Breastfeeding, first-food systems and corporate power: a case study on the market and political practices of the transnational baby food industry in Brazil.

BACKGROUND: The exploitative marketing of commercial milk formula (CMF) reduces breastfeeding, and harms child and maternal health globally. Yet forty years after the International Code of Marketing of Breast-Milk Substitutes (The Code) was adopted by WHO member states, many countries are still to fully implement its provisions into national law. Furthermore, despite The Code, worldwide CMF markets have markedly expanded. In this paper, we adopt Brazil as a case study to understand the power of the baby food industry's marketing and corporate political activity, and how this influences the country's 'first-food system' in ways that promote and sustain CMF consumption. METHODS: We used a case study design, drawing data from from documents and key informant interviews (N = 10). RESULTS: Breastfeeding rates plummeted in Brazil to a historic low in the 1970s. A resurgence in breastfeeding from the mid-1980s onwards reflected strengthening political commitment for a national policy framework and breastfeeding protection law, resulting in-turn, from collective actions by breastfeeding coalitions, advocates, and mothers. Yet more recently, improvements in breastfeeding have plateaued in Brazil, while the industry grew CMF sales in Brazil by 750% between 2006 and 20. As regulations tightened, the industry has more aggressively promoted CMF for older infants and young children, as well as specialised formulas. The baby food industry is empowered through association with powerful industry groups, and employs lobbyists with good access to policymakers. The industry has captured the pediatric profession in Brazil through its long-standing association with the Brazilian Society of Pediatrics. CONCLUSION: Brazil illustrates how the baby food industry uses marketing and political activity to promote and sustain CMF markets, to the detriment of breastfeeding. Our results demonstrate that this industry requires much greater scrutiny by regulators.

Baby food industry interference with infant feeding international regulation-A case study on the standard for follow-up formula.

Introduction: Globally, first-food systems have changed and breastfeeding has decreased due to the increased growth in commercial breast milk substitute (BMS) consumption, which includes both follow-up and toddler formulas. These products are manufactured by a small number of corporate leaders in international BMS sales. Discussions for global regulation of these products take place in the Codex Alimentarius and are permeated by the strong participation of these corporations in the Codex committees. Objective: In the present study, the participation of the baby food industry in the review of the follow-up formula standard in the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU) was analyzed. Methods: The analysis of the CCNFSDU documents was based on the period from 2009 to 2019 and used quantitative and qualitative approaches. Compositional and participation data from country delegations and observer organizations on the representative profiles of the involved institutions and the baby food industry's involvement in this process were established systematically. Results: In total, 134 out of the 189 Codex Alimentarius member countries engaged in the standard review process, of which 28% were involved in the entire process. The private sector was present in 81% of the most assiduous member state delegations to the meetings. Furthermore, ~60% of the observer organizations involved in the review process were business associations representing industry interests. Moreover, the International Special Dietary Foods Industries was the only business association with observer status in the CCNFSDU that was specifically dedicated to representing the baby food industryduring the review process. Conclusion: These research results expand the body of evidence confirming the expressive and disproportionate participation of baby food industries and their representatives in the discussion processes within the scope of the CCNFSDU. However, studies investigating the Codex and the public documents of its respective committees are limited. Thus, this was the first study to analyze the influence of the baby food industry on BMS global regulatory compliance.

Influências da indústria de alimentos na regulação internacional: um estudo da Norma Follow-up Formula do Codex Alimentarius / Influences of the food industry on international regulations: a study of the Follow-up Formula Standard in the Codex Alimentarius

