Brazil at the CRC: Need of Regulatory Decree to Enforce the Code

On September 21 and 22, the Committee on the Rights of the Child considered the combined 2^nd to 4^th periodic report of Brazil on the situation of the implementation of the Convention on the Rights of the Child in the country. 

On this occasion, IBFAN presented an alternative report to inform the CRC Committee on the situation of infant and young child feeding in Brazil.

General overview of breastfeeding in Brazil

IBFAN highlighted that high rate of maternal mortality in Brazil, while the rates of exclusive breastfeeding and continued breastfeeding at 2 years are low. Besides, IBFAN expressed concern about the lack of systematic and regular monitoring of breastfeeding indicators.

Besides, the pre-service training curricula should be reviewed and updated according to the scientific evidence and WHO recommendations. In addition, the practical teaching of clinical management of breastfeeding and healthy complementary feeding should be improved, and health professionals should be properly trained on implementation and enforcement of the International Code of Marketing of Breastmilk Substitutes (hereafter: the Code).

IBFAN also noted that the protection of breastfeeding is insufficient due to the lack of enforcement of the Law 11-265 of 2006 implementing the Code. Therefore, the adoption of a regulatory decree is needed. 

IBFAN further highlighted that women working in the informal sector are not cover by the maternity leave. It also emphasized the small number of "baby-friendly" hospitals (about 9% of all health facilities) of which less than 50% showed to comply with the UNICEF 10 Steps to Successful Breastfeeding and the International Code of Marketing of Breastmilk Substitutes. Only 30% of children are born in an accredited Baby-Friendly Hospital.

Finally, there is no dialogue within the Ministry of Health between the department in charge of Children’s Health and Nutrition and the department in charge of HIV/AIDS, and there is no strategic action plan on infant and child feeding in emergencies.

Discussion on infant and young child feeding

The CRC Committee began by congratulating the state party on the progress achieved in terms of basic health services, but it noted that progress tis still to be made, in particular by improving the access to health services in rural areas. It highlighted that 10% of children have stunted growth and that child obesity rate has increased. The Committee also questioned the number of health personnel in hospitals and the quality of their training. It also mentioned the long queues of patients waiting to access hospital services and the medical errors that occurred in emergency departments. The Committee finally expressed concerns about the high rates of maternal and child mortality as well as about the rate of caesarean sections.

Regarding basic health care services, the Brazilian delegation answered that despite 40,000 basic health care units providing health services for free, the number of doctors is still insufficient. Therefore, the government launched the "More Doctors" programme and hired Cuban physicians to reinforce basic health care units. In addition, the delegation noted that child malnutrition decreased from 14% in 1990 to 1.7% in 2012. However, there is still a significant number of cases of malnutrition, especially among indigenous children. Indigenous population also shows higher child mortality rates than in the average population. For these reasons, the government has allocated more doctors in indigenous areas. 

In its follow-up questions, the Committee noted that Brazil has not yet ratified the ILO Convention No. 183 and asked whether the government plans to ratify it. Indeed, the Committee highlighted that such ratification could help improving the situation of working women, allowing them to continue breastfeeding. The Committee mentioned the Brazilian exemplary Law 11-265 of 2006 implementing the Code. However, it noted with concern the lack of a regulatory decree to enforce the law. Finally, the Committee asked how many hospitals comply with the UNICEF 10 Steps to Successful Breastfeeding.

The delegation admitted that 51% of the population is overweight (35% of boys and 32% of girls) and ensured the Committee that measures have been adopted to tackle this issue, including measures to promote breastfeeding and healthy eating habits for pregnant mothers and mothers of children under 5 years. A guide which focuses on healthy eating habits has been issued and updated in 2014. Besides, a regulatory decree enforcing the Law 11-265 of 2006 is to be signed in order to regulate the marketing of breastmilk substitutes. The decree is to be launched on the 12 October at the occasion of Children’s Day.

The Committee further asked the delegation to what is done to inform HIV-infected mothers about infant and young child feeding and especially breastfeeding. The delegation answered that the national policy on HIV/AIDS and breastfeeding provides that infected women should refrain from breastfeeding. Therefore, the government allocates them financial support to buy infant formula.

