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Wamahiu et al. Globalization and Health (2025) 21:32
https://doi.org/10.1186/s12992-025-01127-2
Globalization and Health
*Correspondence:
Maryanne Wamahiu
maryanne.wamahiu@uni-bayreuth.de
1Faculty of Life Sciences: Food, Nutrition and Health, University of
Bayreuth, Kulmbach, Germany
2Bayreuth International Graduate School of African Studies, University of
Bayreuth, Bayreuth, Germany
3School of Public Health, University of Sydney, Sydney, Australia
Abstract
Background The World Health Organization recommends initiating breastfeeding in the first hour of life, exclusive
breastfeeding for six months, and continued breastfeeding for at least two years. Aggressive marketing of breast milk
substitutes (BMS) undermines breastfeeding and is linked to adverse child and maternal health outcomes. This is
particularly problematic in the Global South, where socioeconomic conditions often amplify the risks associated with
BMS. The adoption of national BMS legislation in line with the 1981 International Code of Marketing of Breast-milk
Substitutes is therefore crucial but difficult due to strong opposition from the transnational formula milk industry.
Breastfeeding advocates in Kenya were able to overcome this powerful opposition when the country adopted a
strict BMS Act in 2012, which has since facilitated and protected remarkable improvements in breastfeeding rates. We
conduct a qualitative case study to identify the political enablers of the successful adoption of this important law.
Results BMS legislation was first politically debated in Kenya in the 1980s following mobilization of women-led civil
society organizations, namely the Breastfeeding Information Group and the Maendeleo ya Wanawake Organization.
The issue re-emerged on the political agenda in the 2000s but faced opposition from the transnational formula milk
industry. Kenya’s BMS Act was ultimately adopted during a policy window opened by a constitutional reform. Support
for the adoption of this landmark law was led by effective female political leaders, including public health minister
Beth Mugo, the ministry’s nutrition division head Terrie Wefwafwa, and members of the Kenya Women’s Parliamentary
Association. In the formulation and adoption of the law, these female leaders received important support from
international organizations, such as the United Nations Children’s Fund, as well as from powerful male allies, including
president Mwai Kibaki.
Conclusions The Kenyan case illustrates how women’s political leadership can counteract the power of the
transnational formula milk industry and help achieve strict BMS legislation. Effective female leadership for BMS
legislation can occur in various political offices and positions, including those of ministers, legislators and bureaucrats.
Female leaders can leverage their own influence by strategically exploiting policy windows and recruiting male allies.
Keywords Breastfeeding, Breast milk substitutes, Formula milk, International code, Kenya, Male allies, Women’s
political leadership, Transnational corporations
Generating political priority for breastfeeding
and the adoption of Kenya’s 2012 BMS act: the
importance of women’s leadership
Maryanne Wamahiu1,2*, Phillip Baker3 and Tim Dorlach1
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Wamahiu et al. Globalization and Health (2025) 21:32
Introduction
Breastfeeding is considered the best feeding for infants.
Breastfeeding reduces the likelihood of common child
hood illnesses and malnutrition [1–3], women’s risk of
diabetes and reproductive cancers [4–6] and has sig
nificant benefits for sustainability, climate change miti
gation, and food security of the child [7, 8]. In contrast,
bottle feeding with breast milk substitutes (BMS) can
pose severe risks to infant health, especially in the Global
South. Contamination from unsafe water can cause diar
rhea, while over-dilution of formula can result in under
nutrition [1, 2]. The World Health Organization (WHO)
therefore recommends initiation of breastfeeding within
one hour of birth, exclusive breastfeeding for six months,
and continued breastfeeding up to at least two years
of age [9]. While important progress has been made in
recent years, only 48% of the world’s babies are exclu
sively breastfed [10].
One of the main reasons behind low breastfeeding
rates is the aggressive marketing of BMS by the transna
tional formula milk industry. These marketing practices
include misleading advertising on the supposed superior
ity of BMS to breast milk, offering free samples to moth
ers in hospitals, and promotion through health workers
[11–13]. While BMS can fulfil important functions, for
instance, when breastfeeding is medically contra-indi
cated in rare cases or to support women’s labor force par
ticipation, aggressive marketing practices can effectively
prevent women from making informed decisions.
BMS marketing became a globally salient political issue
in the 1970s, e.g., through the 1974 report “The Baby
Killer”, the 1975 documentary film “Bottle Babies”, and
the 1977 launch of a consumer boycott against Nestlé
[14]. In 1981, the World Health Assembly (WHA) passed
the International Code of Marketing of Breast-milk Sub
stitutes [15–17]. This International Code is a “set of rec
ommendations to regulate the marketing of breast-milk
substitutes, feeding bottles and teats”, which “aims to stop
the aggressive and inappropriate marketing of breast-
milk substitutes” [18]. The International Code is a living
document, which is updated biannually through WHA
resolutions, that have the same legal status as the initial
code, in response to WHO technical guidance and evolv
ing industry practices. When we refer to the Interna
tional Code, we therefore mean the code and subsequent
resolutions.
While the International Code represents a landmark
achievement in the global regulation of BMS marketing,
it was adopted as a non-binding code of conduct [15, 17,
19]. The adoption of binding national legislation in line
with the International Code is therefore crucial. Yet, by
2022, only 32 countries worldwide had adopted legisla
tion that it “substantially aligned” with the International
Code [20]. The existing literature has already identified
various enabling factors of programs and policies to
protect, promote and support breastfeeding, including
“evidence-based advocacy” and “political commitment”
[21–26]. Other studies have focused on the barriers
to the adoption of strict BMS legislation, in particular
extensive corporate lobbying, or corporate political activ
ity, by the transnational formula milk industry [27–30].