As práticas de marketing da indústria de fórmulas são bastante conhecidas, mas pouco se sabe sobre as atividades políticas corporativas (CPA) das indústrias desses produtos nas políticas e normas em âmbito global. No Codex Alimentarius, a discussão sobre o produto follow-up formula tem muitos desafios, como a faixa etária proposta para o uso, a falta de dados sobre o consumo global, a diretriz da Organização Mundial de Saúde que o classifica como desnecessário na alimentação infantil e o aumento do consumo desses produtos para crianças de 24 a 36 meses de idade. As indústrias, com seu alto poder econômico, têm influenciado as políticas públicas, as pesquisas e as práticas dos profissionais de saúde e usam as CPA para garantir um ambiente político favorável. Esta tese buscou analisar os posicionamentos e as interferências da indústria de alimentos no processo decisório referente à regulação das follow-up formula no âmbito do Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU). Realizou-se uma análise exploratória, por meio do estudo de caso do produto follow-up formula. Utilizou-se da abordagem qualitativa para a análise dos documentos do CCNFSDU nos anos de 1966 a 2019, com o objetivo de produzir um relato do processo de incorporação das normas para as fórmulas. Para análise das CPA da indústria de alimentos nos anos de 2009-2019 foi utilizada a abordagem sistemática passo a passo recomendada por Mialon (2018) e uma análise quantitativa para explicitar e sistematizar os aspectos de composição e participação das delegações dos países e das organizações observadoras, o perfil dos participantes e a capilaridade da indústria de alimentos nesse processo. Dos 189 membros do Codex, 134 participaram do processo de revisão da Norma e desses, 28% participaram de todo processo. A média de participação de representantes de interesse privado nas delegações nacionais foi de 42%. Verificou-se uma baixa participação de representantes de organizações de defesa de direitos, menos de 10% das organizações observadoras eram de interesse público e mais de 59% delas eram associações de interesse das indústrias. As Big Formula participaram de todo o processo de revisão. Identificamos 171 exemplos de práticas de CPA realizadas por 11 organizações observadoras, sendo que a maioria das práticas foi de estratégias discursivas usadas para "moldar o debate sobre alimentação e saúde pública" e combinadas com estratégias instrumentais. Os temas DHA, proteínas e carboidratos foram os assuntos sobre os quais a indústria mais se posicionou, seguidos do fator de conversão de nitrogênio, do leite materno como referência para follow-up formulas, da rotulagem, da inclusão de referências às resoluções da WHA/WHO, da promoção cruzada e das alegações nutricionais e de saúde. O processo de revisão da Norma foi moroso, com disputas sobre temas que são caros para a indústria de alimentos e para a saúde pública. É notório que a indústria utiliza da discussão da saúde pública para acomodar a importância econômica do setor e é representada por organizações comerciais nos lócus de tomada de decisão.

The formula industry's marketing practices are well known, but little is known about the corporate policy activities (CPA) of formula industries in global policies and regulations. In Codex Alimentarius, the discussion about the follow-up formula product has many challenges, such as the age group proposed for use, the lack of data on global consumption, the World Health Organization guidelines that classify it as unnecessary for infant feeding, and the increased consumption of these products among children from 24 to 36 months of age. Industries, with their strong economic power, have influenced public policy, research and the practices of healthcare professionals and use CPA to ensure a favorable policy environment. This thesis sought to analyze the positions and interferences of the food industry in the decision-making process regarding the regulation of follow-up formulas within the scope of the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU). An exploratory analysis was carried out through the case study of the product Follow-up Formula. A qualitative approach was used to analyze the documents of the CCNFSDU in the years 1966 to 2019, with the objective of reporting the process of incorporating the norms for formulas. For the analysis of the CPAs of the food industry in the years 2009-2019, the systematic step-by-step approach recommended by Mialon (2018) was used and a quantitative analysis was used make explicit and systematize the aspects of composition and participation of country delegations and observer organizations, the profile of the participants and the capillarity of the food industry in this process. Of the 189 Codex Members, 134 participated in the Standard review process, of which 28% participated in the entire process. The average participation of private interest representatives in national delegations was 42%. There was a low participation of representatives of organizations for the defense of rights, less than 10% of the observer organizations were of public interest and more than 59% of them were associations of interest to industries. Big Formula participated in the entire review process. We identified 171 examples of CPA practices carried out by 11 observer organizations, with the majority of practices being discursive strategies used to "shape the debate on food and public health", combined with instrumental strategies. The themes DHA, proteins and carbohydrates were the subjects on which the industry focused most intensely, followed by the nitrogen conversion factor, breast milk as a reference for follow-up formulas, labeling, inclusion of references to WHA/WHO resolutions, cross promotion and nutrition and health claims. The Norma review process was lengthy, with disputes over issues that are important to the food industry and public health. It is well known that industries use the discussion of public health to accommodate the economic importance of the sector and are represented by commercial organizations in the decision-making locus.

Política Nacional de Atenção Básica no Brasil: uma análise do processo de revisão (2015–2017)

[RESUMO]. Objetivo. Apresentar e discutir acontecimentos relacionados ao processo de revisão da Política Nacional de Atenção Básica (PNAB) no Brasil, de modo a evidenciar narrativas que possam contribuir para análises futuras sobre a formulação, implementação e avaliação dessa Política. Métodos. Trata-se de relato de experiência de participantes do processo de revisão da PNAB, a partir da análise de conteúdo complementada por análise documental. Resultados. O processo de revisão da PNAB, ocorrido entre 2015 e 2017, foi fortemente marcado por disputas técnico-políticas entre o Ministério da Saúde e as instâncias representativas de secretarias municipais e estaduais de saúde. As principais mudanças introduzidas pela nova versão da PNAB são a possibilidade de financiamento de outros modelos de organização da atenção básica além da Estratégia Saúde da Família; a ampliação das atribuições dos agentes comunitários de saúde; a construção da oferta nacional de serviços e ações essenciais e ampliadas da atenção básica; e a inclusão do gerente de atenção básica nas equipes. Conclusões. A implementação da nova PNAB, fruto de disputas travadas no campo da gestão interfederativa, dependerá da confluência de interesses no sentido da efetivação de uma atenção primária acessível e resolutiva, fortalecendo o Sistema Único de Saúde, o que requer substancialmente a participação e o protagonismo da sociedade na luta pelo direito à saúde no Brasil.