Concluding Observations

In its Concluding Observations, the Committee made both indirect and direct recommendations related with infant and young child feeding. It first recommended Brazil to increase investment in existing programmes aimed at improving the reach and quality of health services in order to ensure access to quality health services, particularly for indigenous children, Afro-Brazilian children and children living in rural and marginalized areas (§54) and to strengthen its efforts to ensure that Family Health Support Units (NASF) are accessible for indigenous children was also required (§56b). The Committee also urged the country to provide the Special Secretariat for Indigenous Health (SESAI) with adequate human, technical and resources to guarantee access to quality services for all indigenous population (§56a).

With regard to nutrition, the Committee recommended Brazil to allocate adequate human, technical and financial resources to the Indigenous Nutritional Supervision System (SISVAN) to ensure that children affected by malnutrition receive adequate food and safe drinking water (§56c).

After expressing concerns on the high level of obesity and vulnerability of children to unregulated advertising promoting unhealthy food (§57), the Committee thus recommended the State party to take all necessary measures to address obesity, promote healthy lifestyles, raise awareness of health nutrition and establish a regulatory framework from advertising in order to control misleading advertising (§58).

The Committee also highlighted the increase in new HIV infections among adolescents (§61), recommending Brazil to improve access to quality, age appropriate HIV/AIDS, sexual and reproductive health services (§62a). With regard to children and business sector, the Committee specifically recommended Brazil to establish a regulatory framework for the impact of business sector on children’s right particularly the mining and construction sector, agribusinesses, food enterprises to ensure that their activities do not affect human rights (§22a). Likewise, it recommended the state party to ensure effective implementation by companies of international and national environment and health standards and appropriate sanctions or remedies when violations occur (§22b) as well as full disclosure of the environmental, health and human rights impacts of company’s business activities and their plans to address such impacts (§22c).

With reference to environmental health, the Committee recommended the state party to ensure the enforcement of existing laws and regulations concerning the use of agrochemicals (§66a) and improvement of water supply infrastructure (§66b), and to raise awareness programmes for communities living in affected areas to minimize the risks of being exposed to contaminated water and food (§66d).

Finally, regarding breastfeeding promotion, the Committee urged Brazil to improve the practice of exclusive breastfeeding for the first six months of age through awareness-raising measures including campaigns, information and training  for relevant officials, in particular staff working in maternity units and parents as well as to strengthen the monitoring of existing marketing regulations relating to breast milk substitutes (§68). 

Update 4 November 2015: The President of Brazil signed the regulatory decree related to the Law 11-265 of 2006 and thus, allowed full enforcement of the law implementing the Code.

69th Session of the CRC Committee: Recommendations related to Breastfeeding

The 69^th Session of the Committee on the Rights of the Child (CRC Committee) took place in Geneva from May 18 to June 5, 2015. The Committee reviewed the progress of the implementation of the Conventionon the Rights of the Child in 6 countries: Eritrea, Ethiopia, Ghana, Honduras, Mexico and Netherlands. IBFAN submitted alternative reports on the situation of infant and young child feeding in 5 of the reviewed countries (Ethiopia, Ghana, Honduras, Mexico, and Netherlands).   The reports on Ethiopia, Ghana, Honduras, Mexico and Netherlands were prepared by the IBFAN groups in the countries. Spanish and French summaries of the alternative reports were prepared in order to inform Spanish- and French-speaking members of the Committee (see http://ibfan.org/reports-on-the-un-committee-on-the-rights-of-the-child).

In its Concluding Observations, the CRC Committee referred specifically to breastfeeding for 2 of the 6 countries under review (Ethiopia, Ghana and Mexico). Honduras and Netherlands did not receive any direct recommendation on breastfeeding, but they received recommendations on other specific health issues that are indirectly connected to breastfeeding.

General measures of implementation

The Committee has put an emphasis on the improvement of the data collection system in 5 of the countries under review (Ethiopia, Ghana, Honduras and Netherlands) stressing the importance of collecting disaggregated for the the analysis on the situation of all children, particularly those in situations of vulnerability.

Then, a great focus was placed on the need to regulate the impact of the business sector on children’s rights. In its recommendations to Ethiopia, Ghana, Mexico and Netherlands, the CRC Committee expressly drew attention to its 2013 General Comment N° 16 on State obligations regarding the impact of the business sector on children’s rights, which specifically calls on States Parties to establish a clear regulatory framework on business conduct to ensure that the business sector do not have an adverse impact on child rights, imposing sanctions and providing remedies, when any violation occurred. Moreover, these four reviewed countries are recommended to require companies to undertake assessments, consultations, and full public disclosure of the environmental, health-related and human rights impacts of their business activities and their plans to address such impacts.

