The Royal Government of Cambodia has had a longstanding commitment to supporting breastfeeding. Its efforts to promote breastfeeding led to a massive increase in breastfeeding rates from 2000-2010, with the exclusive breastfeeding rate rising from 11% in 2000 to 74% in 2010. Since then, however, progress has stalled and bottle feeding and the use of breastmilk substitutes have risen. The practice of bottle feeding children under 6 months doubled between 2000 and 2005, and again from 2005 to 2010 (3.4% to 7.0% and then 14.3%1). The 2014 Cambodia Demographic and Health Survey revealed that between 2010 and 2014, exclusive breastfeeding during the first six months fell from 74% to 65%.
These concerning trends may be due to the aggressive promotion of breastmilk substitutes by companies. Such promotion violates the Sub-Decree on Marketing of Products for Infant and Young Child Feeding (Sub-Decree 133), Cambodia’s interpretation of the World Health Organization’s (WHO) International Code of Marketing of Breast-Milk Substitutes. ARCH research in Phnom Penh in 2014 found that 86% of mothers reported observing commercial promotions for breastmilk substitutes, 19% reported observing infant and young child food product brands/logos on health facility equipment, and 18% reported receiving a recommendation from a health professional to use a breastmilk substitute.
In 2014, HKI supported the government in conducting a situation analysis to assess awareness and enforcement of Sub Decree 133 by the Ministry of Health and other line ministries within the Government of Cambodia who were charged with its implementation. The study found that overall, awareness was very low and regular monitoring and enforcement were lacking. These findings helped propel the government to action. That same year, a multi-sectoral Oversight Board (OB) was created to better monitor and enforce Sub-Decree 133. The OB is led by the Ministry of Health; however, the four line Ministries (Health, Commerce, Information, and Industry and Handicraft) are also represented by their Secretaries. The group developed guidelines which include monitoring checklists for all relevant institutions at the national and sub-national level involved in the implementation, monitoring, and enforcement of Sub-Decree 133. Per the guidelines, the group needs to report to the Council for the Agricultural and Rural Development (CARD) on progress of enforcement of Sub-Decree 133.
Implementation of the International Code in Cambodia
1981: International Code of Marketing of Breast-milk Substitutes adopted by World Health Assembly
2005: Cambodian Sub-Decree 133 passed
2007: Joint Sub-Decree (Joint Prakas No 061) passed to operationalize the implementation and monitoring of the Sub-Decree 133
2014: Oversight Board established; situation analysis conducted
2015: Terms of Reference for Oversight Board established; implementation guidelines developed for Sub-Decree 133 and Joint Prakas No 061; survey on public awareness of Sub-Decree 133 conducted
2016: Monitoring tools established; trainings, workshops held
2017: Pilot of whole monitoring system (underway)
This past March (2017), the guidelines were put into action in four test-pilot provinces (Battambang, Siem Reap, Sihanoukville and Phnom Penh). CAMCONTROL2 and Department of Drug and Food Safety inspectors carried out inspections, monitoring, and reporting activities in point-of-sale locations (supermarkets, baby shops, pharmacies, etc.). During the inspection visits, inspectors monitored if promotion and labeling violations existed, so that they could report violations to OB for actions. During store visits, Inspectors also provided advice on regulations around sale and promotion of breastmilk substitutes (BMS) under Sub-Decree 133. Ministry of Health National Nutrition Program monitors at the sub-national level (monitoring officers at PHD and ODs) also carried out inspections, monitoring, and reporting activities in health facilities (hospital and health centers etc.).
Civil society organizations, including HKI, are continuing efforts to support the government to effectively monitor and enforce the Code legislation. ARCH is currently supporting supervision visits and monitoring efforts when national level staff/trainers from the relevant line ministries visit the subnational level staff tasked with health facility monitoring and point-of-sale inspections. During these visits, national level staff review and discuss recent monitoring work, review checklists and reports, and help trouble-shoot and encourage efforts. These supervision visits began in March, and additional rounds of visits are scheduled to take place in May, June, July and August 2017.
While Cambodia still has a way to go in terms of having a fully functioning monitoring and enforcement mechanism in place, its recent efforts can serve as a model for other countries seeking to strengthen the Code and improve infant and young child feeding practices.
1Cambodia Demographic and Health Survey, 2000, 2005, 2010, MOP
2Cambodia Import-Export Inspection and Fraud Repression Directorate-General (CAMCONTROL)