PHM-Exch> Comment on the DRAFT FOR CONSULTATION;“INVESTING IN OUR COMMON FUTURE” by UN Secretary-General Ban Ki-moon

[Claudio Schuftan]

*Comment on the DRAFT FOR CONSULTATION;“INVESTING IN OUR COMMON FUTURE”
Joint Action Plan for Women’s and Children’s Health by UN Secretary-General
Ban Ki-moon *

* *

*Accessed on June 22, 2010*

*http://www.who.int/pmnch/topics/maternal/201006_jap_pamphlet/en/index.html*

* *

The UN Secretary-General Ban Ki-moon’s  “Joint Action Plan for Women’s and
Children’s Health” is a very welcome step and so is the consultative process
to invite comments from all including the governments and civil society. The
plan is rightly focused on women’s and children’s health to achieve health
related MDGs in developing countries.  Since it will be a major fundraising
initiative, and has the potential to galvanize/revitalize action, we wish to
state some of our concerns, which could be addressed in the final document.



*Concerns: *



1.         The Joint Action Plan relies on the 2009 Consensus on Maternal,
Newborn and Child Health,
http://www.who.int/pmnch/topics/maternal/consensus_12_09.pdf, however it
needs to harmonize in outputs with the Plan especially to focus on
*infancy*as infants are at a greater risk,
*and ‘ improved child nutrition’ as has been in the Consensus 2009. *.
Specifics suggestions are provided in the end to achieve this.



2.         There is need to bring in the Human Rights Framework; the UN
General Assembly report A/HRC/13/32, of 22nd February 2010, notes this
concern too.  “…In addition to the International Covenant on Economic,
Social and Cultural Rights, the CRC establishes the international protection
and care framework for children. Seen in line with food, health and care as
three conditions to achieve nutritional security, the Convention includes
provisions that protect the right to nutrition. Reality remains nonetheless
bleak. In 2008, 8.8 million children born across the world died before their
fifth birthday. More than one third of child deaths worldwide are attributed
to malnutrition”.



3.         The document misses the critical need to implement policies
required for child nutrition for example, enactment of the International
Code of Marketing of Breast- milk Substitutes and Maternity Protection for
women has been emphasized by the PMNCH Countdown 2010 report.



4.         This Plan lacks recognition of the fact that suboptimal
breastfeeding during first six months, as a major cause of child mortality.
To focus on infancy has been clearly recognized by the World Health Assembly
in its adoption of the Global Strategy for Infant and Young Child
Feeding[1]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftn1>,
in 2001, which says 2/3rd of all child deaths, are related to inappropriate
feeding practices and occur during first year of life. With more than half
of these deaths in the first month or so, it is imperative to focus during
first year.Further the World Health Assembly resolution 63.23 also
recognizes the fact that “inappropriate feeding practices and their
consequences are major obstacles to attaining sustainable socioeconomic
development and poverty reduction;” and that “the improvement of exclusive
breastfeeding practices, adequate and timely complementary feeding, along
with continued breastfeeding for up to two years or beyond, could save
annually the lives of 1.5 million children under five years of age;”



5.         Outputs in the Plan lack a focus on underlying social
determinants and other factors such as women’s status,  sanitation and safe
drinking water is lacking in the document.



6.         Family level/home based interventions are totally missing.



7.         Creating support systems for women is missing.



8.         Though the joint plan notes that funding should not be
fragmented, there should be one national plan, which is country led,
according to ACCRA Declaration, but outputs reveal a focus on new vaccines,
and supplements for nutrition, which was not a part of the Consensus of
2009, and is rather prescriptive. On nutrition, supplements alone are only a
part of the answer to address malnutrition that begins before birth and
during the period of  complementary feeding. Reducing common illnesses
through exclusive breastfeeding is perhaps the most important way to avoid
under- and over-nutrition.



9.         In the funding graphs, nutrition segment is not visible, in the
top set of interventions, is it an error /chance?



*Our inputs /Comments and the rationale*

* *

*In June 2010, The MDG
Report[2]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftn2>2010
notes that
*



“…Halving the prevalence of underweight children by 2015 (from a 1990
baseline) will require accelerated and concerted action to scale up
interventions that effectively combat undernutrition. *A number of simple
and cost-effective interventions at key stages in a child’s life could go a
long way in reducing undernutrition, such as breastfeeding within one hour
of birth, exclusive breastfeeding for the first six months of life, adequate
complementary feeding and micronutrient supplementation between six and 24
months of age…” (Emphasis Added)*





*In May 2010, the World Health Assembly adopted a resolution 63.23 on Infant
and Young Child Nutrition, *