Regarding environmental health, the Committee recommended Mexico to require companies to assess air, water, soil and electromagnetic pollution on children and maternal health as a basis to design a well-resourced strategy to remedy the situation, prohibit the import and use of pesticides or chemicals and examine and adapt its legislative framework to ensure the legal accountability of business enterprises involved in activities having a negative impact on the environment. 

Health resources and budget

The Committee called for strengthening of resources allocated to health by urging Ethiopia, Ghana, Honduras and Mexico to increase their allocations in the area of health to adequate levels. Likewise, the Committee urged Ethiopia to develop and implement policies to improve health infrastructures.

In particular, the Committee recommended Honduras to allocate adequate human, technical and financial resources to its immunization programme.

Preventive health

The importance of preventive health has been highlighted in several recommendations. While Ghana has been urged by the Committee to undertake all necessary measures to reduce mortality rates by improving prenatal care and preventing communicable diseases and finalize and operationalize the National New born Strategy and Action Plan, Netherlands was asked to take measures to prevent infant mortality by providing effective and quality neonatal care services among infants. The Committee also called Mexico to strengthen its efforts to reduce maternal and child mortality.

The need to provide equal access to health services in terms of coverage and quality was also stressed in the recommendations to Ethiopia, Mexico and Netherlands. Drawing attention to its General Comment No 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health, the Committee urged Honduras to progress in the adoption of a primary-health care strategy, allocate adequate resources to the immunization programme and improve the coverage and quality of services, paying particular attention to rural and indigenous neglected populations.

Finally, the Committee recommended Ethiopia, Ghana and Mexico to implement the OHCHR Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce and eliminate preventable mortality and morbidity of children under 5 years of age (hereafter: OHCHR Technical guidance on child mortality), which includes specific recommendations on breastfeeding protection (including the implementation of the International Code) and promotion.

Malnutrition and safe drinking water

The Committee expressed concern over the persistent high rates of malnutrition, therefore, recommended Ethiopia to effectively address malnutrition in terms of stunting, wasting and low weight, particularly in rural and remote areas. Honduras was also urged to intensify its efforts to reduce chronic malnutrition, which affects twice as many children in rural as in urban areas.

In its recommendations to Mexico, the Committee highlighted the need to evaluate the initiatives to reduce malnutrition, overweight and obesity among children, and based on the results draft a national strategy on nutrition, which also includes measures to ensure food security, in particular in rural and indigenous areas. It also encouraged Ethiopia to develop public awareness programmes on food diversity.

The Committee expressed concerns over the significant numbers of overweight and obese children in Netherlands, asking the State to provide access to nutrition education and sufficiently nutritious food to all children in order to promote healthy eating habits.

The Committee also focused on nutrition, recommending Mexico to continue raising awareness at the national, federal and local level on the negative health impacts of processed food, and strengthen regulations to restrict advertising and marketing of junk, salty, sugary and fatty foods and their availability for children. It also called Ghana to expedite the approval of the National Nutritional Policy.

Finally, regarding safe drinking water, the Committee asked Ghana to improve the access to safe drinking water and adequate sanitation facilities by resolutely finalizing and implementing the Water Sector Strategy Development Plan and investment plan and strengthening its efforts to continue implementing the Rural Sanitation Model and Strategy. The Committee also called Honduras for improving the access to water and sanitation in rural, indigenous and Afro Honduran areas.

HIV/AIDS

The Committee addressed the issue of mother-to-child HIV transmission by requesting Ethiopia to take all appropriate measures to prevent it and address geographic disparities regarding HIV infection and access to treatment, by enhancing free access to neonatal care, vaccination, prevention of transmission of HIV/AIDS from mother to child and anti-retroviral therapy. It also called for the improvement of the access to quality, age-appropriate HIV/AIDS, sexual and reproductive health services.

Honduras and Ghana were requested to sustain the measures in place to prevent mother-to-child transmissions of HIV/AIDS and were called to develop a roadmap to ensure the implementation of effective preventive measures. The Committee also recommended them to improve the follow-up treatment for HIV/AIDS-infected mothers and their children in order to ensure early diagnosis and initiation of the treatment, as well as the improvement to access to antiretroviral therapy for children, mothers and pregnant women.

