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.

Can Results-Based Financing improve health outcomes in resource poor settings? Evidence from Zimbabwe

Result Based Financing (RBF) has been implemented in health systems across low and middle-income countries (LMICs), with the objective of improving population health. Most evaluations of RBF schemes have focused on average programme effects for incentivised services. There is limited evidence on the potential effect of RBF on health outcomes, as well as on the heterogeneous effects across socio-economic groups and time periods. This study analyses the effect of Zimbabwe's national RBF scheme on neonatal, infant and under five mortality, using Demographic and Health Survey data from 2005, 2010 and 2015. We use a difference in differences design, which exploits the staggered roll-out of the scheme across 60 districts. We examine average programme effects and perform sub-group analyses to assess differences between socio-economic groups. We find that RBF reduced under-five mortality by two percentage points overall, but that this decrease was only significant for children of mothers with above median wealth (2.7 percentage points) and education (2.1 percentage points). RBF increased institutional delivery by seven percentage points – with a statistically significant effect for poorer socio-economic groups and least educated. We also find that RBF reduced c-section rates by three percentage points. We find no detectable effect of RBF on other incentivised services. When considering programme effects over time, we find that effects were only observed during the second phase of the programme (March 2012) with the exception of c-sections, which only reduced in the longer term. Further research is needed to examine whether these findings can be generalised to other settings.

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Zimbabwe's national Results Based Financing scheme decreased under-five mortality.

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Among higher wealth and education groups.

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RBF increased institutional deliveries in the poorest and least educated groups and reduced the rate of c-section.

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There were no programme effects on other incentivised services.

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The RBF programme effects generally appear to be stronger earlier in the implementation process.

Post-acute care for children with special health care needs

BACKGROUND

Almost all studies of post-acute care (PAC) focus on older persons, frequently those suffering from chronic health problems. Some research is available on PAC for the pediatric population in general. However, very few studies focus on PAC services for children with special health care needs (SHCN).

OBJECTIVE

To investigate factors affecting the provision of PAC to children with SHCN.

METHODS

Pooled cross-sectional data from Texas Department of State Health Services hospital discharge database from 2011-2014 were analyzed. Publicly available algorithms identified chronic conditions, complex chronic conditions, and the principal problem leading to hospitalization. Analysis involved estimating two logistic regressions, with clustered robust standard errors, concerning the likelihood of receiving PAC and where that PAC was delivered. Models included patient characteristics and conditions, as well as hospital characteristics and location.

RESULTS

Only 5.8 percent of discharges for children with SHCN resulted in the provision of PAC. Two-thirds of PAC was provided in a health care facility (HCF). Severity of illness and the number of complex chronic conditions, though not the number of chronic problems, made PAC more likely. Patient demographics had no effect on PAC decisions. Hospital type and location also affected PAC decision-making.

CONCLUSIONS

PAC was provided to relatively few children with SHCN, which raises questions concerning the potential underutilization of PAC for children with SHCN. Also, the provision of most PAC in a HCF (66%) seems at odds with professional judgment and family preferences indicating that health care for children with SHCN is best provided in the home.