Why is Singapore more worried about money than about health?

Why is Singapore more worried about money than about health?

Instead of protecting breastfeeding and infant health, Singapore seems more concerned about a surge in formula prices.

Just recently, a detailed investigation into formula milk prices by the Competition Commission of Singapore (CCS) was widely reported in the media in Singapore. The report released by CCS called for a halt on aggressive marketing tactics of formula milks. Such tactics include inducements to hospitals in the form of sponsorships, gifts, and payments in exchange for their products to be in “first-mover advantage” – being distributed in maternity wards and to parents of newborns, and for their products to stay on longer on the milk rotation systems. While the Ministry of Health is riding on the attention of this report to “encourage” hospitals to adhere to the Baby-friendly Hospital Initiative (BFHI) guidelines, the focus of the media reports was primarily on the steep increase in price of formula milks.

The report highlights that sponsorship and payments to hospitals are marketing tactics that lead to “conflicts of interest” because they distort the “equal opportunities” rotation system to which only public hospitals adhere. However, the CCS and the media said nothing about existing minimum marketing standards. They are enshrined in the International Code of Marketing of Breastmilk Substitutes and subsequent WHA resolutions (“the International Code”). The Singapore government endorsed the Code and resolutions at the annual WHO meetings. The aim of the International Code is to stop inappropriate marketing of formula milks by banning all forms of direct and indirect promotion. The Code’s scope includes all infant, follow-up, and growing-up formulas.

The report’s focus on surging prices ignores the fact that the International Code, once adopted into national measures and properly enforced, acts to protect breastfeeding and to ensure the public’s access to unbiased infant and young child feeding information, including information on the risks of using formula milks. It aims to protect the health of all infants and young children. While the Ministry of Health encourages hospitals to seek BFHI accreditation, it fails to mention that adherence to the International Code is one of the core BFHI criteria. The blatant omission of the International Code in all these reports may well have something to do with the fact that the country is one of the very few to have an “industry code”, i.e. rules written by industry rather than by public health authorities. The reports fail to mention that, while company sponsorship of hospitals leads to conflicts of interests that are unethical and unacceptable, the deeper and more pervasive conflict of interest lies in the fact that “industry codes” are driven by corporate interests. From the number of reports on Code violations in Singapore received by IBFAN-ICDC over the years, it is evident that such violations are rampant. It is a thriving market and the price escalation only shows how companies are greedy for more market share and higher profits. The reports we keep on receiving (and publishing) are signs that there are health advocates in the country who are worried about the low percentage of mothers who breastfeed. Aggressive promotional tactics such as “premiumisation” have long been denounced as effective means to discourage and undermine breastfeeding.

WHO recommends exclusive breastfeeding for the first six months of life. At six months, solid foods, such as mashed fruits and vegetables, should be introduced to complement breastfeeding for up to two years or more. Infants may not die in Singapore but they would be much, much better off if breastfed. Breastmilk gives infants all the nutrients they need for healthy development, and contains antibodies which help protect against many common childhood illnesses. Boosting rates of exclusive breastfeeding for infants less than 6 months of age would significantly reduce costs for treatment of childhood illnesses such as pneumonia, diarrhoea and asthma. Beyond the immediate benefits for children, breastfeeding contributes to a lifetime of good health. Adolescents and adults who were breastfed as babies are less likely to be overweight or obese. They are less prone to develop type-II diabetes later in life and perform better in intelligence tests. Infant formula does not contain the antibodies found in breastmilk. The long-term benefits of breastfeeding for mothers and children cannot be replicated with infant formula. The Ministry of Health needs to raise awareness of the risks of bottle-feeding. It is sad that there has been no concrete action toward adopting the International Code as a national measure.  

Even though the surge of formula prices is of legitimate concern, the media, health professionals and government authorities, everyone in Singapore, should be even more concerned about the lack of regulations which allows companies to promote (and price) their products to the hilt. The country must enact the Code to protect the health of its infants and young children. After all, it is the moral obligation of the State to ensure its adoption, and a fiduciary duty of health professionals to adhere to the International Code to protect, promote, and support breastfeeding.


In light of IBFAN-ICDC’s concern regarding the lack of acknowledgement of the importance of the International Code and its functions to protect breastfeeding reflected in the media, ICDC submitted a letter titled “Focus more on protecting breastfeeding and infant health” to the Straits Times to iterate these important points.