Breastfeeding national strategy

In its recommendation to Ghana, the Committee stressed the need to expedite the approval of the National Nutritional Policy and strengthen monitoring of implementation of the Breastfeeding Promotion Regulation 2000 (BPR), implement a deterrent sanctioning system and ensure the Food and Drugs Authority commitment to enforce the BPR. The Committee also recommend Ghana to finalize and operationalize the National Newborn Strategy and Action Plan.

Breastfeeding protection

The Committee specifically urged Mexico to promote the adequate implementation of the International Code of Marketing of Breast-Milk Substitutes and the Child-Friendly Hospital Initiative.

Breastfeeding promotion

Out of 6 reviewed countries, 3 were recommended to strengthen efforts to promote breastfeeding (Ethiopia, Mexico and Ghana). Ethiopia was encouraged to develop public awareness programmes on the benefits of breastfeeding while Mexico was recommended to increase efforts to promote breastfeeding through educational campaigns and training to professionals. Finally, Ghana was recommended to continue encouraging exclusive breastfeeding for six months with appropriate introduction of an infant diet thereafter, aimed at reducing neonatal as well as under-five mortality.

Breastfeeding support

Following the 69^th Session, no specific recommendations have been issued by the CRC Committee with respect to training on and support to breastfeeding.

Table 1. CRC Committee - Session 69/2015 – Summary of Concluding Observations on IYCF