[ABSTRACT]. Objective. To describe and discuss events associated with the latest review of the national primary health care (PHC) policy in Brazil (Política Nacional de Atenção Básica, PNAB) so as to highlight narratives that may contribute to future analyses focusing on the formulation, implementation, and assessment of this policy. Method. Participant observation report of the PNAB review process, based on content and document analyses. Results. The review process of PNAB, which took place between 2015 and 2017, was strongly marked by technical and political dispute among the Ministry of Health and authorities representing municipal and state health departments. The main changes introduced by the new version of PNAB are the financing of other PHC organizational models in addition to the Family Health Strategy; attribution of additional responsibilities to community health agents; introduction of a national set of core and extended PHC services and actions; and introduction of a manager role as part of PHC teams. Conclusions. Implementation of the revised PNAB, which was the result of interfederation dispute, will depend on the convergence of interests in a PHC that is accessible and effective, strengthening the Unified Health System. This will substantially require societal engagement and leadership in the fight for the right to health in Brazil.

[RESUMEN]. Objetivo. Presentar y discutir los acontecimientos relacionados con el proceso de revisión de la Política Nacional de Atención Básica (PNAB) en Brasil, de manera de obtener información que pueda contribuir a futuros análisis sobre la formulación, implementación y evaluación de esa política. Métodos. Se evaluó el relato de la experiencia de los participantes del proceso de revisión de la PNAB a partir del análisis de contenido, complementado por un análisis documental. Resultados. El proceso de revisión de la PNAB, que tuvo lugar entre 2015 y 2017, presentó marcadas disputas técnico-políticas entre el Ministerio de Salud y las instancias representativas de las secretarías municipales y estatales de salud. Los principales cambios introducidos por la nueva versión de la PNAB son la posibilidad de financiamiento de otros modelos de organización de la atención básica además de la Estrategia Salud de la Familia, la ampliación de las atribuciones de los agentes comunitarios de salud, la construcción de la oferta nacional de servicios y acciones esenciales y ampliadas de atención básica, y la inclusión del gerente de atención básica en los equipos. Conclusiones. La implementación de la nueva PNAB, fruto de las disputas entabladas en el campo de la gestión interfederativa, dependerá de la confluencia de intereses hacia la efectivización de una atención primaria accesible y resolutiva, fortaleciendo el Sistema Único de Salud, lo que requiere la participación y el protagonismo de la sociedad en la lucha por el derecho a la salud en Brasil.

[National primary health care policy in Brazil: an analysis of the review process (2015-2017)Política Nacional de Atención Básica en Brasil: un análisis del proceso de revisión (2015-2017)]. / Política Nacional de Atenção Básica no Brasil: uma análise do processo de revisão (2015­2017).

OBJECTIVE: To describe and discuss events associated with the latest review of the national primary health care (PHC) policy in Brazil (Política Nacional de Atenção Básica, PNAB) so as to highlight narratives that may contribute to future analyses focusing on the formulation, implementation, and assessment of this policy. METHOD: Participant observation report of the PNAB review process, based on content and document analyses. RESULTS: The review process of PNAB, which took place between 2015 and 2017, was strongly marked by technical and political dispute among the Ministry of Health and authorities representing municipal and state health departments. The main changes introduced by the new version of PNAB are the financing of other PHC organizational models in addition to the Family Health Strategy; attribution of additional responsibilities to community health agents; introduction of a national set of core and extended PHC services and actions; and introduction of a manager role as part of PHC teams. CONCLUSIONS: Implementation of the revised PNAB, which was the result of interfederation dispute, will depend on the convergence of interests in a PHC that is accessible and effective, strengthening the Unified Health System. This will substantially require societal engagement and leadership in the fight for the right to health in Brazil.