As corporate lobbying clearly presents a major barrier to
the adoption of strict BMS legislation, more fine-grained
research is needed on the political factors and strategies
that can enable the adoption of strict BMS legislation at
the national level.
To contribute to a better understanding of the politi
cal enablers of strict BMS legislation, we conduct a case
study of Kenya, which adopted the Breast Milk Substi
tutes Act (BMS Act) in 2012. The Act has been praised as
an important piece of legislation, not only for the protec
tion, promotion and support for breastfeeding in Kenya,
but also for the improvement of nutrition and health
outcomes [31]. However, little is known about the politi
cal factors that made its enactment possible [15]. In this
paper, we analyze the policy process that led to the suc
cessful adoption of Kenya’s 2012 BMS Act.
Research design
We conduct a case study of Kenya’s 2012 BMS Act. This
law introduced several important policy changes, most
importantly the prohibition of all advertising and promo
tion of BMS. BMS covered by the Act include infant for
mula for infants below 6 months, follow-on formula for
children between 6 and 24 months and complementary
foods. Follow-on formula is among the fastest growing
segments of the global baby food market but is criticized
for contributing to child obesity (as it often contains
added sugar, especially in low- and middle-income coun
tries) and for facilitating so-called “cross-promotion” of
breast milk substitutes, a strategy used to circumvent
restrictions on infant-formula marketing [13, 32, 33]. The
law also established a National Committee on Infant and
Young Child Nutrition, which fulfils a policy advisory
role to the Minister for Health.
In 2022, Kenya was one of 14 African countries with
legislation substantially aligned with the International
Code (Fig. 1). Overall, Kenya ranked fifth in Africa in
terms of International Code alignment (with 82 out of
100 possible points), trailing only Sierra Leone (99),
South Africa (87), Ethiopia (85) and Nigeria (84) [20].
Kenya has recorded steady improvements in exclusive
breastfeeding rates since the early 2000s (Fig. 2), with
the highest rise recorded between 2008 (32%) and 2014
(61%). Together with other reforms, such as the expan
sion of paid maternity leave in 2007 [34], the 2012 BMS
Act has been key in facilitating and protecting these
improvements.
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Wamahiu et al. Globalization and Health (2025) 21:32
Physical archival research and in-person interviews
were conducted during three rounds of fieldwork in Nai
robi, Kenya, between 2023 and 2024. Primary documents
reviewed for this study include archival documents
accessed in the Kenya National Archives, including cor
respondence, newsletters and minutes from files annexed
under the Ministry of Health Nutrition Division, Kenya
Bureau of Standards, and the Ministry of Social Services.
The Parliamentary Hansard and regulatory documents
were also reviewed, some online and others in the Kenya
Parliamentary Library. News coverage was accessed from
the Nation Media and Standard Group libraries, in addi
tion to online repositories. 21 semi-structured key-infor
mant interviews were conducted, both in-person and
remotely, with representatives from relevant government
institutions, civil society organizations and academia (see
Table S1). Interviewees were selected through purposive
snowballing [39].
To develop an explanation of the successful adoption
of Kenya’s 2012 BMS Act, we used inductive process
tracing, a method that is ideally suited for studying the
causes of specific policy outcomes [40, 41]. Our process
tracing analysis is complemented by a within-case com
parison [42] of the successful adoption of the 2012 BMS
Act with the failed introduction of BMS legislation in the
early 1980s. We employ qualitative content analysis [43]
to extract relevant information from our interview and
document sources.
Theoretical framework
Our case study is guided by the policy cycle framework of
the policy process [44]. This framework “has become the
conventional way to describe the chronology of a policy
process” [44]. It divides the policy process into a sequence
of distinct stages, most commonly agenda setting as well
as policy formulation, adoption, implementation and
evaluation. We find the policy cycle framework particu
larly useful for studying the politics of BMS regulation,
as it allows us to distinguish the political dynamics of the
struggle for strict BMS regulation during these different
phases [23, 24]. In this paper, we focus on the agenda-
setting, formulation and decision-making processes that
Fig. 1 National legal status on the International Code in Africa, 2022
Source: WHO (2022) [20]
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Wamahiu et al. Globalization and Health (2025) 21:32
led to the adoption of Kenya’s 2012 BMS Act. Here we
also draw on the literature on the determinants of politi
cal commitment and priority for nutrition [45, 46].
In substantive theoretical terms, we draw on the lit
erature on women in politics [47]. By studying what can
be described as “women’s political leadership” [48], this
literature has highlighted how women can bring about
policy change when achieving positions of power, be it in
the executive, legislature or judiciary. In other words, this
literature investigates when and how descriptive repre
sentation, i.e., women’s presence in leadership positions,
also results in substantive representation, i.e., representa
tion of women’s interests [49]. Studies on African coun
tries, where elected female heads of state have remained
relatively rare, have mostly examined the policy impact
of female legislators and cabinet members [49–51]. This
literature has highlighted the importance of cross-party
women’s caucuses and the strategic recruitment of “male
allies” in enhancing female political leaders’ ability to
bring about policy change [52, 53].
We also draw extensively on the theoretical literature
on the transnationalization of national policy making
[54]. Research has demonstrated that domestic policy
making processes, especially but not only in the Global
South, are often strongly influenced by transnational
actors and networks. Accordingly, domestic policy entre
preneurs are often embedded in “transnational epistemic
communities” [55] or “transnational advocacy networks”
[56]. Likewise, transnational corporations often use their
immense economic resources and political power to
influence domestic policy decisions [57, 58]. The policy
field of BMS regulation is characterized by intense trans
nationalization. National BMS regulations are regularly
opposed by transnational formula milk industry [28,
59]. At the same time, national advocates for stricter
BMS regulation are usually supported by a transnational
network that includes the international organizations
UNICEF and WHO as well as the non-governmental
International Baby Food Action Network (IBFAN) [19,
28, 59]. Indeed, the case of IBFAN directly informed the
original development of the theoretical concept of “trans
national advocacy networks” [16, 56].