	Country		IBFAN report	Summary of specific recommendations on IYCF
Session 69 – January 2015	1	Ethiopia (4th-5th periodic report)	yes	Indirect – General measures of implementation (§14, 22c): develop and implement a comprehensive framework of data collection which will cover all areas of the Convention and will be disaggregated […]; develop and implement a comprehensive framework on business conduct in order to ensure that business activities do not have adverse impact on human rights or endanger environmental and other standards, in particular those relating to children and women, and impose sanctions and provide remedies when violations occur. Health (§ 56a,b,c,e): raise the annual per capita expenditure on health and eliminate regional disparities in the provision of health services, including prenatal and postnatal care, immunization coverage […]; implement and apply the OHCHR Technical guidance on child mortality (A/HRC/27/31); develop and implement policies to improve health infrastructures, and intensify training programmes for all health professionals, including the pastoralist health extension workers; effectively address malnutrition in terms of stunting, wasting and low weight, particularly in rural and remote areas HIV/AIDS (§ 58a,d): take all appropriate measures to address geographic disparities regarding HIV infection and access to treatment; improve access to quality, age-appropriate HIV/AIDS, sexual and reproductive health services […]; improve access to quality, age-appropriate HIV/AIDS, sexual and reproductive health services […].   Direct (§ 56c): develop public awareness programmes on food diversity consumption of nutritious food and benefits of breast-feeding and engage with World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF).
	2	Ghana (3rd-5th periodic report)	yes	Indirect – General measures of implementation (§ 16, 20a-b, 50b, 50c, 50f, 50h): […] urges the State party to expeditiously improve its data collection system; establish clear regulations and a nation-wide legislative framework (...) requiring companies operating in the State party to adopt measures to prevent and mitigate adverse child rights impact of their operations in the country; require companies to undertake child rights assessments, consultations, and full public disclosure of the environmental, health-related and child rights impacts of their business activities and their plans to address such impacts […]. Health (§50a,b,c,f,h): allocate sufficient financial and human resources to health services, particularly to child health and nutrition, providing effective access to trained and qualified health care; finalize and operationalize the National New born Strategy and Action Plan; undertake all necessary measures to reduce mortality rates by improving prenatal care and preventing communicable diseases; expedite the approval of the National Nutrition Policy; implement and apply the OHCHR Technical guidance on child mortality (A/HRC/27/31). HIV/AIDS (§54b,d): improve follow-up treatment for HIV/AIDS-infected mothers and their children […]; improve access and coverage of antiretroviral therapy for HIV-infected children, mothers and pregnant women […]. Direct (§ 50d,e):  continue encouraging exclusive breastfeeding for six months with appropriate introduction of an infant diet thereafter, aimed at reducing neonatal as well as under-five mortality; strengthen monitoring of implementation of the BPR, implement a deterrent sanctioning system and ensure the Food and Drugs Authority is committed to enforce the BPR.
	3	Honduras (4th-5th periodic report)	yes	Indirect - General measures of implementation (§ 16a-c): provide the adequate resources for the effective functioning of data collection systems; strengthen the capacity of State institutions to provide pertinent, high quality and timely information; ensure that data covers all areas of the Convention and is disaggregated […]. Health (§61a-c): progress in the adoption of a primary-health care strategy; allocate adequate human, technical and financial resources to the immunization programme; improve coverage and quality of services with particular attention to rural and indigenous neglected populations. HIV/AIDS (§67b-c): sustain measures in place to prevent mother-to-child transmission of HIV/AIDS […]; improve follow-up treatment for HIV/AIDS-infected mothers and their infants […]. Nutrition (§ 69c): intensify its efforts to reduce chronic malnutrition;
	4	Mexico (4th-5th periodic report)	yes	Indirect – Health (§ 48c, e): Evaluate the initiatives taken to reduce malnutrition, overweight and obesity among children and based on the results draft a national strategy on nutrition, which also includes measures to ensure food security, in particular in rural and indigenous areas; continue raising awareness at national, federal and local level on the negative health impacts of processed food including and strengthen the regulations to restrict the advertising and marketing of junk, salty, sugary and fatty foods and their availability for children. Health services (§ 48a,b): ensure the availability and accessibility of quality health services for all children, in particular rural and indigenous children, including by allocation adequate resources; strengthen its efforts to reduce maternal and child mortality, including by implementing the OHCHR Technical Guidance on child mortality (A/HRC/27/31). Environmental health (§52a-c): Assess the impact of air, water, soil and electromagnetic pollution on children and maternal health as a basis to design a well-resourced strategy at federal, state and local levels (...) to remedy the situation and drastically decrease the exposure to pollutants; prohibit the import and use of any pesticides or chemicals that have been banned or restricted for use in exporting countries; examine and adapt its legislative framework to ensure the legal accountability of business enterprises involved in activities having a negative impact on the environment, in the light of its general comment No. 16 (2013) on State obligations regarding the impact of the business sector on children’s rights. Direct (§48d): Increase efforts to promote breastfeeding through educational campaigns and training to professionals, adequately implement the International Code of Marketing of Breast-Milk Substitutes and the Child-Friendly Hospital Initiative.
	5	Netherlands (4th periodic report)	yes	Indirect - General measures of implementation (§17, 23a-b): improve its data collection system. The data should include both qualitative and quantitative indicators and cover all areas of the Convention and should be disaggregated […]; implement regulations to ensure that the business sector complies with international and national human rights […] particularly with regard to children’s rights ; establish a clear regulatory framework for the industries under the State party’s jurisdiction to ensure that their activities both at home and abroad do not negatively affect human rights […]; effective monitoring of implementation of these standards and appropriately sanctioning and providing remedies when violations occur […]. Health (§43a,c,d): take measures to prevent infant mortality by providing effective and quality neonatal and other care services for infants throughout the Kingdom; ensure that all children in the State party have access to free of charge basic health care […]; ensure that children without documentation have access to information on their rights, including their right to basic free health care.   Nutrition (§43b): provide access to nutrition education and sufficiently nutritious food to all children in the State party in order to promote healthy eating habits.
	6	Eritrea (4th periodic report)	no	Indirect - General measures of implementation: (§20a-b, 23a,c) collect data which covers all areas of the Convention and disaggregate them […]; ensure that data collection captures the situation of children in situations of vulnerability […]; take immediate action to allow human rights defenders and civil society organizations […] to exercise their right to freedom of expression, opinion and association without threats and harassment; involve all NGOs working in the field of children’s rights in the development, implementation, monitoring and evaluation of laws, policies and programmes related to children […]. Health (§56a-c,f-g): adopt, implement and monitor relevant national strategies on child health, including a national child survival strategy, a strategy on adolescent health and information services, and on HIV/AIDS, sexually transmitted diseases […]; focus its efforts on reducing disparities in achieving health and nutrition goals […]; intensify nutrition and health intervention targeting children affected by severe malnutrition; continue efforts to translate commitments made in the context of the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA) into results-oriented action, and adequately train health personnel on the reduction of maternal mortality and morbidity; take into account the OHCHR Technical Guidance on child mortality  (A/HRC/27/31) as well as the OHCHR Technical Guidance on maternal morbidity and mortality (A/HRC/21/22). HIV/AIDS (§ 50b): […] support children affected by HIV/AIDS and their families. Direct (§56h): strengthen necessary laws and policies to promote exclusive breastfeeding for 6 months, including through the regulation of marketing of breast-milk substitutes.