Nous has made a number of recommendations that relate to the MAIF Agreement and to the APMAIF. The recommendations, together with the findings that support each recommendation, are outlined in Table 1 below. These recommendations should be considered in light of the following contextual information.

The MAIF Agreement is one of several ways in which Australia has implemented the provisions of the WHO Code. Other mechanisms include the Infant Feeding Guidelines for Health Care Workers, and existing labelling laws as they apply to infant formula. Both the Infant Feeding Guidelines and the labelling laws for infant formula are currently being reviewed.

The context in which Australia’s child and maternal health care is delivered also influences the rates of breastfeeding. The Australian health care system is complex and multi-layered. Initiatives run through health care providers at state and territory level such as Baby Friendly Health Initiative accreditation, as well as community organisations that provide peer and family support: all play a role in the support and promotion of breastfeeding.

The complex interplay between these and other factors has been recognised in the Breastfeeding Strategy 2010-2015. The implementation plan developed to support the strategy identifies ten priority areas where effort could be focused to improve breastfeeding rates in Australia. Included among those priority areas was the commitment to revisit Australia’s response to the WHO Code. This Review of the MAIF Agreement has been undertaken as one element of that commitment.

Table 1: Recommendations

Rec NoRecommendationFindings supporting recommendation
1. Content of the MAIF Agreement :

The following changes should be made to the wording of the MAIF Agreement to ensure it reflects current legislation, standards, marketing practices and modern health terminology:
    a. The preamble to the MAIF Agreement should clearly identify the relationship between the MAIF Agreement and the WHO Code and identify any relevant legislation operating in parallel
    b. Clause 4 should be amended to change the term ‘superiority’ with wording that focuses on the benefits, importance and biological norm of breastfeeding
    c. Clause 4(a) should be amended to include reference to ‘electronic media and social marketing’
    d. Clause 6 should be amended to replace the term 'mothercraft nurse' with 'child and family nurse'
    e. Clause 7(c) should be amended to provide clear guidance around what constitutes an ‘inducement’
    f. Clause 7 (d) should be amended to provide clear guidance around what is considered a ‘sample’ and what constitutes ‘professional evaluation’
    g. Clause 9 should be amended to replace the reference to ‘Australian Food Standard R7’ with ‘Australian Food Standard 2.9.1’
    h. Clause 9(b) should be amended to replace the phrase ‘should not discourage breastfeeding’ with a statement about the importance of breastfeeding.
Wording of the MAIF Agreement needs to be updated to reflect changes to legislation, standards and modern health terminology. The proposed updates will provide clearer guidance for APMAIF in making interpretations.
There have been significant changes to the marketing environment – many new forms of marketing (including electronic marketing and social media) are not currently covered explicitly under the MAIF Agreement.
2. Coverage of the MAIF Agreement :

The voluntary, self-regulatory nature of the MAIF Agreement is the most cost effective regulatory mechanism and should continue, providing:
    a. it continues to promote the achievement of the aim of the MAIF Agreement
    b. industry coverage levels remain high. New entrants (manufacturers and importers of infant formula) should be encouraged to sign the MAIF Agreement.
Regulation of infant formula varies across countries. However, the scope of the MAIF Agreement is similar to regulatory approaches operating in many other countries. Like Australia, New Zealand has adopted a voluntary Code whilst many other countries have implemented the WHO Code via legislation. There does not appear to be any causal relationship between the level of regulation of infant formula (or implementation of the WHO Code) and breastfeeding rates.
Although there have been a number of regulatory changes since 1992, these have not impacted the effectiveness of the MAIF Agreement. Future trends towards deregulation and initiatives to reduce compliance costs are similarly predicted to have no significant impacts on the MAIF Agreement. The self-regulation model is operating effectively. Self-regulation encourages high levels of consultation between government and industry and creates a sense of ownership by industry.
3Coverage of the MAIF Agreement :

The coverage of the MAIF Agreement should not be extended to cover:
  • any food described or sold as an alternative for human milk for the feeding of infants beyond the age of twelve months;
  • retailers and pharmacies;
  • other infant feeding products such as bottles, teats and complementary foods.
Regulation of products sold for feeding infants beyond twelve months - This Review did not identify sufficient evidence to warrant the regulation of products beyond twelve months (see Recommendation 4).