Results
The adoption of Kenya’s 2012 BMS Act was the culmina
tion of decades-long political efforts for BMS legislation.
In the following sections, we causally reconstruct the
political process that led to the successful adoption of the
Act. We begin with a brief account of a first attempt to
introduce BMS legislation in the 1980s. We then focus on
the re-emergence of BMS legislation on the policy agenda
in the 2000s and the parliamentary debate and adoption
of the law in 2012. In a nutshell, we argue that the efforts
of women leaders, supported by male allies and transna
tional networks made a strong contribution towards the
adoption of this landmark BMS law.
Fig. 2 Exclusive breastfeeding (0–5 months) trends in Kenya
Source: Kenya Demographic and Health Surveys (2003, 2008, 2014, 2022) [35–38]
Page 5 of 14
Wamahiu et al. Globalization and Health (2025) 21:32
Early problem definition and advocacy
Like in many other countries, breastfeeding and BMS
marketing first began being politically problematized
in Kenya during the 1970s. Transnational BMS produc
ers had first entered the Kenyan market in 1913 [60]. By
the 1970s, BMS marketing had become widespread and
aggressive. Nestlé’s Lactogen was the most advertised
brand on Swahili radio at the time, alone accounting for
11% of all (not just BMS) advertisements [61]. Rampant
advertising of BMS was associated with low exclusive
breastfeeding rates and what Derrick and Patrice Jelliffe
have described as “commerciogenic malnutrition” [62].
Indeed, the problem was so pronounced that Kenyans
reportedly developed the term chupa-itis to “describe
diarrhea and dysentery in bottle-fed babies (chupa
means bottle in Kiswahili)” [63]. The situation in Kenya
became a central reference point in international debates
about the specific risks of BMS in the Global South. For
instance, the influential 1975 documentary film “Bottle
Babies” by West German filmmaker Peter Krieg, which
became instrumental in the 1977 Nestlé boycott, was pri
marily shot in Nairobi’s Kenyatta National Hospital [64].
Women-led civil society organizations, supported
by international donors, were central in advocating for
stricter regulation of BMS marketing in Kenya. The
first among these was the small, Breastfeeding Informa
tion Group (BIG), a voluntary women-led organization
focused on breastfeeding promotion. The organization
was established in 1978 in Kenya, as the first African
breastfeeding advocacy group by the Ugandan Marga
ret Kyenkya and a group of women from various coun
tries including Rachel Musoke from Kenya [65, 66]. BIG’s
establishment was motivated by an encounter of Marga
ret Kyenkya with the American Helen Armstrong, a for
mer Peace Corps and La Leche League volunteer [65, 67]
and was also supported by other expatriate volunteers,
such as the Canadian Linda George [68]. BIG became
affiliated with IBFAN, which was founded in 1979. In
the late 1980s, BIG employed twelve salaried staff mem
bers and had received most of its funds from interna
tional donors, including Norwegian International Aid for
Development (NORAD), Oxfam, UNICEF, the Danish
International Development Agency and the Ford Foun
dation [69]. Working closely with the Ministry of Health,
BIG was able to push the breastfeeding agenda through
individual counselling and talks with mothers in mater
nal and child health facilities, providing in-service train
ing in breastfeeding management to health workers and
women’s groups in rural areas, and conducting research
on breastfeeding trends in the 1980s and early 1990s [70].
In 1982, BIG successfully recruited an important ally
in its fight to promote breastfeeding and push for strong
national BMS regulation, namely the Maendeleo ya Wan
awake Organization (MYWO), then Kenya’s “biggest
and politically powerful grassroots women’s organiza
tion” [65]. At the time, MYWO largely relied on funding
from international donors. For instance, in 1979, MYWO
launched a Maternal Child Health and Family Planning
program with funding from Pathfinder International,
the World Bank, USAID and NORAD [71]. MYWO was
particularly influential between 1971 and 1984, when it
was chaired by Jane Kiano, who enjoyed strong ties with
Kenya’s ruling party and was the spouse to an influential,
long-serving minister [65, 72].
A first attempt at BMS legislation
In the early 1980s, and especially after the adoption
of the International Code in 1981, BIG and MYWO
jointly advocated for the introduction of strong national
BMS legislation in Kenya through a Kenya Code [73].1
MYWO’s chairperson, Jane Kiano, threw her politi
cal weight behind the cause, reportedly demanding in a
meeting that “I want this Code. Definitely. And I want it
soon.” [65]. The formulation of this Kenya Code was ini
tially led by the Ministry of Health but was soon taken
over by the Kenya Bureau of Standards (KEBS), an agency
under the Ministry of Industry [77]. Representatives
of the BMS industry and Nestlé in particular “insisted
on being full participants in the drafting process” [65]
and were in fact overrepresented according to BIG [78].
Indeed, the 1982 draft of the Kenya Code fell substan
tially short of the standards set out in the International
Code and lacked a clear enforcement mechanism [79].
After further revisions and an influential National Work
shop in Infant Feeding Practices in April 1983 [80, 81],
the Kenya Code for Marketing of Breast Milk Substitutes
was eventually adopted as a voluntary KEBS standard in
May 1983 [82].
BIG and MYWO therefore ultimately failed at generat
ing enough political support for BMS legislation, unable
to overcome the strong opposition of the BMS industry.
Yet, even this adoption of a voluntary code can be viewed
as a certain policy achievement. By 1991, only three
African countries, Kenya, Nigeria and South Africa, had
adopted such voluntary codes, while none had adopted
comprehensive and legally binding BMS regulations [83].
