Digital Marketing Under The Scanner at WHO: The Case of Breast-Milk Substitutes
Newsletter Edition #256 [The Files In-Depth]
Hi,
Across sectors, regulators are mostly playing catch up in the face of technological change and reduced capacities, while trying to keep pace with corporate strategies aimed at market expansion.
But this becomes even more acute and urgent, when it comes to regulating corporate practices especially when they impact health outcomes.
Today’s edition focuses on a resolution being discussed at the World Health Organization that seeks to address digital marketing, and its impact on information and consumption of breast-milk substitutes.
These efforts also show the crucial role provided by civil society organizations in their support for WHO member states on matters that affect all countries. This assumes even greater significance at a time when WHO is under pressure financially.
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I. FOLLOW UP EB156
Digital Marketing Under The Scanner at WHO: The Case of Breast-Milk Substitutes
By Priti Patnaik & Bhadra G
WHO member states treasure the organization’s norms setting mandate, that has now come under threat as a result of a financing crisis precipitated by the Trump administration, exacerbating the challenges at the chronically under-funded institution.
At the Executive Board meeting last month, countries struggled to reconcile financial realities with the many resolutions that have been proposed. By May 2025, countries will closely monitor the costs of resolutions as a part of a broader exercise of reprioritisation of activities at WHO, in time for adoption at the World Health Assembly.
One of the resolutions being considered by countries is on regulating the digital marketing of breast-milk substitutes. While the costs associated with the resolution is not significant, such an initiative shows the importance of WHO’s norms-setting functions and how it builds on previous efforts.
More importantly, the resolution draws attention to the imperatives for regulation in a context where swiftly changing marketing strategies, often determined by algorithms, result in selling personalized content to vulnerable users.
Work in this area has been initiated for the last several years. Activists and regulators have documented that digital marketing is emerging as a predominant source of exposure to promotion of baby feeding products globally.
In 2022, WHO mapped the cross border extent and power of such marketing approaches in a report on digital marketing of breast-milk substitutes. This has only accelerated with the rise of paid influencers and misinformation undermining recommendations from WHO and national authorities, and disempowering parents, activists say.
WHO followed up the 2022 report with a guidance on regulatory measures aimed at restricting digital marketing of breastmilk substitutes published in November 2023.
The latest resolution takes these efforts further by recognizing the “inappropriate promotion of foods for infants and young children”, and refers to previous commitments by countries to address these matters, by emphasizing expanding the kinds of stakeholders regulators could work with, building on good governance, better monitoring and compliance among other measures.
In this story we take a detailed look at the issues at stake and the efforts made by various stakeholders to address such marketing approaches, as described by WHO. We take a step back and look at an earlier guidance issued by WHO, that helps put in context the importance of this resolution.
International Baby Food Action Network, (IBFAN), an international coalition working on maternal and infant and young child health through the protection, support and promotion of breastfeeding, said at the Executive Board meeting last month:
“IBFAN welcomes the draft Resolution and urges all to support it. Mothers are being bombarded by misleading marketing online. In one click health authority advice is disregarded. This has long-term consequences for child health and survival. There are 144 national laws based on the International Code and when these are enforced breastfeeding rates improve. However, many laws do not include the 20 resolutions that keep pace with new marketing strategies and the ultra-processed products for children that are causing so much harm. There is no need for significant resources to enforce this Resolution. Governments must allocate specific legal duties to the social media platforms and service providers who have control over their content. Governments must follow the WHO Guidance that this Resolution is about.”
The group also said that there is no need for governments to expend significant resources to enforce every violation.
“The other actors in the digital supply chain have control over monitoring the content on their platforms and in many countries already do so for other regulated marketing practices and products such as pharmaceutical, tobacco, alcohol as well as intellectual property infringements etc. The approach set out in the WHO Guidance is not new or practically difficult to implement, but is very important to implement as soon as possible,” a statement from IBFAN said.
THE RESOLUTION
The resolution focuses on the marketing of breast-milk substitutes, feeding bottles and teats, and recognizes “inappropriate promotion of foods for infants and young children”.
(Foods for infants and young children are defined as commercially produced food or beverage products that are specifically marketed as suitable for feeding children from the age of 6 months to 36 months, accordingly with the Guidance on ending the inappropriate promotion of foods for infants and young children.)