* *

*It calls upon Member States *



“…..to scale up interventions to improve infant and young child nutrition in
an integrated manner with the protection, promotion and support of
breastfeeding and timely, safe and appropriate complementary feeding as core
interventions…”;



“…*to end inappropriate promotion of food for infants and young children and
to ensure* that nutrition and health claims shall not be permitted for foods
for infants and young children, except where specifically provided for, in
relevant Codex Alimentarius standards or national legislation; (emphasis
added)



*Further the Resolution *

“..CALLS UPON infant food manufacturers and distributors to comply fully
with their responsibilities under the International Code of Marketing of
Breast-milk Substitutes and subsequent relevant World Health Assembly
resolutions;…”



*Similarly again in May 2010, the World Health Assembly adopted another
resolution 63.15 on ‘Monitoring of the achievements of the health related
Millennium Development Goals’ calls upon Member States *



“..to renew their commitment to prevent and eliminate maternal, newborn and
child mortality and morbidity: through an effective continuum of care,
strengthening health systems, and comprehensive and integrated strategies
and programmes to address root causes of gender inequalities and lack of
access to adequate care and reproductive health, including family planning
and sexual health; by promoting respect for women’s rights; and *by scaling
up efforts to achieve integrated management of newborn and child health
care, including actions to address the main causes of child mortality, in
particular through interventions that increase rates of exclusive and
sustained breastfeeding;…..” (Emphasis added)  *



*The Countdown to 2015, Maternal, Newborn Child Survival, Report monitors 20
core interventions was released in May 2010.* .
http://www.countdown2015mnch.org/documents/2010report/CountdownFlyerHeadlinesEnglish.pdf.
Early and exclusive breastfeeding for the first six months, as well as
complementary feeding are a part of this list. It is therefore necessary to
be consistent what interventions concerning ‘improving child nutrition’ that
was mandated in the Consensus 2009.  *See below Fig 1* on the coverage of
postnatal interventions in the Countdown to 2015 report. The care indicators
like early and exclusive breastfeeding for the first six months and
postnatal visits at the lowest end among all that is counted.



This is sufficient justification to scale up action towards supporting women
for breastfeeding to get higher and then a universal coverage. Earlier
Countdown reports of the year 2005 also highlight these nutrition indicators
more clearly and call for policy support to nutrition through International
Code of Marketing of Breast- milk Substitutes, and BFHI.



*In October 2009 an expert working on Countdown to 2015 argues,* “Despite
the importance of nutrition in early life for adult health and human
capital, this topic has received little international funding, especially
when compared with large investments for the control of other diseases.
Furthermore, the limited funding for combating undernutrition is dominated
by programmes for food aid and micronutrient supplementation. Although such
programmes have a definite role in some circumstances, one would also like
to see strong investments in community-based approaches—e.g., the promotion
of breastfeeding and appropriate complementary foods—which have
well-established effects on child survival and nutritional status.” (
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61725-6/fulltext
).



*In 2008, evidence was presented by Lancet* and based that increasing
exclusive breastfeeding rates* *is the most effective intervention as
concluded by the Lancet series  (
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61693-6/fulltext
).  .

Lancet also brings to light that support to early and exclusive
breastfeeding during the first 6 months is very crucial to achieve MDG 4, as
suboptimal breastfeeding during this period contributes to the 1.06 million
children deaths and 43 million DALYS.



*The State of Breastfeeding in 33 Countries 2010*

One of IBFAN’s recent
assessments[3]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftn3>in
33 countries of policies and programmes to support women to
breastfeed,
demonstrate significant gaps in policy adoption and programme implementation
(http://www.worldbreastfeedingtrends.org/index.php). It takes a lot to
increase exclusive breastfeeding rates, apart from a skilled health worker,
access to skilled counseling on breastfeeding, support at work places,
maternity entitlements, implementation of the International Code of
Marketing of Breast- milk Substitutes, and special support to women with HIV
infection, and women facing disasters and emergencies*. *When it comes to
complementary feeding it requires food security at household level in
addition to counseling.



An important understanding needs to get in our heads: for initiating
breastfeeding within one hour, it’s only one sector that comes into play,
the health sector. For exclusive breastfeeding for the first six months to
go up, many other sectors like labour, national policy and planning, HIV,
disaster management, have to come into play. Within the health sector
‘breastfeeding counseling’ has been found to be “…According to strict
criteria around admissible evidence, breastfeeding counseling, vitamin A
supplementation, and zinc fortification have the greatest
benefits……”[4]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftn4>.
“Breastfeeding Counseling” is a very special skill aimed at building
confidence of women, as human milk production and flow is government by
hormones, which are dependant on mother’s state of mind and suckling
stimulus by the baby.