It also appears that the 1983 Kenya Code was enforced
relatively effectively in public hospitals through a series
of health ministry directives. In conjunction, the Kenya
Code and these directives “effectively banned the free
supply of infant formula to Kenyan hospitals” [84]. Yet,
1 It is regularly noted that Kenya was the first country to vote in favor of
adopting the International Code at the 1981 World Health Assembly [74,
75], implying that Kenya was a leading proponent of the measure. While
Kenya was indeed the first country to cast its vote, this was accidental, as it
was randomly selected to commence a roll-call vote in alphabetical order on
the resolution [76].
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Wamahiu et al. Globalization and Health (2025) 21:32
the goal of adopting comprehensive BMS legislation
remained unattained.
Declining interest in BMS legislation
This early policy window for adopting BMS legisla
tion closed again after the mid-1980s, as both BIG and
MYWO were weakened. Kiano, MYWO’s powerful
chairperson, who had embraced the issue of BMS regula
tion, stepped down in 1984 [71]. Kyenkya, BIG’s founding
director, moved to New York in 1987 and started working
for UNICEF [65]. These personnel changes were accom
panied by a funding crunch for civil society organiza
tions. Oxfam, which had paid Kyenkya’s salary as BIG’s
coordinator, withdrew from funding BIG in 1987 [69].
NORAD, which had been a major funder of both BIG and
MYWO was expelled from the country in 1990 due to an
unrelated political conflict between Kenya and Norway
[69, 71]. All of these changes occurred in the context of
the increasingly authoritarian presidency of Daniel arap
Moi.
In 1989, the issue of BMS legislation briefly flared up
again. At a regional conference of IBFAN Africa in Nai
robi, Mwai Kibaki, Kenya’s health minister from 1988 to
1991 (who would later become president and sign the
2012 BMS Act into law), expressed commitment to enact
a binding Kenya Code, “to be followed by marketers of
baby foods or infant formula to protect mothers from
being cheated and confused” [85]. However, nothing
came out of Kibaki’s pledge at the time, likely because of
a fallout with President Moi and a relatively brief tenure
as health minister [86].
In the 1990s, the issue of BMS legislation largely dis
appeared from Kenya’s political agenda. The report of a
fact-finding mission, deployed by UNICEF and IBFAN,
revealed that, in the second half of the 1990s, “a broad
range of actions and funding to assist protection, pro
motion and support of breastfeeding, have declined very
markedly”, while “interest” in binding BMS legislation has
“waned” [87]. Some of this had, without doubt, to do with
the continued influence of BMS producers and with the
fact that KEBS (rather than the health ministry) remained
in charge of BMS regulation [87]. Yet, it was also a result
of rising rates of HIV infections in Kenya and growing
concerns about the risk of HIV transmission through
breastfeeding [88]. In 1997, this led to a specific recom
mendation by the Kenyan health ministry that “women
with HIV will be advised to avoid breast-feeding their
children and use alternative feeds” [88]. In sum, political
priority for BMS regulation had reached a low point in
the late 1990s.
Renewed advocacy and an opening policy window
Advocacy for BMS legislation began to re-emerge in
the early 2000s. One specific transnational event that
“renewed interest” [87] was the participation of three
Kenya-based breastfeeding advocates in a training course
on International Code compliance, hosted by IBFAN’s
International Code Documentation Centre (ICDC) in
Penang in September 2000. The ICDC was established by
IBFAN in 1985 “to conduct courses on Code implemen
tation and Code monitoring” [12, 89]. The three partici
pants from Kenya included Rachel Musoke, a pediatrics
professor and co-founder of BIG, Catherine Muyeka
Mumma, a lawyer from the Office of the Attorney Gen
eral, as well as a UNICEF program officer [87]. After
the training course, there was “some resolve to move
the Code from the Bureau of Standards to the Ministry
of Health” and Mumma was “highly motivated to draft
new legislation once she gets the go ahead” [87]. Mumma
subsequently began working on a draft law, which would
later form the basis for the 2012 BMS Act [90].
The policy window for BMS legislation slowly began
to open with the election of President Mwai Kibaki in
December 2002, which ended the 24-year rule of Dan
iel arap Moi. From the beginning, Kibaki demonstrated
a greater willingness to support women’s political lead
ership. His appointment of Charity Ngilu as the first
woman Minister of Health (2003–2007) indicated his
trust in women’s leadership in the health sector. Appoint
ing “a woman at the helm of health was a strategic deci
sion that served to refocus the ministry to women’s
healthcare, which was in dire need of attention” [91]. In
2007, the publication of a new South African study on the
effects of exclusive breastfeeding on mother-to-child HIV
transmission motivated the health ministry leadership to
revisit the issue of BMS regulation [92]. This resulted in
the formation of a technical team within the health min
istry, headed by Annah Wamae of the Division of Child
and Adolescent Health, that began to reconsider the issue
of BMS regulation.
The policy window further opened after the highly dis
puted general election of December 2007, in which both
Kibaki and opposition leader Raila Odinga had claimed
victory. After post-election violence that claimed over
1,000 lives, the two conflicting parties entered into a
power sharing agreement that resulted in a “grand coali
tion” government with Kibaki as president and Odinga
as prime minister from 2008 to 2013. This arrangement
shaped the political process of Kenya’s 2012 BMS Act in
several ways. It facilitated an important constitutional
reform in 2010 and translated into a less divided parlia
ment [93], which would diminish the role of party lines in
the legislative adoption process of the law in 2012.
