COVID-19 and the Code: Revisiting the Philippine Experience

The Code was adopted by the World Health Assembly (WHA) in 1981 “to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, based on adequate information and through appropriate marketing and distribution” (WHO, 1981). According to the Code, a breast-milk substitute means any food being marketed or otherwise presented as a partial or total replacement for breast milk, whether or not suitable for that purpose. In effect, it bans the promotion to the general public of all milk products that may replace breast milk in the first three years of life. Formula feeding, on the other hand, refers to the infant consumption of breast milk substitutes. 

Ratifying the Code is an economically sound policy because formula milk is more expensive compared to breast milk—a natural, free, and species-specific source of infant nutrition and health. Moreover, formula feeding has been associated with suboptimal breastfeeding practices among lactating mothers, resulting in an increased incidence of malnutrition and diarrhea among infants (Victora et al., 2016). A 2005 estimate by the United Nations Children’s Fund (UNICEF Philippines, n.d.) underscored the costs of formula feeding for the families and the Philippine economy. Formula feeding is valued at an average of USD 100 a month per infant and Filipinos spend almost USD 1 billion a year with prices adjusted for inflation. It also requires sterile water and shall be administered immediately to prevent contamination. To save on expenses, some families dilute the formula or use other kinds of milk (including condensed milk) leading to malnutrition, illnesses, and death.

There are hidden costs which include physician’s consultation, medicines, and hospitalization, often unaccounted to the burden of formula feeding. The costs of outpatient treatment for acute respiratory infections caused by formula feeding amount to USD 1.37 million per year, while hospitalization is worth USD 640 thousand annually (UNICEF Philippines, n.d.). The parents also have to miss working days resulting in loss of income. The total lost wages due to tending formula-fed children for diarrhea and acute respiratory infections during the first six months of life is USD 20 million. Funeral costs associated with child deaths due to formula-feeding and other inappropriate infant feeding habits sum up to USD 13 million.

Formula feeding is also detrimental to the environment because of the huge amounts of waste it generates: cans, cartons, feeding bottles, and teats. The limited milk production in the Philippines necessitates importation to meet the demand for breast milk substitutes. The country’s National Dairy Authority reported that the amount of imported milk rose to a record-high of USD 1.13 billion in 2019 (Arcalas, 2020). These indirect costs suggest that the Code is a value-for-money intervention every nation can adopt.

As of 2018, only 35 out of 194 countries fully implement the Code after almost 40 years since the WHA adoption (WHO, 2018). In Southeast Asia, only the Philippines and Thailand have full Code provisions covered in law (see Table 1). The Philippines is among the first countries that took immediate action after the WHA Resolution 34.22 by transforming the Code into national law. It is important to note that the Code was adopted as a recommendation rather than regulation, hence, it did not readily “come into force” for member states. The crux is that the Philippine version of the Code is not dependent on the age of the child but the kind of product being marketed to the public.