Extension to retailers and pharmacies – although many consumer stakeholders indicated that there should be mandatory participation by industry, the MAIF Agreement currently has wide market coverage despite its voluntary nature.

Expansion of the MAIF Agreement to retailers would require a major change to current regulations. One significant issue is the practicality of whether both major as well as smaller retailers should be covered under the MAIF Agreement. There are also likely to be significant costs associated with expansion of the scope to the retail market. Results from this review do not provide sufficient evidence to warrant a regulatory expansion of this extent.

Extension to other infant feeding products - bottles and teats are used by infant formula feeding parents, but are also used by breastfeeding parents (e.g. for expressed breast milk). As such, restrictions on these products would be inappropriate.

4Coverage of the MAIF Agreement :

Consideration should be given as to how to best restrict manufacturers’ labelling of toddler milk drinks with product identifiers resembling those of infant formula labels. Labelling of products should be sufficiently different to enable consumers to clearly and quickly distinguish between infant formula and toddler milk drinks.
Expansion of scope to toddler milk drinks has a number of implications. The major concern regarding toddler milk drinks is the use of brand identifiers resembling infant formula. Extending the MAIF Agreement to cover any food described or sold as an alternative for human milk for the feeding of infants beyond the age of twelve months is inconsistent with the WHO Code. An alternative mechanism to prevent toddler milk drinks being used as de-facto advertising for infant formula is placing restrictions on the ability of industry to market and label both infant formula and toddler milk drinks in a similar manner.
5Operations of the MAIF Agreement - to improve effectiveness of the APMAIF in actively monitoring industry compliance with the MAIF Agreement including the complaints handling process :

The APMAIF’s monitoring role should be expanded from a purely reactive monitoring role to also encompass a proactive approach that actively monitors compliance. Its functions and powers should be changed in the following ways:
    a. to be able to initiate an investigation on its own
    b. to receive direction from the Minister to investigate a particular matter
    c. to require signatories to publically advertise a breach finding made against it in a prominent position on its website, a national newspaper and other relevant health sector publications as determined by the APMAIF.
Improvements are required to the complaints handling process – Stakeholders indicated that the complaints handling process needs to be more transparent and timely and that stronger communication is required between the APMAIF and the community. Although many investigations of complaints will continue to be reactive, the current APMAIF Terms of Reference allow for more proactive monitoring of industry behaviour. Breaches should be broadly publicised as a stronger disincentive for non-compliance. Stronger powers of enforcement are required to ensure the voluntary, self-regulated model remains effective.
6Operations of the MAIF Agreement - to improve effectiveness of the APMAIF in actively monitoring industry compliance with the MAIF Agreement including the complaints handling process :

The APMAIF should publish its decisions (and reasons for the decision) on all complaints (having regard to complainants’ and commercial confidentialities) on the DOHA website.
The APMAIF does not currently publish its full decision made on a complaint, but does provide a summary of its finding in its Annual Report. Publication of its decision (including reasons for the decision) would increase the transparency of the complaints process and also provide a valuable source of interpretation of the MAIF Agreement.
7Operations of the MAIF Agreement - to improve effectiveness of the APMAIF in actively monitoring industry compliance with the MAIF Agreement including the complaints handling process :

The currency of the MAIF Agreement should be reviewed regularly through:
    a. an external review every five years of the efficiency, effectiveness and appropriateness of the MAIF Agreement
    b. annual reviews of the coverage and effectiveness of interpretive guidelines.
It is best practice to undertake regular reviews of regulatory instruments. Given the rate of change in the marketing environment it is important that interpretive guidelines are regularly reviewed and updated.
8Operations of the MAIF Agreement - to improve effectiveness of the APMAIF in actively monitoring industry compliance with the MAIF Agreement including the complaints handling process :