Creation of a public health ministry
Most immediately, the formation of a coalition govern
ment in 2008 had important consequences for Kenya’s
health ministry, which was back in charge of BMS
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Wamahiu et al. Globalization and Health (2025) 21:32
legislation. The power sharing agreement led to the for
mation of an inflated, 43-person cabinet [94]. To create
new cabinet positions, some ministries were split up dur
ing the 2008–2013 period. This included the Ministry of
Health, which was divided into the Ministry of Medical
Services (MoMS) and the Ministry of Public Health and
Sanitation (MoPHS). This newly created MoPHS sought
to shift the “focus of government and donor spend
ing from curative to preventive health strategies” [95].
The Division of Child and Adolescent Health, which
had begun to re-engage with the issue of BMS regula
tion in 2007, was allocated to the MoPHS. Significantly,
the MoPHS and the MoMS soon displayed distinct per
spectives on BMS. The MoMS viewed BMS primarily
as a curative medical product. The MoPHS, in contrast,
viewed BMS primarily as a hindrance to breastfeeding,
especially in the many cases where formula feeding was
not necessary. The creation of the MoPHS therefore pro
vided a distinct institutional space for this public health
perspective on BMS.
President Kibaki appointed Beth Mugo to lead the new
MoPHS. Mugo would become the most influential politi
cal actor behind the 2012 BMS Act. At the time, she was
a member of Kibaki’s Party of National Unity and had
served as an Assistant Minister for Tourism and Infor
mation in Kibaki’s previous government [96]. Mugo was
well connected in Kenya’s political elite, in part because
she was the “favorite niece” of Jomo Kenyatta, Kenya’s
first post-independence president [97], and enjoyed a
close relationship with President Kibaki [96]. Mugo had
been a member of Kenya’s (then) unicameral parliament
since 1997. Doubling as minister and legislator from 2008
to 2013 allowed Mugo to be closely involved in both the
formulation and adoption of the BMS Act. Beth Mugo
was broadly committed to public health promotion, for
instance, through the implementation of Kenya’s 2007
Tobacco Control Act [98, 99].
By the time Beth Mugo became Minister of Public
Health and Sanitation, she was already a key figure in
the Kenyan women’s movement. Mugo ran a family busi
ness and was Kenya’s national chairperson of the Inter
national Federation of Business and Professional Women
from 1984 to 1987 [99]. When Mugo became a member
of parliament (MP) in 1997, she was one of six elected
women MPs [100]. In 2000, Mugo sponsored a landmark
affirmative action bill that sought to increase the political
representation of women and other marginalized groups
[101]. In 2001, Mugo co-founded (together with Martha
Karua and Charity Ngilu) the Kenya Women’s Parliamen
tary Association (KEWOPA), a bi-partisan women’s cau
cus dedicated to supporting women’s representation and
women-centered policies in parliament [102]. KEWOPA
would later play a vital role in the parliamentary adoption
of the BMS Act.
Creation of a nutrition division
The new Ministry of Public Health and Sanitation cre
ated a dedicated new Division of Nutrition, focusing on
the implementation of preventative nutrition interven
tions. This portfolio was previously with a Unit, which
had more limited autonomy. Initially, the allocation of
nutrition-related departments was contested between the
MoPHS and the MoMS [103]. The Division of Nutrition
was eventually allocated to the MoPHS (while a new Unit
of Clinical Nutrition was created in the MoMS). From
2008 to 2014, this division was headed by Terrie Wef
wafwa, a nutritionist and career civil servant, who had
worked as a provincial nutrition officer since the 1970s.
Her strong support for BMS regulation was informed by
her experience with the negative effects of bottle feed
ing as a District Nutrition Officer. During her time at
the helm of the Division of Nutrition, Wefwafwa showed
strong political leadership for public health nutrition,
ranging from breastfeeding promotion to mandatory
food fortification [104].
Wefwafwa’s work emphasized better coordination
among stakeholders and a strengthening of government
leadership in the field of nutrition. Historically, nutrition
programming in Kenya was often fragmented and domi
nated by NGOs [105]. After a severe drought and famine
in 2006 [106] and the creation of the Division of Nutri
tion in 2008, development partners such as UNICEF and
the WFP began clarifying their roles and responsibilities.
This resulted in a 2009 “partnership framework”, which
formalized a “common vision for nutrition services”,
including the “transition of leadership and governance”
to the health ministry [105]. In practice, this resulted in
the creation of an interagency coordination committee
and several government-led working groups, including
a Maternal, Infant and Young Child Nutrition (MIYCN)
Technical Working Group [105]. The MIYCN working
group, which brought together representatives from the
government, WHO, UNICEF, IBFAN and other NGOs,
played an important role in the formulation of the 2012
BMS Act.
The new political leadership at the Ministry of Pub
lic Health and Sanitation soon focused on Kenya’s poor
trends in child mortality indicators. The country’s
infant mortality rate, after years of decline, had actu
ally increased in the 1990s to reach 77 deaths per 1,000
live births in 2003 [35]. While this rate was back down
to 52 in 2008/09, this was still significantly higher than
the Kenya Vision 2030 target of 25 by 2012 [37, 107].
The MoPHS and its partners argued that the promotion
of exclusive breastfeeding during the first six months,
even for mothers with HIV, was one of the most effec
tive interventions for reducing child mortality [105, 108].
And, crucially, they re-focused on the regulation of BMS
marketing as a central tool for promoting and protecting
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Wamahiu et al. Globalization and Health (2025) 21:32
exclusive breastfeeding. In this context, IBFAN Africa’s
2007 regional conference in Maputo was an impactful
event, as it highlighted that Kenya had become a regional
laggard in breastfeeding protection and International
Code implementation. Indeed, Tanzania and Uganda,
two of Kenya’s key neighboring countries, already had
BMS legislation in place by 2006 [93].