OBJETIVO: Presentar y discutir los acontecimientos relacionados con el proceso de revisión de la Política Nacional de Atención Básica (PNAB) en Brasil, de manera de obtener información que pueda contribuir a futuros análisis sobre la formulación, implementación y evaluación de esa política. MÉTODOS: Se evaluó el relato de la experiencia de los participantes del proceso de revisión de la PNAB a partir del análisis de contenido, complementado por un análisis documental. RESULTADOS: El proceso de revisión de la PNAB, que tuvo lugar entre 2015 y 2017, presentó marcadas disputas técnico-políticas entre el Ministerio de Salud y las instancias representativas de las secretarías municipales y estatales de salud. Los principales cambios introducidos por la nueva versión de la PNAB son la posibilidad de financiamiento de otros modelos de organización de la atención básica además de la Estrategia Salud de la Familia, la ampliación de las atribuciones de los agentes comunitarios de salud, la construcción de la oferta nacional de servicios y acciones esenciales y ampliadas de atención básica, y la inclusión del gerente de atención básica en los equipos. CONCLUSIONES: La implementación de la nueva PNAB, fruto de las disputas entabladas en el campo de la gestión interfederativa, dependerá de la confluencia de intereses hacia la efectivización de una atención primaria accesible y resolutiva, fortaleciendo el Sistema Único de Salud, lo que requiere la participación y el protagonismo de la sociedad en la lucha por el derecho a la salud en Brasil.

Política Nacional de Atenção Básica no Brasil: uma análise do processo de revisão (2015­2017) / National primary health care policy in Brazil: an analysis of the review process (2015­2017) / Política Nacional de Atención Básica en Brasil: un análisis del proceso de revisión (2015­2017)

Objetivo. Apresentar e discutir acontecimentos relacionados ao processo de revisão da Política Nacional de Atenção Básica (PNAB) no Brasil, de modo a evidenciar narrativas que possam contribuir para análises futuras sobre a formulação, implementação e avaliação dessa Política. Métodos. Trata-se de relato de experiência de participantes do processo de revisão da PNAB, a partir da análise de conteúdo complementada por análise documental. Resultados. O processo de revisão da PNAB, ocorrido entre 2015 e 2017, foi fortemente marcado por disputas técnico-políticas entre o Ministério da Saúde e as instâncias representativas de secretarias municipais e estaduais de saúde. As principais mudanças introduzidas pela nova versão da PNAB são a possibilidade de financiamento de outros modelos de organização da atenção básica além da Estratégia Saúde da Família; a ampliação das atribuições dos agentes comunitários de saúde; a construção da oferta nacional de serviços e ações essenciais e ampliadas da atenção básica; e a inclusão do gerente de atenção básica nas equipes. Conclusões. A implementação da nova PNAB, fruto de disputas travadas no campo da gestão interfederativa, dependerá da confluência de interesses no sentido da efetivação de uma atenção primária acessível e resolutiva, fortalecendo o Sistema Único de Saúde, o que requer substancialmente a participação e o protagonismo da sociedade na luta pelo direito à saúde no Brasil.(AU)

Objective. To describe and discuss events associated with the latest review of the national primary health care (PHC) policy in Brazil (Política Nacional de Atenção Básica, PNAB) so as to highlight narratives that may contribute to future analyses focusing on the formulation, implementation, and assessment of this policy. Method. Participant observation report of the PNAB review process, based on content and document analyses. Results. The review process of PNAB, which took place between 2015 and 2017, was strongly marked by technical and political dispute among the Ministry of Health and authorities representing municipal and state health departments. The main changes introduced by the new version of PNAB are the financing of other PHC organizational models in addition to the Family Health Strategy; attribution of additional responsibilities to community health agents; introduction of a national set of core and extended PHC services and actions; and introduction of a manager role as part of PHC teams. Conclusions. Implementation of the revised PNAB, which was the result of interfederation dispute, will depend on the convergence of interests in a PHC that is accessible and effective, strengthening the Unified Health System. This will substantially require societal engagement and leadership in the fight for the right to health in Brazil.(AU)

Objetivo. Presentar y discutir los acontecimientos relacionados con el proceso de revisión de la Política Nacional de Atención Básica (PNAB) en Brasil, de manera de obtener información que pueda contribuir a futuros análisis sobre la formulación, implementación y evaluación de esa política. Métodos. Se evaluó el relato de la experiencia de los participantes del proceso de revisión de la PNAB a partir del análisis de contenido, complementado por un análisis documental. Resultados. El proceso de revisión de la PNAB, que tuvo lugar entre 2015 y 2017, presentó marcadas disputas técnico-políticas entre el Ministerio de Salud y las instancias representativas de las secretarías municipales y estatales de salud. Los principales cambios introducidos por la nueva versión de la PNAB son la posibilidad de financiamiento de otros modelos de organización de la atención básica además de la Estrategia Salud de la Familia, la ampliación de las atribuciones de los agentes comunitarios de salud, la construcción de la oferta nacional de servicios y acciones esenciales y ampliadas de atención básica, y la inclusión del gerente de atención básica en los equipos. Conclusiones. La implementación de la nueva PNAB, fruto de las disputas entabladas en el campo de la gestión interfederativa, dependerá de la confluencia de intereses hacia la efectivización de una atención primaria accesible y resolutiva, fortaleciendo el Sistema Único de Salud, lo que requiere la participación y el protagonismo de la sociedad en la lucha por el derecho a la salud en Brasil.(AU)