In this part is shown how international and national efforts have contributed to overall effectiveness of BPNI campaign. The report list out several successes and how these happened. What strategies worked and what ate the challenges ahead of BPNI. The Table 3 points out very clearly the agenda and real results that BPNI has been able to achieve.

Some of the key lessons that emerge from BPNI's campaign are:

--Effective change requires long-term campaigns and results at different levels.
--Collaboration is essential to achieve these changes, while individuals are the key role to play.
-- While campaigns are essential, additional inputs are required to achieve results at grassroots level.
--Even though campaigns start with a narrow focus, there is need to be broadened at a later stage to achieve real changes at grassroots level.

Effect of advocacy at international level on the promotion of breastfeeding in India

BPNI works closely with Government of India, Association for Consumers Action on Safety and Health (ACASH) and academic professional bodies like Indian Academy of Pediatrics (IAP), Federation of Obstetrics and Gynecological Societies of India (FOGSI), Indian Medical Association (IMA), Trained Nurses Association of India (TNAI), international agencies like WHO, and UNICEF. BPNI supports the national programmes of Ministry of Health and Family Welfare (MOHFW) to promote breastfeeding especially through Baby Friendly Hospital Initiative (BFHI) and works in close liaison with the Department of Women and Child Development, (DWCD) of Govt. of India to protect breastfeeding through monitoring of the law from commercial influence.

Here is a brief account of the effect that the international campaign on protection, promotion and support of breastfeeding had in India.

The baby food campaign is a long established international campaign with significant direction given by the International Baby Food Action Network (IBFAN) established in 1979 and grown over the years into a global network of public interest groups and individuals. IBFAN has led many campaigns since then and acted on many fronts to ensure full compliance with the International Code of Marketing of Breastmilk Substitutes and subsequent World Health Assembly Resolutions.

With the pressures from groups in India, work on the control of marketing of breastmilk substitutes progressed fairly quickly, the Government of India passed the "Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act, 1992" (The IMS Act). The Act and the Rules made there under came into force on 1st August 1993.

Since the enactment, significant developments had taken place including legal action against some companies. Advocacy at the Indian Academy of Pediatrics led to a general body resolution that IAP shall not receive money from industry related to infant formula /infant foods. IMA also joined hands in this regard to ask all its branches not to receive funds from infant formula industry.

From the year 1994 when BPNI was gazetted to be the official monitoring agency under the IMS Act, our work has made considerable progress in making this Act work. The World Alliance for Breastfeeding Action (WABA) founded in 1991, spearheaded campaigning and social mobilization all around the world through one of its major tools World Breastfeeding Week (WBW) each year from August 1-7.

BPNI in India has been on the forefront of coordinating a massive movement in the country during the WBW for the last nine years where every sector now participates and owns this activity.

Creating Baby Friendly Hospitals was one of the initial themes of WBW and taking on from there BPNI in collaboration with UNICEF, GOI and others trained a large number of health workers who became involved in the Baby Friendly Hospital Initiative (BFHI) and WBW activities and soon became strong advocates of breastfeeding in their area of influence.

This work has now been taken up locally to support lactating mothers with the training of grassroots workers in breastfeeding and in some states through innovative ways to build support for mothers like setting up mother support groups.

To bring long lasting changes BPNI's work is now progressing towards strengthening the basic education curriculum at all levels including primary/secondary schools and professionals. For the doctors and nurses, Guidelines on Breastfeeding and Complementary Feeding have already been developed and for frontline workers these are under development.

Providing accurate and consistent information to people is a challenge BPNI is taking up. Recently BPNI has also developed a research agenda to address the needs of communicators.

All this was possible through the various players who act as task force coordinators of BPNI and its advisory council.

Success of BPNI effort in India

Table 1 briefly summarizes the success of the effort that BPNI has made in India of course in collaboration with many more partners.

Despite the impressive achievements there is still a long way to go to achieve a real change at grassroots level. Many mothers are still opting to give artificial milks with bottle-feeding as early as first month of life. Incidence of diarrhea and pneumonia is very high and so is infant mortality and malnutrition. BPNI believes that to reduce malnutrition infant feeding practices must improve.

How all that happened

The factors that contribute to this change are many including collaborations, legitimacy, individuals, mobilization, specific focus, and the role of government, the international context and ability to threaten commercial forces.

It is not a single event that brought changes but a continuous movement and cumulative effect of the BPNI's work over the years. Our campaign does not have a very clearly defined beginning or the end. But from the stage of setting the agenda, the needs and observations led to emergence and progress of the activities.

Working at different levels

To be successful we thought that work has to be done at different levels and groups targeted included the UN bodies, governments, public, health workers, and community workers etc. The campaign started from a narrow focus on protecting breastfeeding, and then found it broadening to promoting better nutrition and child health. The levels that have proved most helpful in bringing the results are listed in Table 2. It was a challenge to work, firstly at international level and then at country level. The success of BPNI campaign and impact of its work at different levels is summarized in Table 1; and Table 3 summarizes the activities and how agenda were set that brought these changes.