Drafting of the BMS bill
The main drafting process of Kenya’s BMS Act began in
2008 under the leadership of Terrie Wefwafwa [109]. This
process was supported by the assignment of a state legal
officer from the Attorney General’s office. The drafting
process occurred in close coordination with WHO and
UNICEF, in particular with David Clark, a legal specialist
from UNICEF headquarters in New York [110]. The first
complete draft of Kenya’s BMS Act was completed by
2012 and was largely in line with the International Code.
The policy window for introducing the BMS draft
law into parliament fully opened in August 2010 when
Kenya adopted a new constitution through a referendum,
replacing the country’s previous constitution of 1969.
Just two weeks after this referendum, Beth Mugo publicly
announced that “plans are underway to enact the regula
tory law of breast milk substitutes on the Kenyan mar
ket” [111]. The new constitution facilitated the adoption
of BMS legislation in multiple ways. It enshrined human
rights through a comprehensive bill of rights, which in
the following years gave rise to a general atmosphere of
reform to realize these newly defined rights [112]. New
constitutional provisions that “every child has the right to
[…] basic nutrition, shelter and health care” as well as to
“parental care and protection” provided a direct justifica
tion for the BMS Act [113].
The new constitution also cleared a crucial veto point
that had previously hindered stricter BMS regulation.
BMS legislation had previously been stalled by Kenya’s
long-time attorney general Amos Wako, who had been in
office since 1991. He had acquired a reputation for being
complicit in various corruption cases [91]. As “the princi
pal legal adviser to the Government” [113], the Attorney
General plays a central role in Kenya’s legislative pro
cess, including in legislative drafting. Indeed, Beth Mugo
would later report that a draft bill once even disappeared
from the Attorney General’s office [114, 115]. Kenya’s
new constitution, however, explicitly required Wako to
step down within one year, which he did in August 2011
[116]. Wako was succeeded by the politically much less
entrenched Githu Muigai, which cleared the crucial veto
point of the Attorney General’s office.
Parliamentary debate of the BMS bill
On 2 August 2012, the Breast Milk Substitutes (Regula
tion and Control) Bill was introduced into Kenya’s (then
still unicameral) National Assembly [117]. The bill was
guided through the parliamentary process by Beth Mugo,
who was also a member of parliament. Mugo was moti
vated to get the bill passed quickly, as a breast cancer
diagnosis in January 2012 made her consider retirement
from political office, which she would later announce in
December 2012 [118].
Throughout the parliamentary process, the bill faced
strong opposition from the transnational formula milk
industry. While BMS producers abstained from speak
ing out openly against the bill, they strongly mobilized
against the bill behind the scenes. Farah Maalim, the dep
uty speaker of parliament and one of Mugo’s major allies
in support of the BMS bill, noted during the parliamen
tary debate that “it is an open secret that the stakeholders
from the industry have been camping out there” [119].
Maalim later specified that “when we were enacting the
breast milk law […] Nestle gave us a serious pushback.
The Nestle lobby in Parliament was well oiled & very
loud” [120]. Incidentally, Nestlé had replaced its Nairobi-
based regional Chief Executive Officer in June 2012 “to
attain a firmer grip on the [African] region” [121]. The
Kenya Association of Manufacturers (KAM) opposed the
law explicitly, as it would “hinder the business of affected
companies” [122].
The main parliamentary debate of the BMS bill
occurred on 19 and 20 September 2012. Representatives
of UNICEF initially followed the debate from parlia
ment’s public gallery but later decided to leave to avoid
the impression of an externally imposed law. While no
member of parliament openly argued against the bill
as such, there was strong pressure to weaken the bill
through amendments. In particular, three (ultimately
rejected) amendments would have significantly reduced
the stringency of the BMS bill. A first amendment (pro
posed by Charles Keter) would have added three indus
try representatives, nominated by the Kenya Association
of Manufacturers (KAM), to the newly created National
Committee on Infant and Young Child Feeding, to ensure
that “the manufacturers have their representation” [119].
This would have granted industry representatives a privi
leged position to influence the implementation, monitor
ing and enforcement of the law. A second amendment
(also proposed by Keter) would have allowed enforce
ment officers to access the premises of BMS manufac
turers or distributors only with a court warrant, which
would have greatly complicated enforcement. A third
amendment (proposed by Robert Monda) would have
allowed health workers and proprietors to accept finan
cial assistance from the formula milk industry, e.g.,
through research grants, as long as there was full disclo
sure. This amendment would have arguably gone furthest
in weakening the bill, as it would have opened substantial
space for conflict of interest and industry influence over
Page 9 of 14
Wamahiu et al. Globalization and Health (2025) 21:32
the healthcare system. the promotion of BMS and com
plementary feeding products. All three of these amend
ments were eventually rejected and the BMS bill was
passed with only minor amendments on 20 September
2012.
Sources of support for the BMS bill
The first and most central factor behind the successful
adoption of the BMS bill was the strong, bipartisan sup
port by all women MPs. This support was institutionally
facilitated by KEWOPA, which endorsed the bill [123].
KEWOPA members embraced the bill as a women-cen
tered and women-led law. For instance, Rachel Shebesh
argued that such a bill was only possible “because we
have a woman as a Minister and that is why we need
more women Ministers” [119]. During the parliamentary
debate, no female MP opposed the bill.2 Instead, many
KEWOPA members actively supported it. Key among
those was Martha Karua, who together with Beth Mugo
had co-founded KEWOPA in 2002 and had served as
justice minister from 2005 to 2009. Karua’s support was
significant as she was the former Minister for Justice
and Constitutional Affairs, often described as the “iron
lady” of Kenyan politics. On several occasions, Karua
rose to support Mugo in defending the bill against hostile
amendments.
While KEWOPA’s support was central in establishing
a bipartisan basis of support, female MPs made up only
10% of MPs in 2012 [124]. Hence, broad support from
“male allies” was essential for the adoption of the bill [53].