It refers to the United Nations Convention on the Rights of the Child, under which 196 States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health, and emphasis on breastfeeding under Article 24 of the Convention.
It notes the “interference of marketing by breast-milk substitute manufacturers and distributors” is relevant for the implementation of States Parties’ commitments under the United Nations Convention on the Rights of the Child.
It takes into account the evidence on the marketing of breast-milk substitutes, “including recognizing that digital technologies have created powerful new marketing tools for the promotion of breast-milk substitutes, and the needs to strengthen the implementation of the International Code of Marketing of Breast-milk Substitutes”.
On digital marketing, the resolution makes note of personalized content. The resolution says that digital marketing, including influencer marketing, “has become the dominant form of marketing in many countries; that when not effectively regulated, it leads to harmful impact on public health; and that parents and caregivers in every country of the world are exposed to direct and indirect promotions of breast-milk substitutes.”
It recognizes that “effective application of the International Code of Marketing of Breast-milk Substitutes to digital environments requires the development of national regulatory mechanisms, coordination across a broader set of government bodies within Member States, as appropriate, and between Member States, as appropriate, and the establishment of specific legal duties on the range of entities involved in digital marketing, including influencer marketing, along with effective, proportionate deterrent sanctions and disincentives for non-compliance with any established mandatory regulatory measures.”
It emphasizes good governance measures, noting the limitation of voluntary approaches and stresses the “the importance of ensuring that effective monitoring and enforcement systems are developed to function in a transparent and independent manner that is free from commercial influence.”
The operative paragraphs asks member states to put in place regulatory measures to oversee such marketing approaches; strengthen their monitoring systems and technologies to identify and report on marketing of breast-milk substitutes and foods for infants and young children; empower government agencies to implement and monitor the various agreed upon strategies to address these issues; and to safeguard against conflicts of interest in the development, implementation, monitoring and evaluation of regulatory measures.
It also seeks the role of civil society and regional economic integration organizations in these efforts. The resolution directs that WHO provide technical support to countries as requested, and compile these efforts and report back to the Eighty-first World Health Assembly on the progress.
THE NEED FOR SUCH A RESOLUTION
At a webinar organized by the Geneva Global Health Hub in January 2025, ahead of the WHO Executive Board meeting, Patti Rundall, Policy Director, IBFAN Global Advocacy discussed the efforts towards the resolution with WHO official Lawrence Grummer Strawn, from the WHO Department of Nutrition and Food Safety, , among other participants. We present a gist of the context provided by Strawn of WHO in a detailed presentation on the matter.
The report on digital marketing of breast-milk substitutes
In 2019, as a part of the report on the International Code of Marketing of Breast-milk Substitutes (adopted in 1981), WHO raised the concern to the World Health Assembly, that it witnessed the “growing use of digital tools for the promotion of breast milk substitutes”, an area that was not adequately covered in the current regulations.
In response to a request made by member states, WHO filed a report on the scope and impact the digital marketing strategies for the promotion of breast milk substitutes.
The report found that digital marketing of these products had become the dominant form of marketing in many countries, and such strategies went beyond occasional appearances on social media or on the internet, “exploiting mothers' vulnerabilities and fears.”
Strawn explained: “It's not just a matter of putting an ad that they might see on a billboard in the past or in the newspaper, but in fact, as it has been building upon the vulnerabilities that mothers might have and their fears, and can be particularly targeted with personalized data. Algorithms get quite sophisticated, the mother might be doing something like a search on, “how do I know if I'm producing enough milk for my baby?” And this gets processed as, this is a woman, and it would be acceptable to give her an ad about why she needs our formula to top off her own milk supply. And so, they can actually become very personalized at that level.”
He pointed out that this kind of marketing is extremely cost effective, and can turn that into sales immediately. It's often not recognized as advertising. “We know what we're dealing with here, but it comes through as just an advice that they're getting or information. It's often seen as someone being helpful, when in fact, it is a way of promoting breast milk substitutes, and as such, is often below the radar of regulators. It's not even something that they're looking for or recognizing. This is something that we ought to be regulating, because this is really, sliding under the radar screen,” he said.