Effective strategies used by BPNI

BPNI's campaign seeks to bring about changes in national policy. It has grown from people's personal commitment, experience and opportunities. It has targeted at different levels focusing mainly on health care practices and training of health workers. It started with a few key persons and that has made all the difference. Individual motivation has been the driving force and the campaign has relied much on the voluntary efforts.

Legitimacy

BPNI had to spend time and energy to establish its legitimacy and also contest the industry's claims. It was found to be the essential component of the BPNI's initial work and its success. To mobilize resources legitimacy has been an important factor.

Collaboration

For an effective work, we have observed that collaborations (both formal and informal) have been found to be essential strategy to move forward. However, when more players are involved the cooperation becomes a bit complex but it is challenging to maintain the pressures of the campaign in which BPNI has been involved.

Individuals and mobilization of people

Key individuals who were responsible for working at national and international level initially started BPNI's campaign. These were able to motivate others and gave strategic vision to the movement and groups as the work progressed more and more individuals and groups joined in.

Role of governments and parliamentarians

The Government of India played a significant role in setting agenda with the National Plan of Action and National Nutrition Policy. The IMS Act came into force in 1993 with the strong efforts of key individuals in the parliament and the governments. Government has taken steps to implement the law. The Cable TV Networks Regulations Act was amended in September 2000, a historical moment for the Government, to ban advertisements of infant foods on the cable service.

Narrow focus

BPNI started with a narrow focus to monitor the compliance of International Code and later the IMS Act and benefits of breastfeeding. About a decade back, it was important to set agenda to public as well as policy makers. It was not easy to move forward without a focused agenda. This has played off and has been a significant contribution to BPNI's work. Later, the work was broadening into areas of malnutrition, child and women's health.

International context

To move the campaign forward collaboration with the international groups of IBFAN was very crucial. Groups in the UK, Geneva and Penang especially did very useful work to put the issue on agenda. It helped in our advocacy work and brought the Code into practice as the IMS Act. They used the International Code, the WHA resolutions, Innocenti Declaration, CRC and other instrument very intelligently. Their role continues to be significant even now. It also helped BPNI in giving a platform in joint fundraising and expanding its base that is very crucial to the campaign work.

Challenges ahead

With its impressive gains made at policy level, BPNI marches ahead with many challenges ahead. The impact at the community level to see increased rate of exclusive breastfeeding and timely complementary feeding is the real change as long-term goal. To bring this change advocacy is not enough. Many factors would come into play such as:

Work at grassroots level

Without working at grassroots it is difficult to bring real change in breastfeeding practices and children would continue to be offered bottle-feeding when mothers opt for this method of feeding early in their life. In our case, crucial importance is information regarding breastfeeding initiation, establishment and maintenance of breastfeeding, increasing skills of grassroots workers to help mothers and support to women working out side home. These are major task ahead for all at BPNI, Government of India and other collaborating NGOs and concerned UN agencies. BPNI has already started such work in UP and Maharashtra and lessons learnt will be available soon.

Government being the only agency having the largest reach has a challenge to train the grassroots workers in health and nutrition sector to bring real changes at the grassroots and people/community level.

Implementation and monitoring of the IMS Act

Simply having policies and legislation is not enough; enforcement is all that is crucial for achieving their objectives for which the law is made. In our case the IMS Act is being implemented with a slow pace and monitoring process is in place but requires systematic approach, greater emphasis, resources and planning. NGOs have to play a role to publicize the violations; media will have to respond to the needs from time to time. To give effect to have a permanent loophole free IMS Act is another challenge with the Government of India.

Promoting the national and international instruments

As an important area of work to promote tools that are helpful in keeping the agenda active for a sustainable change. Like for example CRC, a report that is expected from the Government in every five years at the UN Committee for CRC where NGOs can also contribute in reporting to the committee. It provides transparent mechanism of functioning and feedback by way of which action is taken at the government level. Other international documents that need continuous monitoring are the International code, WHA resolutions and the subsequent resolutions.

Research

Need of continuous research on infant feeding practices addressing to interventions and geographical changes, and qualitative behavior research for positive deviance for the future work.

Assessing effectiveness

To keep on assessing the effectiveness of our work will be important to BPNI and the targets to achieve towards real change. Many complex areas are operating. But there are no general rules for assessment as the areas of activities are different. As one moves ahead, certain parameters can be drawn that help to assess the change, for example, number of health workers trained, violations reported and legal actions taken, rates of exclusive breastfeeding in the area can be used to assess the volume of work done in one area. The other way to look at is the collaborations, how they work and what threatens such fusions, where there is need to change or broadening the focus etc.