Such male support was not a given, as all parliamentary
opposition to the bill was voiced by male MPs (see Table
S2). Indeed, Karua had explicitly called out her “male col
leagues” for attempting to delay the parliamentary debate
on the bill [114]. But Mugo managed to successfully
recruit several influential male legislators to support the
bill. After Mugo had introduced the bill on 19 September,
she was seconded by Amos Kimunya, the male transport
minister. Indeed, the fact that Mugo decided to have her
bill co-sponsored by a male rather than a female legislator
even surprised the parliament’s deputy speaker in charge
of the session, who noted to Mugo that “my presumption
was that you would look for a lady who has breastfed like
you” [119]. The bill was then formally supported by two
other male MPs before other female MPs expressed their
support. Another important male ally was trade minister
Moses Wetangula, whose support was significant given
that the trade ministry often sides with industry interests.
2 This unanimous support of female MPs does not to imply that all women
were in complete agreement regarding the BMS bill. For instance, a former
chairwoman of the Kenya Nutritionists and Dieticians Institute reportedly
advocated against the bill.
Overcoming opposition to the BMS bill
Another factor that contributed to the successful adop
tion of strict BMS legislation was the effective bypassing
of public participation requirements. Public participa
tion requirements, e.g., in the form of “notice and com
ment” procedures, are often introduced as an instrument
to “democratize” policymaking. In practice, however,
formalized public participation requirements have been
shown to create an access point to policymakers that is
primarily used by business actors [125]. Kenya’s 2010
constitution introduced the requirement that parliament
“facilitate public participation and involvement in the
legislative and other business of Parliament and its com
mittees” [126]. In 2012, however, the modalities of such
public participation in the legislative process had not yet
been clarified [126]. The parliamentary proponents of
the BMS bill exploited this temporary opportunity and
proceeded without formal public participation in order
to limit industry influence. The Kenya Association of
Manufacturers later lamented the limited involvement
of industry actors in the formulation of the law and the
deliberate exclusion of the private sector from the newly
established National Committee on Infant and Young
Child Feeding, which was to advise the government on
the implementation of the law [122, 127, 128]. This strate
gic bypassing of public participation mechanisms limited
industry influence and thus contributed to the successful
adoption of the BMS Act.
In October 2012, after the BMS bill had already been
passed by parliament, the Global Alliance for Improved
Nutrition (GAIN) sought to convince the government to
not sign it into law [129]. GAIN is a public-private part
nership focused on reducing micronutrient deficiencies
through food fortification [130]. At the time, GAIN was
primarily funded by the Bill & Melinda Gates Foundation,
while its business partner network included the transna
tional formula milk corporations Danone and DSM [129,
131]. GAIN prepared an antagonistic policy briefing
that it sent to the MoPHS [129]. GAIN’s main concern
was that the bill also sought to restrict the advertising of
“complementary food products”. But GAIN did not just
advocate for the exemption of specific, relatively more
accepted complementary food products, such micronu
trient powders for home fortification, which reportedly
was negotiated anyway [132]. Instead, GAIN lobbied for
weaker regulation of “all complementary foods” [129],
which would have also included growing-up (or toddler)
formula. To convince the government not to proceed,
GAIN claimed that the bill was “not currently consis
tent with international recommendations or Scaling Up
Nutrition (SUN) interventions for complementary feed
ing” and suggested that “if this Act is adopted, there is a
risk of reduction of investment in infant and young child
Page 10 of 14
Wamahiu et al. Globalization and Health (2025) 21:32
nutrition” [129].3 Kenya’s government, however, was
unmoved by this lobbying attempt and President Kibaki
signed the BMS bill into law on 11 October 2012.
Discussion
Our analysis reveals four main political enablers of strict
BMS legislation in Kenya: women’s political leadership,
the recruitment of influential male allies, support from
a transnational advocacy network, and the opening of a
policy window. In combination, these four enabling fac
tors allowed advocates of BMS legislation to overcome
the power of the transnational formula milk industry.
First, we find that women’s political leadership was cen
tral in generating political priority for BMS legislation.
The issue was first brought onto Kenya’s political agenda
in the 1980s by the women-led civil society organizations
BIG and MYWO. The formulation and adoption of the
BMS Act in the later 2000s and early 2010s was led by
Beth Mugo and Terrie Wefwafwa at the Ministry of Pub
lic Health and Sanitation. The support of the bipartisan
women’s parliamentary caucus KEWOPA was central in
achieving parliamentary approval, even though female
MPs made up only 10% of parliament. This is in line with
previous research asserting that women’s political leader
ship can be influential despite limited numerical strength
[101]. Overall, our analysis confirms that women’s repre
sentation in powerful political positions can significantly
contribute toward improved public health [135]. Our
findings about the centrality of women’s political leader
ship for effective BMS legislation mirrors much earlier
observations by Derrick and Patrice Jelliffe on the impor
tance of voluntary women’s groups, such as La Leche
League, in breastfeeding promotion [62].
Second, we highlight the crucial role of male allies in
the adoption of BMS legislation. President Mwai Kibaki
was a particularly important ally, who paved the way for
women-led health policy by appointing Charity Ngilu as
health minister in 2003 and Beth Mugo as public health
minister in 2008. Kibaki also provided the ultimate sup
port for BMS legislation by signing the 2012 BMS bill
into law. Male allies were also critical in the parliamen
tary approval process, as women MPs were in the clear
minority in the National Assembly. The backing of sev
eral of Mugo’s male cabinet colleagues, including Amos
Kimunya and Moses Wetangula, was key in generating
sufficient parliamentary support for the BMS bill. These
3 GAIN’s attempt to stop Kenya’s BMS bill had global repercussions. It
resulted in the WHO Executive Board’s decision, in January 2013, to post
pone consideration of GAIN’s application to enter into “official relations”
with the WHO, requesting that GAIN clarify its “links with the global
food industry” and its “support and advocacy of WHO’s nutrition policies,
including infant feeding and marketing of complementary foods” [131, 133].