Digital marketing as different from traditional marketing
The Code was adopted in 1981, when video sharing or games, apps did not exist. These recent ways of sharing information through networks, now provides opportunities for marketing, authorities observe.
“There are new strategies that have taken over, and now, it [is] used for promotion of a specific product, we increasingly see product lines cross promotions, where you don't even need to talk about the product that you're promoting a breast milk substitute, but you talk about some other products, but it has a crossover because of similar logos, similar look and feel, that actually does have the effect of promoting breast milk substitutes,” he explained.
Companies also use influencer marketing, where the person promoting the product may not be directly paid by the company, but actually is able to make profits because of the kinds of information that they are sharing, or their opinions that they are reflecting, that they are getting recompensed in various ways to push this kind of information forward, the WHO official pointed out.
Traditionally, a manufacturer would hire a promotion firm or an ad firm, and get information on products out on their behalf. There is now a much more complicated spectrum of a whole system that works on the targeting of these ads, collecting the information about potential users, and process it in a way that can then facilitate the targeting that is going on, those that are hosting the information on various platforms, pushing those platforms out are the producers themselves. “So, there's so many more players that need to be regulated in this context,” Strawn said.
Acting on the evidence, WHO then developed a guidance.
Scope of guidance
WHO’s guidance on digital marketing, began with a focus on breast milk substitutes, but later stakeholders suggested expanding the scope to foods for infants and young children, because they are often promoted in the same ways through the cross promotion, the official said.
The guidance offers recommendations on products that are within the scope of the code. These cover milk products up through the age of three years, any other foods or liquids targeted for children under six months, as well as feeding bottles and teats. In addition, there are recommendations specific to foods for infants and young children, on those commercial products that are specifically marketed for the feeding of children up to 36 months.
How can countries apply the code in the digital era?
The guidance also has recommendations on applying the code to digital media. It addresses
direct to consumer marketing in terms of promotion to the general public, samples, gifts, direct or indirect contact, informational labels, education, cross promotion, among others.
The guidance has recommendations for the digital context, Strawn said, “…as we are regulating, what are the things we need to be calling out for, looking for monitoring, making sure that we have enforcement mechanisms that can find those actors who are doing that kind of promotion in digital space that might actually look a little bit different, even though it's still the same issue that was identified in the code…. So, what you actually see when you're purchasing these products is invisible in front of you in those contexts.”
Monitoring and enforcement
The guidance also expands what legal duties of compliance mean. “…Whereas the primary focus previously was really on the manufacturer and distributor of the formulas themselves or the breast milk substitutes, this is now saying, look, there may be others that you hold, need to be held responsible. It may be that the platform itself, needs to be held responsible for what ads it accepts on its platforms or what kinds of tools it uses in that context, those that are producing that material, those that are helping with the targeting and are selling their services to those platforms. How can we actually hold them responsible? They may not have the same duties, because their responsibility for what the messages are may not be their issue, but the fact that they are carrying out something that should otherwise be illegal does put upon them some duty, as that needs to be laid out in the regulations themselves,” Strawn said.
The recommendations provide for the kinds of actors that can be responsible agencies at the national levels. The guidance also spells out the need for sanctions in the regulations.
Strawn also highlighted the changing nature of technologies and the challenges of dealing with cross-border promotions. “We know oftentimes digital space works differently, whereas the ads are not actually from companies that even come within the country. And how do you actually deal with an ad that is produced in one country, it appears on the web or is reaching people's cell phones as it reaches across borders? There are various things that can be done in terms of the legal obligations of the domestic entities that are distributing even if they're not distributing the marketing content itself, they might be dealing with the products, and therefore are responsible for how it is being promoted. There may be prohibitions that can be done from one country to another, that your nationals or domestic entities are not allowed to do outside of your borders. And then there needs to be better international cooperation for these enforcement actions, perhaps in regional compacts and agreements that could be put in place. Here is a growing problem of cross border marketing, but there are a number of options to deal with that,” he said.
TAILPIECE:
Activists and regulators hope that this resolution following the guidance and earlier reports would build upon member state practice in other areas of digital regulation. After all similar strategies are used for not only breast milk substitutes but also tobacco, alcohol, and food.
Addressing the commercial determinants of health requires the understanding and acting upon the complex nature of influence and keeping pace with how technology shapes public health outcomes.
References: FAQs on the code
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