The APMAIF should promote community and health care professionals’ awareness of the MAIF Agreement and the complaints process through:
    a. development of a website that supports information dissemination and lodgement of complaints
    b. education and general media events.
Stakeholders identified that there is limited awareness and understanding of the WHO Code and MAIF Agreement in the community and that health professionals and industry members require a stronger understanding of their responsibilities under the MAIF Agreement. The effectiveness of the MAIF Agreement is impacted by these limited levels of community awareness.
Stakeholders suggested that the requirement to lodge complaints in hardcopy is sub-optimal. Allowing online lodgement would improve the transparency and efficiency of the complaints process.
9Operations of the MAIF Agreement - to improve effectiveness of the APMAIF in actively monitoring industry compliance with the MAIF Agreement including the complaints handling process :

The APMAIF should continue to maintain strong formal and informal communication channels with industry to ensure a consistent understanding and interpretation of the MAIF Agreement and to play an education role following breaches.
The APMAIF has established effective consultation arrangements with signatories. This supports the effective operation of a self-regulatory code.
10Operations of the MAIF Agreement - to improve effectiveness of the APMAIF in actively monitoring industry compliance with the MAIF Agreement including the complaints handling process :

The APMAIF should introduce the following changes to improve the efficiency of the complaints handling process:
    a. design and implement an APMAIF service charter that sets out KPIs on service obligations including targets for timeliness of responses to complaints
    b. increase the use of out-of-session meetings and other flexible working arrangement to improve the timeliness of its decisions.
There is value to both consumers and industry in the timely resolution of complaints. It increases consumer protection by facilitating compliance with the MAIF Agreement, and it provides signatories with certainty in their obligations under the MAIF Agreement. A service charter and more flexible working arrangements would help achieve this.
11Operations of the MAIF Agreement - to improve effectiveness of the APMAIF in actively monitoring industry compliance with the MAIF Agreement including the complaints handling process :

An appeals process should not be introduced for complaints.
There is sufficient procedural fairness in the current complaints handling process, so an appeals process is not warranted.
12Operations of APMAIF – to improve the efficiency, transparency, cost-effectiveness and appropriateness of APMAIF processes :

The APMAIF should include a report card in its Annual Report which could include:
    a. reporting of complaints data against new service charter KPIs
    b. a summary of APMAIF decisions over the previous 12 months including updated interpretations.
The APMAIF Annual Report currently includes complaints statistics, details of breaches and any issues arising from APMAIF business. The Annual Report could be further strengthened by the inclusion of a ‘report card’ that highlights performance against set KPIs (performance against KPIs proposed in this Report could also be reflected in the report card).
13Operations of APMAIF – to improve the efficiency, transparency, cost-effectiveness and appropriateness of APMAIF processes :

The existing level of funding of the APMAIF by DoHA is appropriate given its current functions and powers. Funding levels should be revised if additional functions are added to the APMAIF Terms of Reference. The previous practice of industry co-funding the operation of the APMAIF should not be re-introduced.
The majority of stakeholders strongly opposed cost recovery through industry funding of the APMAIF. Maintenance of funding by DoHA reinforces the objectivity of the APMAIF.
14Operations of the MAIF Agreement – to improve the effectiveness of governance arrangements :

The APMAIF’s Terms of Reference remain valid. The APMAIF should consider if any changes to the terms of reference are necessary to enable implementation of Recommendation 5.
The current terms of reference provide a clear framework for the operations of the APMAIF. However, the APMAIF could be more proactive in implementing the terms of reference.
15Operations of the MAIF Agreement – to improve the effectiveness of governance arrangements :

Procedures for the appointment of members to the APMAIF should be reviewed and made publicly available. Consideration should be given to the inclusion of public advertising and application procedures for APMAIF positions.
APMAIF members are currently appointed through nominations from DoHA to the Parliamentary Secretary. The current process lacks transparency, with few stakeholders aware of the appointment procedures. Increased transparency of appointments to the APMAIF will support stakeholder confidence in the impartiality of the process.
16Operations of the MAIF Agreement – to improve the effectiveness of governance arrangements :

The existing APMAIF composition (number and designation of members) is appropriate and should continue.
The inclusion of appropriate representatives on the APMAIF is a key factor for maintaining consumer confidence in the complaints handling process.
The existing APMAIF member categories and role statements are appropriate and should be retained.
Existing APMAIF members should continue to conduct themselves in accordance with their role description.
The role statements be central to considerations of future member nominations.

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