk substitutes advertising and sale, and further and increased monitoring,
there are still gaps. The WBTi 2015 report states that monitoring measures, which are irregular, mainly apply to solely milk companies (4). In addition, there is no sanction for health associations such as the Association of Pediatrics, the Association of Obstetrics and Gynecology in accepting funding from formula companies (4). When a law enacting the Code is drafted, it must be drafted to cover all possible arenas that these companies may come into contact with to ensure widespread improvements.

In addition, while a country may pass legislation regarding breast milk substitutes and their monitoring, countries with challenging financial environments may find it difficult to pay for monitoring and enforcement. Infant formula companies can and do pay off agencies assigned to monitoring. In addition, it is important to create indicators to measure levels of implementation, as the WHO NetCode toolkit provides direction but not all indicators are defined. Countries must adapt the toolkit to their specific context and needs.

Government infrastructure and awareness is another possible barrier; if government leaders and officials are not sensitized or informed on the issue of breastfeeding in competition with infant formula, they may not be convinced to regulate, promote, fund and enact monitoring/evaluation.

Equity Considerations

Infant formula companies can have a powerful say in government and the public sphere; they are often able to pay
for mass advertisement and sponsor politicians that support them and their efforts. Without a law that first bans these actions and, if such a law is in place, without strict monitoring of this law, infant formula companies may continue to dominate the sphere and imperil optimal breastfeeding practices.

There is a segment of the population who cannot breastfeed, such as mothers with HIV and without access to antiretroviral drugs. In this case, infant formula must be respected as the only viable option for their babies, and instead safe preparation and delivery of the infant formula should be emphasized. These mothers must be considered equally.

References:

1. Legislation to Protect Breastfeeding in Viet Nam: A Stronger Decree 21 Can Improve Child Nutrition and Reduce Stunting (2012). Alive & Thrive; UNICEF. Retrieved from https://www.aliveandthrive.org/sites/default/files/attachments/Policy-brief-on-Marketing-Code-Decree21_April-2012-English.pdf
2. Marketing of Breast-Milk Substitutes: National Implementation of the International Code Status Report 2016 (2016). WHO. Retrieved from https://iris.who.int/bitstream/handle/10665/206008/9789241565325_eng.pdf
3. Decree No. 21/2006/ND-CP: On the Trading in and Use of Nutritious Products for Infants (2006). The Socialist Republic of Viet Nam. Retrieved from https://extranet.who.int/nutrition/gina/en/node/15061; Decree No. 100/2014/ND-CP: On the Trading in and Use of Nutritious Products for Infants, Feeding Bottles, and Teats (2014). The Socialist Republic of Viet Nam. Retrieved from http://extwprlegs1.fao.org/docs/pdf/vie167953.pdf
4. WBTi Viet Nam Assessment Report, 2015. IBFAN. Retrieved from https://www.worldbreastfeedingtrends.org/wbti-country-report.php?country_code=VN
5. Nguyen, Quynh. “Dumex to Leave Viet Nam due to Low Sales,” 2016. Viet Nam Economic Times. Retrieved from http://vneconomictimes.com/article/business/dumex-to-leave-Viet Nam-due-to-low-sales
6. Exclusive Breastfeeding (Percentage Under 6 Months of Age). The World Bank. Retrieved from https://data.worldbank.org/indicator/SH.STA.BFED.ZS?locations=VN
7. Breastfeeding (2017). UNICEF. Retrieved from https://www.unicef.org/nutrition/index_24824.html
8. Van, Thu. “The Endless Battle to Encourage Breastfeeding.” Viet Nam News, 2016. Retrieved from http://Viet Namnews.vn/talk-around-town/302029/the-endless-battle-to-encourage-breastfeeding.html
9. UNICEF Commends Viet Nam on Banning Advertisements of Breast Milk Substitutes for Children Under 24 months, 2012. UNICEF. Retrieved from https://www.unicef.org/eapro/media_18901.html
10. NetCode Toolkit. Monitoring the Marketing of Breast-Milk Substitutes: Protocol for Ongoing Monitoring Systems. 2017. WHO. Retrieved from http://apps.who.int/iris/bitstream/10665/259441/1/9789241513180-eng.pdf?ua=1%20

Could it work?

In Viet Nam, the political drive to protect breastfeeding is evident in their enacting a stronger Code in 2014. Harnessing this political will and properly implementing the Code is not unique to a specific country or health care system.

Will it work?

There are significant considerations to enacting Code legislation and then monitoring and enforcing this legislation. While a country may pass legislation regarding breast milk substitutes, there may be challenges with the human and financial capacity to monitor and enforce, which can be further undermined by incentives and marketing from infant formula companies. The success of the Code is dependent on a country’s political desire to enact strong legislation and to designate and protect a monitoring/enforcing body. Evaluation of these monitoring bodies is critical as they are responsible for action against illegal infant formula advertising and activity by the formula companies.

Is it worth it?

Leaders and government officials must be educated and made aware of issues related to breastfeeding and the harmful effects of infant formula companies in order to garner the political will to establish satisfactory enforcement, monitoring and evaluation of such an intervention. Viet Nam’s legislation represents an important and responsible effort to promote, protect, and support breastfeeding. The crucial monitoring and enforcing piece needs financial, technical, and personnel resources in place. If these are addressed, this intervention is both conceivable and worth the risks.