In turn, this likely contributed to GAIN’s severing of ties with Danone in
mid-2013 [134].
findings confirm the importance of male allies for the
adoption of women-led laws [52, 53].
Third, we identify transnational advocacy networks as
important in supporting government efforts toward strict
BMS legislation. Transnational advocacy by IBFAN and
training courses offered by the ICDC in Penang con
tributed to bringing BMS legislation back onto Kenya’s
political agenda in the early 2000s. Technical support
from international organizations, in particular UNICEF
and WHO, aided the formulation of an effective BMS bill.
These findings demonstrate that transnational advocacy
networks have not only been important in the adoption
of the International Code and subsequent resolutions [16,
19] but are also significant in supporting the formulation
and adoption of BMS legislation at the national level.
Fourth, our analysis highlights the importance of policy
windows, or windows of opportunity, for the adoption
of BMS legislation. While women’s political leadership
together with support from male allies and transnational
advocacy networks were crucial for the formulation and
adoption of Kenya’s BMS Act, this law could arguably not
have been passed without the opening of a policy window
between 2011 and 2013. Key elements of this policy win
dow were the presidency of Mwai Kibaki (2002–2013),
the temporary establishment of a dedicated Ministry of
Public Health and Sanitation (2008–2013), and the adop
tion of a new constitution (in 2010) that necessitated the
replacement of Kenya’s long-time attorney general (in
2011). These contextual factors explain why the BMS Act
was adopted only in 2012. This finding confirms previ
ous research on the centrality of policy windows in other
areas of public health nutrition policy [136, 137].
Conclusion
Our case study of the adoption of Kenya’s 2012 BMS Act
demonstrates that women’s political leadership can coun
teract the political influence of the transnational formula
milk industry and thus help achieve strict national BMS
legislation. We show that effective female leadership for
BMS legislation can occur in a variety of political offices
and positions, including those of ministers and legislators
but also those of domestic and international bureaucrats.
Importantly, female leaders can leverage their own influ
ence by strategically recruiting male allies and exploiting
policy windows.
Future research should continue to investigate the
political conditions for the adoption of strict national
BMS legislation in line with the International Code.
Building on the important literature that demonstrates
the pervasive lobbying of the transnational formula milk
industry in countries such as Brazil [27], the Philippines
[28], Thailand [29] and the United States [138], policy-
oriented research should focus more specifically on how
governments can overcome this influence in order to
Page 11 of 14
Wamahiu et al. Globalization and Health (2025) 21:32
adopt and implement strict BMS legislation. Policymak
ers around the world stand to benefit from such political
analyses when developing BMS legislation and defending
it against industry opposition [139].
Abbreviations
BIG
Breastfeeding Information Group
BMS
Breast Milk Substitutes
GAIN
Global Alliance for Improved Nutrition
HIV
Human Immunodeficiency Virus
IBFAN
International Baby Food Action Network
ICDC
International Code Documentation Centre
International Code
International Code of Marketing of Breast-milk
Substitutes
KAM
Kenya Association of Manufacturers
KEBS
Kenya Bureau of Standards
KEWOPA
Kenya Women Parliamentary Association
MIYCN
Maternal Infant and Young Child Nutrition
MoMS
Ministry of Medical Services
MoPHS
Ministry of Public Health and Sanitation
MP
Member of Parliament
MYWO
Maendeleo ya Wanawake Organization
NGO
Non-Governmental Organization
NORAD
Norwegian Agency for Development Co-operation
UNICEF
United Nations Children’s Fund
USAID
United States Agency for International Development
WHA
World Health Assembly
WHO
World Health Organization
WFP
World Food Programme
Supplementary Information
The online version contains supplementary material available at https://doi.or
g/10.1186/s12992-025-01127-2.
Supplementary Material 1
Supplementary Material 2
Acknowledgements
For comments and suggestions that helped improve this article, we thank
Joseph Harris, Marion Ouma and Stefan Ouma as well as participants at the
2023 Bayreuth-Kulmbach Workshop on Global Health Politics, the 2024 Food
Governance Conference in Sydney, the 2024 World Public Health Nutrition
Congress in London, the 2025 International Studies Association Annual
Convention in Chicago, and a colloquium of the Bayreuth International
Graduate School of African Studies. We also thank Kilian Hastreiter and
Ugbedeojo Sule for excellent research assistance.
Author contributions
Conceptualization: MW and TD; Methodology: MW, PB and TD; Validation:
MW and TD; Investigation: MW; Data Curation: MW; Writing– Original
Draft Preparation: MW; Writing– Review & Editing: MW, PB and TD; Project
Administration: MW; Funding Acquisition: MW and TD.
Funding
Open Access funding enabled and organized by Projekt DEAL.
MW declares funding for this research from the Bayreuth International
Graduate School of African Studies, which is part of the Africa Multiple Cluster
of Excellence funded by the German Research Foundation. PB declares
funding from an Australian Research Council Future Fellowship award (Project
#FT220100690) from the Australian Government, and from a Sydney Horizon
Fellowship award from the University of Sydney, for his research on healthy
infant and young child diets from sustainable first food systems.
Data availability
The data supporting the conclusions of this article are included within the
article and its additional files.
Declarations
Ethics approval and consent to participate
This study was approved by the University of Bayreuth’s Research Ethics
Committee (Reference number: 23–029). All participants provided their
consent prior to interview.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 10 September 2024 / Accepted: 21 May 2025
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