An economist Prof. Abhijit Sen, Member Planning Commission of India said
recently, and said it
[5]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftn5>all,
"...The right to food should apply to a complete diet, not just one or two
items.  It is about nutrition in its entirety. And nutrition, which we are
hugely lacking, is not simply about food or what you eat, its as much about
water, health, most importantly its about what happens just after birth, the
first one hour, the first two years. The government cannot promise that
people will breastfeed their children. But what it should promise is a
government support system for a whole aspect of nutrition which it will
provide....."



Finally, in April 2010, a 6
country[6]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftn6>programme
review by UNICEF led to the recommendation to ..”Develop
and implement a comprehensive IYCF strategy for implementation at scale ….The
Global Strategy for IYCF lays out a comprehensive framework, yet the
tendency is to focus on one or two of the components. Piecemeal approaches
and ad hoc activities leave major barriers to improved practices unaddressed
and fail to reach critical populations.”



*All this action requires funds**. Therefore it needs to be highlighted in
the Joint Action Plan *The UN Secretary-General Ban Ki-moon’s Joint Action
Plan for Women’s and Children’s Health has the potential to make things
happen, It is, therefore, very crucial for the Joint Action Plan to make a
explicit reference to creating support systems for women to succeed in
breastfeeding, along with budgetary provisions.



The Breastfeeding Promotion Network of India (BPNI) is pleased to provide
comments for incorporation in the Plan.  Specifically, our comments are
directed at the inclusion of Public Support systems for women for increasing
the rates of exclusive breastfeeding during the first 6 months in target
countries.  This is an important step to be specifically included in the
interventions listed in the plan, as it requires significant funding through
increased understanding of the donor community. **

* *

*Specific comments on the Joint Action Plan document for additions/deletions
*

* *

*1. *On page 2 Box, on MDG 4, it would be appropriate to add a bullet that “
Suboptimal breastfeeding during first six months is related to 1.06 million
child deaths and 43 millions DALYs. (Evidence from Lancet data).



2. On page 2, on MDG 4: DELETE REFERENCE TO IMMUNIZATION IN THE FIRST
BULLET, for example could be “ improving early nutrition”.



3. On page 3 include a Para on “Investing on Early Nutrition” (Para draft
provided for consideration)



4. On page 4 in Figure 1, in the box on interventions add as a second
bullet:

“Improved child nutrition” to be consistent with the Consensus statement
2009.



5. On Pg.5 – ‘Investing to reach our common goals’.

In Para 1, line 6, add after children’s health, such as…  *“Increasing the
rates of exclusive breastfeeding in these countries” This is logical to the
above. *

* *

6. On Page 6, under the What the ‘Investment will achieve’, add another
bullet,

·       Breastfeeding Counseling made available to millions of women and
families.

·       Millions of women are supported at work …(This is where employers
can contribute)



7. On page 9, under the Government and policymakers add bullets



“ Promote home based care services for infants and young children” and

“Enact International Code of Marketing of Breast- milk Substitutes and
relevant World Health Assembly resolutions”



8. On page 10 under the Private Sector Add a bullet: “ baby food industry
should not promote  ‘breast-milk substitutes’ or ‘infant foods/cereal foods
meant for infants and young children including making use of health claims,
and  ‘Implement International Code of Marketing of Breast- milk Substitutes
and relevant World Health Assembly resolutions’ as per the call of the World
Health Assembly  through Resolution 63.23



In nutshell, an explicit reference is required among interventions/ outputs
 “ Supporting policies and programmes to support women in order to enhance
feeding early and exclusive breastfeeding for the first six months and
complementary feeding”, or simply “Support to implementing a plan of action
based on the Global Strategy for Infant and Young Child Feeding”.

------------------------------

[1]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftnref1>
http://www.ibfanasia.org/docs/gs_iycf.pdf

[2]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftnref2>

http://www.un.org/millenniumgoals/pdf/MDG%20Report%202010%20En%20r15%20-low%20res%2020100615%20-.pdfAccessed
25 June 2010

[3]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftnref3>
A
report in preparation “ State of Breastfeeding in 33 Countries: Tracking
Infant and Young Child Feeding Policies and Programmes Worldwide” as a part
of the programme for the global Breastfeeding Initiative for Child Survival
(gBICS) www.ibfan.org,



[4]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftnref4>Maternal
and Child Undernutrition: Comment in Lancet January 2008. Accessed
June 25, 2010 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)
61869-8/fulltext

[5]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftnref5>
http://www.civilsocietyonline.com/jun10/jun104.asp

[6]<https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#_ftnref6>
http://www.unicef.org/nutrition/files/IYCF_Booklet_April_2010_Web.pdf
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